Assessing Health Care Reform (1993) / Chapter Skim
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Extending Access to Health Care
Extending Access to Health Care
Pages 5-20
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From page 5... ...
Just as Me cost of medical care is a major problem for many Americans, high and increasing hearth care costs are a major obstacle to health care reform. It has, for instance, been argued that heady care costs must be contained before major steps to extend health coverage can be undertaken.
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From page 6... ...
may be too low to secure adequate access to care for beneficiaries; and shortfalls in our knowledge of how clinical care, Be community and workplace environments, and individual social, cultural, and biological characteristics interact to affect health status and Be use of health services. To the extent Cat health care reform helps to reduce these barriers, it can allow more people to improve their heals and well-being by using the right medical services at the right time.
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From page 7... ...
In general, a long-term co~runitment to He objectives of heady care reform requires a prudent appreciation of both the promise and limits of health care reform for achieving better health outcomes. FINANCIAL ACCESS Principles On bow philosophical and practical grolmds, the committee believes that an attack on financial barriers to health care should work from the basic, interrelated principles outlined below (IOM l991f, 1993a,b; NRC/TOM, 1992)
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From page 8... ...
If multiple heath benefit plans are permitted, policies should minimize barriers to initial and continued health coverage (e.g., waiting periods and restrictions on coverage for preexisting health problems) for those who move, change jobs, become ill, start or stop receiving public assistance, or face similar changed c~rcurnstanc".
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From page 9... ...
augmenting any individual payments for coverage with contributions from employers, governments, or others that are adequate to cover appropriate, efficient care to the specific my of more and less healthy individuals who select any particular plan. Without such adjustments, which may involve government, employers, or specially created organizations such as purchasing cooperatives, health plans will face strong incentives to market only ~ the well and to discourage enrollment by the less healthy.
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From page 10... ...
Some of the most politically sensitive questions any reform proposal must answer are: who will define and update the basic package and determine any restrictions on supplemental coverage, what measures of effectiveness will be employed to include, exclude, or discontinue coverage for specific services, and what over criteria for inclusion will be employed? The stakes involved In benefit design are very high for specific categories of health care providers and patients.
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From page 11... ...
Given the difficulty consumers now have in understanding health insurance contract language, it is hard to imagine they would understand a health insurance contract or contract addendum with hundreds of pages of fine print spelling out such things as whether a coronary artery bypass graft would be covered for an individual with mild chronic stable angina who has single-vessel disease and a negative exercise electrocardiogram and who is not a candidate for percutaneous transluminal cutaneous angioplasty. It is even harder to imagine such contracts in the context of health plans that would compete (and be evaluated by consumers)
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From page 12... ...
Depending on Be way core and supplemental benefits are structure in ache context of a comprehensive plan for health care reform, adverse selection might make supplemental benefits unworkable except perhaps for those provided across-the-board by employers to ~l Weir employees. Eighth, a provision for standardized benefits implies a process for defining benefits that applies to health maintenance organizations and other network heath plans as well as fee-for-service settings, assuming that a reform proposal accommodates both.
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From page 13... ...
Health care reform proposals that aim to provide universal coverage and control costs should define the role of existing public sector health care coverage or service programs such as Medicare, Medicaid, the Department of Veterans Affairs health system, public health services, and various federal blow grants to states and communities. Even if reform proposals do not directly encompass the beneficiaries of such programs, they should be clear about how close massive public programs ought to tackle their own serious access and expenditures issues.
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From page 14... ...
Assessing Access Provisions of Reform Proposals Whatever their specific philosophy and approach, reform proposals should be sufficiently detailed that policymakers and others can understand and evaluate sue key dimensions of the reform strategy. These dimensions are: The processes and criteria that would be used to define He core benefit package, including how Key would take into account health outcomes, financial constraints, community values, patient preferences, and scientific evidence; how Be package would be revised to take changing technology or odler factors into account; how He benefit package would relate to prepaid or capitated delivery systems; and what kind of role would be envisioned for coverage that individuals or Heir employers could purchase to supplement Be core benefits.
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From page 15... ...
health care practitioners to support expanded access to primary and preventive services, especially in areas where such services are already in short supply; clinical and health service research Hat provides a better knowledge base on which to construct education, heath promotion, and special outreach activities; and vigorous, well-financed programs of quality assurance and health seances research to help protect against potential unwanted side effects of health system bureaucracies (both public and private) and cost containment efforts.
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From page 16... ...
Also, health plan features designed wig Me middle class in mind may prove to be significant obstacles to obtaining appropriate, effective, and timely care for those with low levels of income and education. For example, some managed care plans now decline to pay for more than 24 hours of hospital care following normal childbirth, thus reducing the opportunity to monitor newborns in the critical first one or two days after birth and to teach new mothers how to care for their babies.
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From page 17... ...
Such efforts will supplement quality assurance and research programs and help to identify and remedy bow financial and nonfinancial barriers to appropriate care.
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From page 18... ...
If multiple health benefit plans are permitted, policies should minimize barriers to initial and continued heath coverage (such as waiting periods and restrictions on coverage for preexisting health problems) for those who move, change jobs, become ill, start or stop receiving public assistance, or face similar changed circumstances.
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From page 19... ...
Critical coverage, funding, and other health plan features should be made more consistent across heady plans, more reliable and predictable over time, and less of a barrier to continuity of health care and job mobility. Heath care reform proposals should define the role of existing public sector health care coverage or service programs such as Medicare, Medicaid, Be Department of Veterans Affairs health system, public heard services, and various federal block grants to states and communities.
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From page 20... ...
Proposals to extend health insurance should define where coordination is needed with other public and private programs that target nonfinancial barriers to improved access and heady status. Because reforms, once adopted, cannot just be assumed to be successful in meeting Weir objectives, policymakers need to monitor changes in access over time.
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Key Terms
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