The Future U.S. Healthcare System

by Altman, Stuart H.; Reinhardt, Uwe E.; Shields, Alexandra E.

• ISBN13: 9781567930672
• ISBN10: 1567930670
• Format: Paperback
• Copyright: 1997-10-01
• Publisher: Health Administration Pr

Table of Contents

Foreword	xiii	(4)
Steven A. Schroeder
Acknowledgments	xvii
1. Healthcare for the Poor and Uninsured: An Uncertain Future	1	(24)
Stuart H. Altman
Uwe E. Reinhardt
Alexandra Shields
Introduction	1	(1)
The Number of Uninsured in the United States: What Is the Magnitude of the Problem?	2	(3)
The Implications of Being Without Health Insurance	5	(2)
Why Has the Problem Persisted?	7	(5)
Increasingly Less Healthcare Available for the Uninsured	12	(3)
Concrete Proposals for Change	15	(1)
Incremental Reforms at the National and State Levels	15	(3)
Looking to the Future	18	(7)
Part I The Problem of the Uninsured--It's Real and Getting Worse	25	(74)
2. Uninsured in America: The Causes and Consequences	25	(20)
Diane Rowland
Judith Feder
Patricia Seliger Keenan
Introduction	25	(1)
Who Are the Uninsured?	26	(4)
What Is Happening to Health Insurance Coverage?	30	(6)
What Are the Consequences of Lack of Insurance?	36	(5)
Conclusion	41	(4)
3. All Uninsured Are Not the Same	45	(22)
Katherine Swartz
Characteristics of the Uninsured at a Specific Point in Time	46	(6)
Dynamics of Being Without Health Insurance	52	(2)
Policy Choices	54	(10)
Conclusion	64	(3)
4. The Changing Role of Medicaid	67	(20)
John F. Holahan
Medicaid Growth Explosion, 1988-92	67	(6)
Slowdown in Medicaid Expenditure Growth, 1992-95	73	(4)
Medicaid Spending in the Near Future	77	(3)
Implications	80	(4)
Acknowledgments	84	(3)
5. The Medically Uninsured--Will They Always Be With Us?	87	(12)
Steven A. Schroeder
Why We Tolerate Having So Many Uninsured	88	(4)
What Lies Ahead?	92	(7)
Part II Traditional Safety Net Providers: Showing Signs of Strain	99	(90)
6. The Challenges Facing Health Centers in a Changing Healthcare System	99	(24)
Daniel R. Hawkins
Sara Rosenbaum
Introduction	99	(1)
Background and Overview	100	(6)
Trends Affecting Health Centers	106	(8)
Conclusion	114	(9)
7. The Future of Safety-Net Hospitals	123	(28)
Larry S. Gage
Characteristics of Safety-Net Health Systems	125	(3)
Safety-Net Hospitals Provide a Large Volume of Inpatient and Outpatient Care	128	(6)
Safety-Net Hospitals Provide Disproportionate Levels of Medicaid, Medicare, and Uncompensated Care	134	(2)
Safety-Net Hospitals Rely Disproportionately on Medicare, Medicaid, and Local Subsidies to Cross-Subsidize Uncompensated Care	136	(3)
The Impact of Managed Care	139	(2)
Options for Protecting Safety-Net Health Systems	141	(1)
The Need to Reform DSH	142	(1)
The Need for Managed Care Safeguards	143	(1)
The Need for a Level Playing Field for Safety-Net Health Systems	144	(3)
Conclusion	147	(1)
Acknowledgments	148	(3)
8. The Role of Academic Health Centers and Teaching Hospitals in Providing Care for the Poor	151	(16)
James Reuter
Darrell J. Gaskin
Academic Health Centers and Care to the Poor	152	(3)
Academic Health Centers and the New Medical Market	155	(5)
The Impact of the Market on AHCs' Missions	160	(2)
Looking to the Future	162	(5)
9. The Hidden U.S. Healthcare Safety Net: Will It Survive?	167	(22)
Stuart H. Altman
Stuart Guterman
Financing the American Hospital	167	(5)
The Funding That Supports the Safety-Net Hospital	172	(4)
The Critical Role of Private Patient Revenues	176	(2)
Distribution of Uncompensated Care Burden across Hospitals	178	(3)
The Effect of Increasing Financial Pressure on the Distribution of Uncompensated Care	181	(2)
A Worst-Case Scenario	183	(1)
Conclusions	184	(5)
Part III Changes in Hospital Ownership and Care for the Uninsured	189	(44)
10. The Impact of Hospital Conversions on the Healthcare Safety Net	189	(18)
David Schactman
Stuart H. Altman
Introduction	189	(1)
The Provision of Charity Care and Community Benefits	190	(10)
The Provision of Health Services	200	(1)
The Price of Health Services	201	(2)
Conclusion	203	(4)
11. Hospital Ownership Form and Care of the Uninsured	207	(16)
Bradford H. Gray
The Significance of Ownership Form	208	(3)
Ownership Form and Care of the Poor	211	(2)
Uncompensated Care and Tax Exemptions	213	(3)
Conclusion	216	(7)
12. The Role of Investor-Owned and Not-for-Profit Organizations in Providing Healthcare to the Poor and Uninsured: A Perspective	223	(10)
Thomas A. Scully
Introduction	223	(1)
The Changing Healthcare Market	224	(1)
Why the Concern?	225	(1)
Is the Concern Justified?	226	(4)
Conclusion	230	(3)
Part IV The Search for Solutions I: The Road Is Paved with Incremental Reforms at the Federal and State Levels	233	(76)
13. Less Is More: After the Clinton Plan, Let's Think Small	233	(14)
Henry J. Aaron
Introduction	233	(2)
Lessons from the Past	235	(3)
Looking Forward	238	(1)
A Brief Sketch of U.S. Healthcare Financing	239	(5)
Postscript	244	(1)
Acknowledgments	244	(3)
14. Incremental Health Insurance Coverage: Building on the Current System	247	(18)
Karen Davis
Cathy Schoen
Increased Risks for the Uninsured	247	(2)
Prioritizing Coverage	249	(2)
Low-and Modest-Income Families	251	(2)
Building on Existing Administrative Mechanisms	253	(2)
Expanding Medicaid	255	(2)
Making Medicare Available to Older Adults	257	(2)
Financing Options	259	(1)
Trust Fund	260	(1)
Summary	260	(5)
15. Incremental Reform: The Health Insurance Portability and Accountability Act of 1996	265	(8)
Gail R. Wilensky
Incremental Reform: The Way Change Occurs	265	(1)
The Uninsured: A Heterogeneous Group	266	(1)
Implications for Incremental Reform	267	(1)
The Health Insurance Portability and Accountability Act as an Example of Incremental Reform	268	(1)
The Remaining Problems	269	(4)
16. Can We Count on the States to Cover the Poor and Uninsured?	273	(12)
Trish Riley
Introduction	273	(1)
Comprehensive Reforms and Access Initiatives	273	(7)
The Challenge of Financing Incremental Reform	280	(3)
Conclusion	283	(2)
17. The State Health Agenda: Austerity, Efficiency, and Monitoring the Emerging Market	285	(24)
Raymond C. Scheppach
Introduction	285	(1)
The Recent Past	286	(1)
The Federal Framework	287	(5)
Obstacles to Comprehensive State Healthcare Reform	292	(2)
State Challenges	294	(3)
State Fiscal and Regulatory Climates	297	(1)
Increased Access--State Action	297	(3)
The New State Health Agenda	300	(3)
Conclusion	303	(1)
Acknowledgments	304	(5)
Part V The Search for Solutions II: Considerations for Comprehensive Reforms	309	(96)
18. Where Will Americans Obtain Their Health Insurance? The Job Link Revisited	309	(16)
Alain C. Enthoven
Consumer Choice Health Plan	309	(1)
Critique of Employment-Based Health Insurance	310	(8)
Employers Do a Better Job than Government Monopolies	318	(1)
A Program to Extend the Benefits of Employment-Based Coverage to Nearly All Americans	319	(6)
19. Employer-Based Health Insurance: R.I.P.	325	(28)
Uwe E. Reinhardt
Introduction	325	(3)
Pricing Kindness out of a Nation's Soul	328	(4)
Government as a Cost Driver in Healthcare	332	(5)
Employer-Based Health Insurance: Merits and Shortcomings	337	(11)
Alternatives to Employment-Based Health Insurance	348	(5)
20. Trading Cost, Quality, and Coverage of the Uninsured: What Will We Demand and What Will We Supply?	353	(22)
Mark V. Pauly
Introduction	353	(1)
What Competitive Markets Will and Will Not Do	354	(1)
How Healthcare Used to Be: Myth and Reality	354	(3)
An Invidious Distinction	357	(5)
How Far Will It Go and How Long Can It Go On?	362	(3)
Limits on Equity	365	(1)
What to Do in Theory	365	(2)
So Who Pays?	367	(2)
How to Pay	369	(1)
What to Do?	370	(2)
What Will It Take?	372	(3)
21. Seeking More Efficient Healthcare Subsidies	375	(12)
Robert B. Helms
Do Not Increase Taxes or Budget Deficits	378	(2)
Give Consumers a Stronger Role in Seeking Cost-Effective Medical Care	380	(1)
Public Subsidies Should Be Explicit	381	(2)
Minimize the "Woodwork Effect"	383	(1)
Conclusion	383	(4)
22. The Case for Universal Health Insurance Coverage	387	(18)
Thomas Rice
Utilitarianism versus Alternative Philosophies	388	(10)
Implications for Universal Coverage	398	(4)
Acknowledgments	402	(3)
Index	405	(14)
About the Authors	419	(5)
About the Editors	424