Michael sent me this exchange.  The one part that struck me as simply wrong was the notion the ffs medicare is unsustainable.  By that level of generalization canadian medicare should not be working.  The myth of ffs as impossible to control is not what I would have expected fromyou anna.

The absence of serious cost control in the american reform discussion is absolutely true.  See the annals of internal medicine forthcoming in march: a paper by oberlander, white and myself

Regards

Ted marmor



----- Original Message -----

From: Anglo-American Health Policy Network <[log in to unmask]>

To: [log in to unmask] <[log in to unmask]>

Sent: Tue Feb 17 12:45:57 2009

Subject: Re: FW: Medicaid and NHI - NEJM piece



Anna:



Thanks for the note.  Couple of thoughts in response.  First, most  

states are now implementing some form of managed care, at least for  

women and kids.  Moreover, at the top of state agenda's is trying to  

figure out how to bring the aged, disabled and chronically ill into  

some form of managed care as well, though there is much debate on the  

best way to do this.  Having varied approaches to this is one of the  

benefits (I think) to a Medicaid model (as opposed to a Medicare  

model).  Second, my own view is that you do not need equal benefits,  

but you do need some minimum level of standardized benefits.   

Different states or communities could then supplement depending on the  

needs of their own community.  On the other hand, trying to figure out  

when variation is good (and should be encouraged) and when it is bad  

(and should be discouraged or simply not allowed) is a very tough  

question.  Finally, on the question of cost containment more  

generally, I think Medicaid provides a good infrastructure for  

implementing such an effort (indeed, many docs would say Medicaid is  

too good at cost containment and that it needs to raise rates).  But  

this too is a tough one.



Thanks again,



Michael



Quoting Anna Dixon <[log in to unmask]>:



>

> Having recently visited the US and discussed the options for reform   

> I think Michael's proposals seem eminently sensible. What surprises   

> me is that none of the reform proposals seem to tackle head on the   

> issue of cost containment.

>

> Certainly extending Medicare with its predominantly fee for service   

> system would be unsustainable. It seems that public expectations   

> need to be managed, particularly those who are gaining coverage for   

> the first time need to be convinced that a more narrowly defined   

> benefits package (based on cost effectiveness rather than   

> comparative effectiveness?) with a managed network of providers   

> (including gatekeeping primary care physicians paid on the basis of   

> capitation?) is better for their health than a system of fragmented   

> providers who over treat due to reimbursement incentives (the   

> majority of group insurance plans). It was not clear from Michael's   

> articles whether state programs under an expanded Medicaid would be   

> required to do this or whether innovation would result in fiscally   

> responsible and value driven insurance packages.

>

> It is interesting that a more devolved (i.e non federal) system of   

> health care insurance is likely to be more acceptable in the US. Yet  

>  Michael suggests standardised eligibility and minimum benefits. The  

>  English NHS continues to struggle with debates about a postcode   

> lottery. There is great demand for equal benefits across the   

> country. Is this a basic requirement to sustain a universally   

> (federally) funded health system?

>

> Anna

>

> Dr Anna Dixon

> Director of Policy

> King's Fund

>

> Direct line: 020 7307 2682

> PA: Rachel Darlington 020 7307 2692

> [log in to unmask]

>

> -----Original Message-----

> From: Anglo-American Health Policy Network   

> [mailto:[log in to unmask]] On Behalf Of Adam Oliver

> Sent: 16 February 2009 21:45

> To: [log in to unmask]

> Subject: Medicaid and NHI - NEJM piece

>

> Hi

>

> Attached is a short piece by Michael Sparer on the possibility of   

> expanding Medicaid to achieve universal insurance. Michael would   

> appreciate your comments - his email address is [log in to unmask]

>

> All best,

> Adam

>

> Please access the attached hyperlink for an important electronic   

> communications disclaimer:   

> http://www.lse.ac.uk/collections/secretariat/legal/disclaimer.htm

>

> ______________________________________________________________________

> This email has been scanned by the MessageLabs Email Security   

> System. INBOUND IS OK For more information please visit   

> http://www.messagelabs.com/email   

> ______________________________________________________________________

>