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
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-----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
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