Americans have repeatedly demonstrated their preference for health insurance against out-of-pocket payments for large medical bills. The proposed reliance on "competitive markets" is not likely to meet with public or congressional favor, and risks substantial new costs while promising little fiscal relief. A more modest proposal is offered.
Although hospital care forms the largest expenditure under Medicare, long-term reforms in the basic reimbursement system should be approached cautiously. The effects of newly mandated changes--prospective payment and DRGs--have yet to be evaluated, but some modifications should be considered for the near term. Uniform, national payment rates and adjustments for teaching are especially critical areas.
Most operational services within the reorganized British National Health Service are managed by local teams: medical specialist, general practitioner, nurse, administrator, and finance officer. Decision by consensus has worked well to integrate services in a complex and fiscally constrained system. As larger and more formal systems of health care emerge in the United States, the British experience may be relevant.
In 1979 the British people elected a government that explicitly repudiated the basis of post-war political consensus; Americans did likewise in the following year. New policies, it was expected, would be shaped by a new ideology. Britain's National Health Service offers an opportunity to examine the nature of this relationship. Political, professional, and corporate ideologies about resource allocations are inevitably constrained by the prevailing public philosophy.
Some appealing aspects of a voucher program--promise of promoting efficiency while respecting individual preference, and capping federal expenditures--may be illusory. Adverse selection, administrative and regulatory complexity, and serious inequities are not likely to meet tests of feasibility or desirability.
Changes in beneficiary cost-sharing provisions must be part of any multi-faceted strategy for Medicare's fiscal solvency . The current flawed benefit structure is seen as inefficient, inequitable , and contrary to prudent insurance principles. An income-related and selective increase in cost-sharing, combined with maximum liability, is proposed.
Medicare's financial problems are rooted in the program's history--from the initial cost-estimating process through successive legislative and administrative actions to control costs. Even more important has been the persistence of several implicit national health care policies, and these are unlikely to change. Frequent readjustments of financing provisions may become a necessity.
Medicare's system of paying physicians is criticized as being costly, inflationary , inefficient, inequitable , and confusing. Yet when alternative methods--to change practice arrangements, units of service, fee levels, and the assignment option--are examined, no one seems ideal. A fee-for-service system combined with a prospective payment schedule may offer the best compromise.
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