Richard Kronick

A Consumer-Choice Health Plan for the 1990s

We describe the characteristics necessary for a plan for universal health insurance to find broad acceptance. Such a plan must represent incremental, not radical, change; must respect the preferences of voters, patients, and providers; must avoid major disruption in satisfactory existing arrangements; must avoid creating major windfall gains or losses; must avoid large-scale income redistribution; and must not be inflationary. Our proposal would create a framework that would encourage the efficient organization of care. Successful organizations would probably be those that attracted the loyalty and commitment of physicians, integrated insurance and the provision of care, and aligned the interests of doctors and patients toward high-quality, cost-effective care. The proposals chief potential disadvantage would be its effect on the employment opportunities of low-wage workers, but this effect could be minimized. In addition, we discuss a proposal to mandate coverage by employers of full-time employees, legislation enacted recently in Massachusetts, high-risk pools, and the system followed in Canada, comparing each of these alternatives with our proposal.

Effects of Offering Advance Directives on Medical Treatments and Costs

OBJECTIVE To examine the effects of advance directives on medical treatments and on patient satisfaction and well-being and to determine whether the enhancement of patient autonomy through advance directives provides a more ethically feasible approach to cost control than does the imposition of limits through rationing. DESIGN Randomized, controlled trial. SETTING University and Veterans Affairs medical center. PATIENTS Two hundred and four patients with life-threatening illnesses, 100 of whom died after enrollment in the study. INTERVENTION Patients randomly assigned to the experimental group were offered the California Durable Power of Attorney (a typical proxy-instruction directive), and patients assigned to the control group were not offered the advance directive. Hospital admissions were monitored to assure that a summary of the document was present in the active medical record at each hospitalization. MEASUREMENTS Cognitive function, patient satisfaction, psychological well-being, health locus of control, sense of coherence, health-related quality of life, receipt of medical treatments, and medical treatment charges. RESULTS No significant differences were found between advance-directive and control groups regarding psychosocial variables, health outcome variables, and medical treatments or charges. Patients offered an advance directive had an average hospital stay of 40.8 days (95% CI, 32.2 to 49.4 days), compared with an average of 33.1 days (95% CI, 26.0 to 40.2 days) for controls. Patients offered an advance directive were charged an average of

Marital status and longevity in the United States population

19,502 (95% CI,

The effect of health insurance on medical care utilization and implications for insurance expansion: a review of the literature.

13,030 to

The marketplace in health care reform : the demographic limitations of managed competition

25,974) for medical treatments in the last month of life compared with

The Affordable Care Act and Insurance Coverage for Young Adults

19,700 (95% CI,

The Medicaid Rx model: pharmacy-based risk adjustment for public programs.

13,704 to

Health Insurance Coverage and Mortality Revisited

25,696) for controls. CONCLUSIONS Despite claims that public demand for longer life accounts for rising medical costs, most surveys suggest that patients are calling for less, not more, of the expensive, high-technology treatment often used in terminal phases of illness. Executing the California Durable Power of Attorney for Health Care and having a summary copy placed in the patients medical record had no significant positive or negative effect on a patients well-being, health status, medical treatments, or medical treatment charges.

Hard Times And Health Insurance: How Many Americans Will Be Uninsured By 2010?

Purpose: To investigate the relation between marital status and survival. Data sources: The US 1989 national health interview survey (NHIS) merged with the 1997 US national death index. Results: Among 1989 NHIS respondents, 5876 (8.77%) died before 1997 and 61 123 (91.23%) were known to be alive. Controlling for demographic and socioeconomic characteristics, the death rate for people who were unmarried was significantly higher than it was for those who were married and living with their spouses. Although the effect was significant for all categories of unmarried, it was strongest for those who had never married. The never married effect was seen for both sexes, and was significantly stronger for men than for women. For the youngest age group (19–44), the predominant causes of early death among adults who had never married were infectious disease (presumably HIV) and external causes. In the middle aged and older men and women, the predominant causes were cardiovascular and other chronic diseases. Conclusion: Current marriage is associated with longer survival. Among the not married categories, having never been married was the strongest predictor of premature mortality. It is difficult to assess the causal effect of marital status from these observational data.

Medicare And Medicaid Spending Variations Are Strongly Linked Within Hospital Regions But Not At Overall State Level

Both the costs and benefits associated with extending health insurance coverage depend on the extent and exact ways in which health insurance affects the utilization of medical care. We review the literature relating to such effects with the goal of informing researchers interested in simulating the impact of policy initiatives aimed at achieving universal coverage. Overall, this literature is quite consistent in finding significant effects of insurance on all types of utilization. Insurance coverage increases outpatient utilization by roughly 1 visit per year for children and between 1 and 2 visits for adults. For both children and adults, these visits are associated with an increased receipt of preventive care. Insurance coverage also increases inpatient utilization for children and adults; for children, there is some evidence that insurance coverage reduces ambulatory care sensitive hospital admissions.