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Assessing Proposals for Major Health Insurance Reform |
Institute of Medicine's Committee on the Consequences of Uninsurance recommends five principles[1] to guide reforms to extend health insurance to all Americans. The following list of questions can be used to measure how close proposals and strategies for extending coverage come to fulfilling these principles.
1. Health care coverage should be universal.
* Are individuals required to obtain coverage or are employers required to offer it?
* Who is eligible for which types of coverage?
* Who is not eligible for coverage?
* How easy or difficult is it for eligible people to enroll?
* What kinds of subsidies are available for lower-income individuals and families?
2. Health care coverage should be continuous.
* Is re-enrollment required? If so, how frequently?
* How streamlined is that process?
* What happens to people who lose or change jobs?
* What happens to people who have a change in income or family circumstances?
* What happens to children upon reaching the cut-off age for coverage under a parent's policy?
* What happens to early retirees?
3. Health care coverage should be affordable to individuals and families.
* How much are families and individuals expected to contribute toward the premium?
* What kinds of premiums, co-payments, and deductibles are included? Do these cost-sharing amounts vary with family size, health status, family income, or other criteria?
* What subsidies are available to individuals and families, and what are the criteria for qualifying for them?
4. The health insurance strategy should be affordable and sustainable for society.
* Do the assumptions and estimates about the number of people to gain coverage and the cost per person seem realistic?
* Does everyone contribute to the new system? If not, who is excluded and why?
* Who bears the main burden to support the extended coverage?
* Are the sources of revenue/financial support for the extended coverage, such as taxes, likely to be relatively stable even in tough economic times?
* How will funding currently in the system for service to the uninsured, such as the Disproportionate Share (DSH) Adjustment, be treated? How much of the current funding will be shifted to the new system?
* Are utilization controls and cost-control mechanisms built into the program?
* Is the benefit package designed to encourage the use of cost-effective services?
* Does the new strategy emphasize simplicity and administrative efficiency?
5. Health care coverage should enhance health and well-being by promoting access to high-quality care that is effective, efficient, safe, timely, patient centered, and equitable.
* Does the benefit package include preventive and screening services, mental health services, and outpatient prescription drugs as well as hospital and outpatient medical care?
* Are there incentives for enrollees to fully use essential services, such as screening and preventive services?
* Are there incentives for enrollees to avoid overuse and inappropriate use of services?
* Are there incentives for providers to offer high-quality care consistent with medical guidelines and scientific evidence?
[1] The five principles are presented in the committee’s final report, Insuring America’s Health. They are based on the findings of the committee’s earlier reports: Coverage Matters, Care Without Coverage, Health Insurance Is a Family Matter, A Shared Destiny, and Hidden Costs, Value Lost. These reports and more information about uninsurance is available at www.iom.edu/uninsured.
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