For some, these plans represent the most significant promise for moderating healthcare spending to have emerged over the past several decades. For others, they represent a major threat to risk-pooling and to the social solidarity that underlies health insurance. Although it is still early, some information is beginning to emerge that sheds light on the likely effects of CDHPs.

HRAs versus HSAs

Most of the evidence to date has been on health reimbursement accounts. These accounts, initially authorized in 2000, combine high-deductible plans with an employer-funded savings account. Because HRAs are owned by the employer rather than the employee and remain with the employer if the employee leaves the company, these accounts have been thought to be less influential than health savings accounts in promoting cost-conscious behavior.

HSAs, authorized by the Medicare Modernization Act, pair high- deductible plans with tax- advantaged savings accounts, are owned by the employees, and thus, are fully portable. Because HSAs so clearly represent the employees’ own money, most industry analysts have assumed that their effects will be much more pronounced–although this remains supposition until more evidence is available.

WITH President Bush’s reelection in November, the medical-liability crisis was brought into sharper view. Bush had campaigned on liability reform, and in a January speech reiterated his belief that malpractice lawsuits “drive up insurance costs for all doctors . . . even for those who have never had a claim against them.”

To the insurance companies burdened by the skyrocketing cost of medical-liability jury awards, Bush’s stance is presumably a refreshing one. Often the industry is used as a convenient scapegoat, and it has predictably taken hits in the media for its role in the liability mess. Todd A. Smith, president of the Association of Trial Lawyers of America (ATLA), told the New York Times last year that high insurance costs have “everything to do” with greedy insurance companies. But do they?

In Smith’s defense, medical-liability costs are undeniably rising. The question is whether they’re rising owing to insurance-company greed, or to insurance companies’ merely responding to the increasingly bad economics of liability insurance. The growing unwillingness of insurance firms even to underwrite medical-liability insurance suggests something other than greed.

ENTREPRENEURS AGREE THAT the rising cost of health insurance is one of the biggest problems they face. According to a study by research firm Mercer Human Resource Consulting LLC, the average health-plan cost per employee rose by more than 10 percent in 2003. Costs have risen so much that some entrepreneurs are not insuring themselves or their workers.

But while everyone agrees that health insurance costs are skyrocketing, there is little agreement about the best ways to make health care more affordable for small employers. Rep. Nydia Velazquez and Rep. Rick Renzi see drastically different solutions to the healthcare crisis. Velazquez, a Democrat representing New York’s 12th District, is the ranking minority member on the House Small Business Committee; Renzi, a Republican representing Arizona’s 1st District, founded three small businesses before entering Congress.

What one change would most help small companies facing high health insurance costs?

There it was, in an article in black and white, on page 3129 of the June 19, 2002 issue of the Journal of the American Medical Association (JAMA), unequivocally stating: “We recommend that all adults take one multivitamin daily. This practice is justified mainly by the known and suspected benefits of supplemental folate and vitamins … in preventing cardiovascular disease, cancer, and osteoproosis….” The authors of the article even included a nifty little table with an overview on vitamins and their benefits for the attention-deprived reader.

Remember, we are talking about the American Medical Association (AMA) here–doctors from the hallowed halls of mediocrity when it comes to discussing anything to do with dietary supplements. This plainly rings of some sort of endorsement since JAMA is the AMA’s official organ. Could it be someone slipped them some sort of “Sensibility Viagra” which awakened the flaccid brain cells occupying those coveted editorial chairs?

One month later JAMA created another tempest when they revealed, lo and behold, hormone replacement therapy actually carries risks (see accompanying editorial). And this, only a week or two after AMA handwringing in front of the press decrying the cost of malpractice insurance and how it is driving numerous doctors out of business. Although certainly, amputating the wrong foot, as some doctors are wont to do, will always fall under the heading of malpractice. Of course, one or two inadvertent amputations won’t get your license yanked by the “good old boy” network of state medical boards packed with AMA cronies. Bad doctors have more lives than the proverbial cat. Perhaps if that 10 percent of doctors who continually make the major mistakes truly had their licenses revoked, the malpractice insurance rates would go down. But that would be even more of a double standard, since true malpractice exists simply by ignoring what has been in front of you for years; in other words, being so shortsighted you refuse to see the value of vitamin therapy or the danger of hormone replacement. The data is all there, it always has been, it’s just not in JAMA and the other “traditional” journals. Doctors need to actually look for the relevant treatments that will benefit their patients now, not ten years later when they read the watered-down versions. Read something that will be clinically useful…. Hmmm, I can recommend a nice little journal….

More than 20 years ago, Penchansky and Thomas (1981) published an article titled “The Concept of Access: Definition and Relationship to Consumer Satisfaction.” In the opening sentence to this article, they note: “‘access’ is a major concern in health care policy and is one of the most frequently used words in discussions of the health care system.” The same is certainly true today. In many policy discussions, access is equated with health insurance coverage. Although those who have defined access have all included other, nonfinancial, aspects of access in their definitions (Donabedian 1973; Penchansky and Thomas 1981; Millman 1993), we must still often remind ourselves of the importance of each aspect and the interplay between the different aspects.

As conceived by Penchansky and Thomas, access reflects the fit between characteristics and expectations of the providers and the clients. They grouped these characteristics into five As of access to care: affordability, availability, accessibility, accommodation, and acceptability. Affordability is determined by how the provider’s charges relate to the client’s ability and willingness to pay for services. Availability measures the extent to which the provider has the requisite resources, such as personnel and technology, to meet the needs of the client. Accessibility refers to geographic accessibility, which is determined by how easily the client can physically reach the provider’s location. Accommodation reflects the extent to which the provider’s operation is organized in ways that meet the constraints and preferences of the client. Of greatest concern are hours of operation, how telephone communications are handled, and the client’s ability to receive care without prior appointments. And finally, acceptabi lity captures the extent to which the client is comfortable with the more immutable characteristics of the provider, and vice versa. These characteristics include the age, sex, social class, and ethnicity of the provider (and of the client), as well as the diagnosis and type of coverage of the client.

A report released in September by The Commonwealth Fund finds that, as employers cope with rising healthcare costs by dropping health benefits or increasing employee cost- sharing through higher deductibles, workers and their families are being squeezed. When people lose coverage, many who turn to the individual insurance market find that coverage is unobtainable or unaffordable. The report also finds that those with high-deductible health plans are more likely than those with lower deductibles to have burdensome medical debt and to forgo needed health care; those with low incomes are especially at risk.

Of working-age adults who sought coverage in the individual market during the past three years, 89 percent ended up never buying a plan; 58 percent found it very difficult or impossible to find affordable coverage; and 21 percent were turned down, were charged a higher price because of a pre-existing condition, or had a health problem excluded from coverage.

“Most of the increase in the number of uninsured Americans–now upwards of 46.6 million–was due to a decline in workplace coverage,” said Commonwealth Fund assistant vice president Sara Collins, lead author of the report, Squeezed: Why Rising Exposure to Health Care Costs Threatens the Health and Financial Well-Being of American Families. “Although the individual market is a last resort for those shut out of employer-sponsored coverage, it is by no means a safe or secure haven for everyone.”

Here’s a scary statistic: Medical bills are responsible for half–yes, half–of all bankruptcies, according to a recent Harvard University study. Researchers found that in the event of a medical emergency, someone with insurance will still spend an average of $13,000 for out-of-pocket costs like co-payments, deductibles and uncovered services.

A financial intervention now could save you bundles later. Here, three ways to get started saving:

1 Question your statements. Nine out of 10 medical bills contain errors, according to the Medical Billing Advocates of America, a consumer-advocacy group based in Salem, Va., and one study found that more than 75 percent of post-service health insurance coverage appeals are won. Always ask for an itemized bill so you can be on the lookout for overcharges, duplicate bills for the same service or charges for services you never received.

To back up your claim, make sure you’ve saved everything–co-pay receipts, pre-certification letter and explanations of benefits, says Martha Priddy Patterson, a director of Human Capital Services at Deloitte Consulting in Washington, D.C. To protect your credit rating, remind the billing department in writing that you’re disputing this bill.

The aim of this paper is to examine possible determinants of the prevalence of private medical insurance (PMI) in England. The entire British public has access to free care in the National Health Service (NHS) financed by general taxation and national insurance paid by all employed United Kingdom (U.K.) residents. There is no option for U.K. residents to opt out of contributing to the NHS, and NHS coverage is comprehensive. Thus, PMI is supplementary, typically purchased to guarantee faster access to health care (particularly specialists) and in some cases, better amenities in health care facilities. In the United Kingdom, PMI covers treatment for curable, short-term illness or injury. PMI does not cover general practitioner (GP) services, chronic conditions, or conditions an individual had prior to taking out insurance. At the end of year 2000, 6.88 million people in the U.K. (approximately 11.5 percent of the population) were covered by PMI and the value of the PMI market was estimated at 2.45 billion [pounds sterling] (Laing and Buisson 2001), 5.1 percent of the estimated year 2000/2001 NHS expenditure of 48 billion [pounds sterling].

Since 1988, Laing and Buisson, an independent specialist consultancy in health and community care, have reviewed the U.K. PMI market. The number of subscribers covered through an employer-paid plan has increased by approximately 23 percent since 1990, while during the same period, the number of subscribers who were either paying individually or as employees (as partial payment of a company plan) declined by about 6 percent (Laing and Buisson 2001). At the end of 2000, 66.5 percent of PMI subscribers were in plans fully paid for by their employer (Laing and Buisson 2001).

Several recent studies have examined the consequences of uninsurance in a near-elderly population using data from the longitudinal Health and Retirement Survey (Heeringa and Conner 1995). Baker et al. (2001, 2002) found that those who were continuously or intermittently uninsured, or lost their insurance coverage over a 2-4 year period, experienced greater health declines than those who were continuously insured. McWilliams et al. (2004, 2003) found that lack of insurance was associated with significantly increased mortality, and that previously uninsured near-elderly adults who survived to age 65 increased their use of basic clinical services after they obtained Medicare coverage more than those who had been fully insured.

These research findings raise two important questions. Does lack of insurance prior to age 65 result in people qualifying for Medicare in worse health than if they had been insured? If so, is public insurance spending through Medicare and Medicaid on newly enrolled beneficiaries greater than it would be if people had continuous insurance coverage prior to age 65?

Our analysis extends these previous studies in several ways. As the prior studies were not specifically interested in the question of health status at entry to Medicare, they included changes in health for people as young as 57, as well as people who were older than 65 and had already aged into Medicare coverage. If attaining Medicare coverage improves health (Lichtenberg 2002), then the previous results may understate the impact of lack of insurance on health status at age 65. We also analyze data from the Health and Retirement Survey (HRS), but define our endpoint as health status at the last survey before turning 65.

1. FEDERALLY QUALIFIED HEALTH CENTERS

These not-for-profit clinics get money from the government to treat members of the community who have no health insurance and therefore use Medicaid. “These clinics often fill up, but they are obligated to treat patients,” says Rhonda Hagler, a New Jersey physician who runs a private practice. Locate a center near you by visiting cms.hhs.gov/center/fqhc.asp.

2. PARISH NURSING CENTERS

Many churches and synagogues have community outreach health centers at which nurses give free health-care services. Keep in mind that these programs are provided by the church and may come with a little proselytizing as well. Find the best option available to you by searching the Internet using the key words parish nursing or by calling your local churches and temples.