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This paper presents a cyclical theory of U.S. federalism and social policy: Many social policy initiatives are tested and refined at the state level, especially during conservative periods, and later morph into national policies. The paper describes such federalism cycles and offers an interpretation of why and how they occur, focusing on Medicaid. State activism has preserved and expanded Medicaid through policy innovation and resistance to retrenchment, especially in conservative periods, by taking advantage of the flexibility the program provides. I conclude that Medicaid's incremental/partnership approach is appropriate and feasible to build on for a future expansion of health care coverage. [ABSTRACT FROM AUTHOR]

This article presents abstracts of several research papers published online on the Website of the journal "Health Affairs." A paper titled "Public Health Response to Urgent Case Reports," by David Dausey, Nicole Lurie, and Alexis Diamond, evaluates the ability of local public health agencies to meet a preparedness standard set by the U.S. Centers for Disease Control and Prevention. Another paper titled "What High-Deductible Plans Look Like: Findings From a National Survey of Employers, 2005," documents the availability, enrollment, premiums, and cost sharing for high-deductible health plans that are offered with a health reimbursement arrangement or are health savings account-qualified plans.

The Agency for Health Care Policy and Research has had a turbulent history. Created with little opposition in 1989, it narrowly escaped being eliminated in 1995, only to be reauthorized (with a new mandate and name--the Agency for Healthcare Research and Quality, or AHRQ) with overwhelming support in 1999. In focusing on budgetary history, this paper sheds light on why health services research (HSR) has difficulty obtaining funding from a government that is willing to spend vast sums on basic biomedical research. The paper argues that three strategies--bureaucratic, marketing, and constituency building--that advocates adopted in the late 1980s made HSR more visible and consequential and were responsible for AHCPR's budgetary successes as well as its near-demise. [ABSTRACT FROM AUTHOR]

This paper presents selected components of the most recent (1999) Organization for Economic Cooperation and Development (OECD) Health Data. Previous trends in spending for health care, supply and use of health care resources, and health status are updated for the thirty industrialized countries in the OECD. In 1999 the United States spent 53 percent more on health care than any other OECD country spent. The paper reviews two possible reasons for the difference: economic development and population aging. It discusses spending, supply, and utilization for specific categories of health care services: pharmaceuticals, physicians, hospitals, and high-technology services. The paper concludes with a consideration of the strengths and weaknesses of using OECD data to compare health systems. [ABSTRACT FROM AUTHOR]

The papers by Paul Ginsburg and Jason Lee and colleagues make it clear how far we have come on the issue of cost shifting and how far we still have to go. We have created some new myths, persisted in some old confusion, and largely ignored an enduring reality. That enduring reality is that lack of competition in the health care sector permits cost shifting to occur. Instead of focusing on this causal condition, public discussion has been centered on the symptoms. A number of steps can be taken to deal with causes; this paper discusses several of these steps. [ABSTRACT FROM AUTHOR]

The Beacon Community Program is part of a federal strategy for using health information technology as a foundation to improve the nation's health care system. In particular, Beacon Communities seek to increase the quality and efficiency of health care, improve the health of individuals and communities, and inform similar initiatives in other parts of the country. Each Beacon Community has set quality, efficiency, and health-related goals, and each is deploying multiple technology- enabled interventions to achieve them. Yet achieving large-scale and sustainable health care improvement also requires an implementation framework that can foster innovation and continuous learning from results. Based on the early experiences of the seventeen diverse Beacon Communities, this paper describes program design features that characterize how these initiatives are organized. [ABSTRACT FROM AUTHOR]

Better data on the quality of health care being delivered in the United States are urgently needed if efforts to reform the nation's health care system are to succeed. This paper describes a "distributed data approach" to computing performance results while protecting patients' privacy. The strategy builds on the efforts of the Quality Alliance Steering Committee, a multi-stakeholder coalition focused on the implementation of performance measures. Instead of waiting for the government or the private sector to build large data warehouses, existing data from administrative sources, laboratories, clinical registries, and electronic health records could be put to greater use now, resulting in improved patient care and spurring further advances in performance measurement. In this article we introduce an overall framework for achieving these goals, and we describe a set of steps to accelerate and expand the availability of performance measures to improve care now. [ABSTRACT FROM AUTHOR]

Under the Affordable Care Act, the new Center for Medicare and Medicaid Innovation will guide a number of experimental programs in health care payment and delivery. Among the most ambitious of the reform models is the accountable care organization (ACO), which will offer providers economic rewards if they can reduce Medicare's cost growth in their communities. However, the dismal history of provider-led attempts to manage costs suggests that this program is unlikely to accomplish its objectives. What's more, if ACOs foster more market concentration among providers, they have the potential to shift costs onto private insurers. This paper proposes a more flexible payment model for providers and private insurers that would divide health care services into three categories: long-term, low-intensity primary care; unscheduled care, including unscheduled emergency services; and major clinical interventions that usually involve hospitalization or organized outpatient care. Each category of care would be paid for differently, with each containing different elements of financial risk for the providers. Health plans would then be encouraged to provide logistical and analytic support to providers in managing health costs in these categories. [ABSTRACT FROM AUTHOR]

The Beacon Community Program, authorized under the 2009 American Recovery and Reinvestment Act (ARRA), aims to demonstrate the potential for health information technology to enable local improvements in health care quality, cost efficiency, and population health. If successful, these communitywide efforts will yield important lessons that will assist other communities seeking to harness technology to achieve and sustain health care improvements. This paper highlights key programmatic details that reflect the meaningful use of technology in the fifteen Beacon communities. It describes the innovations they propose and provides insight into current and future challenges. [ABSTRACT FROM AUTHOR]

There is broad debate over whether preventive health services save money or represent a good investment. This paper analyzes the estimated cost of adopting a package of twenty proven preventive services--including tobacco cessation screening, alcohol abuse screening, and daily aspirin use--against the estimated savings that could be generated. We find that greater use of proven clinical preventive services in the United States could avert the loss of more than two million life-years annually. What's more, increasing the use of these services from current levels to 90 percent in 2006 would result in total savings of $3.7 billion, or 0.2 percent of U.S. personal health care spending. These findings suggest that policy makers should pursue options that move the nation toward greater use of proven preventive services. [ABSTRACT FROM AUTHOR]

Canada is, in many respects, culturally and economically similar to the United States, and until relatively recently, the two countries had similar health systems. However, since passage of the Canada Health Act in the 1970s, that nation's health statistics have become increasingly superior. Although the costs of Canada's health system are high by international standards, they are much lower than U.S. costs. This paper describes several factors likely to be responsible for Canada's better health at lower cost: universal financial coverage through a so-called single payer; features conducive to a strong primary care infrastructure; and provincial autonomy under general principles set by national law. [ABSTRACT FROM AUTHOR]

The concept of accountable care organizations (ACOs) has been set forth in recently enacted national health reform legislation as a strategy to address current shortcomings in the U.S. health care system. This paper focuses on implementation issues related to these organizations, building on some initial examples. We seek to clarify definitions and key principles, provide an update on implementation in the context of other reforms, and address emerging issues that will affect the organizations' success. Finally, building on the initial experience of several organizations that are implementing accountable care and complementary reforms, we propose a national strategy to identify and expand successful approaches to accountable care implementation. [ABSTRACT FROM AUTHOR]

Primary care is viewed both as the solution to better health care in the United States and as a threatened institution, beset by poor payment and difficult working conditions. Rhode Island has taken a direct approach to making primary care more effective for patients and more attractive for physicians. In 2009 the state's Office of the Health Insurance Commissioner developed "system affordability priorities" for Rhode Island's commercial insurers, including a directive to almost double the portion of their medical expenses devoted to primary care. Initial plans of those insurers to meet those expectations are now being implemented; this paper describes those plans. [ABSTRACT FROM AUTHOR]

Population trends are driving an undeniable imperative: The United States must begin training its primary care physicians to provide higher-quality, more cost-effective care to older people with chronic conditions. Doing so will require aggressive initiatives to educate primary care physicians to apply principles of geriatrics-for example, optimizing functional autonomy and quality of life-within emerging models of chronic care. Policy options to drive such reforms include the following: providing financial support for medical schools and residency programs that adopt appropriate educational innovations; tailoring Medicare's educational subsidy to reform graduate medical education; and invoking state requirements that physicians obtain geriatric continuing education credits to maintain their licensure or to practice as Medicaid providers or medical directors of nursing homes. This paper also argues that the expertise of geriatricians could be broadened to include educational and leadership skills. These geriatrician-leaders could then become teachers in the educational programs of many disciplines. This would require changes inside and outside academic medicine. [ABSTRACT FROM AUTHOR]

The term primary care is widely used as if it were consistently defined or well understood. In fact, neither is the case. This paper offers a definition of primary care derived from historical perspectives-from both the United States and abroad. We discuss the evidence for primary care's important functions and international experiences with primary care. We also describe how and why the United States has deviated from this fuller realization of primary care, as well as the steps needed to achieve primary care and health outcomes on a par with those of other developed countries. These include doubling primary care financing to 10-12 percent of total health care spending-a step that would be likely to pay for itself via resulting reductions in overall health spending. [ABSTRACT FROM AUTHOR]

This paper examines various reasons for the growth in Medicaid spending in the current decade. Although Medicaid spending has grown faster than the rate of increase in national health spending, much of this is explained by increased enrollment. Per enrollee, Medicaid spending actually compares favorably to increases in medical care prices and gross domestic product. The relative success in Medicaid cost containment seems to be attributable to limits on provider payment rates, expansion of managed care, limits on the use and pricing of prescription drugs, and expansion of community-based long-term care programs. We suggest two strategies for further cost containment. [ABSTRACT FROM AUTHOR]

Compelling evidence suggests that the United States lags behind other developed nations in the health of its population and the performance of its health care system, partly as a result of a decades-long decline in primary care. This paper outlines the political, economic, policy, and institutional factors behind this decline. A large-scale, multifaceted effort—a new Charter for Primary Care—is required to overcome these forces. There are grounds for optimism for the success of this effort, which is essential to achieving health outcomes and health system performance comparable to those of other industrialized nations. [ABSTRACT FROM AUTHOR]

Many policymakers believe that comparative effectiveness research will reduce "waste" in the U.S. health care system by providing guidance on what health care options work best for different patients. How such research will produce findings that identify waste has not been clearly elucidated. This paper presents a conceptual framework for different evidentiary categories of what we call "marginal medicine." This framework could help clinicians, researchers, and policymakers align the results of comparative effectiveness research with efforts to identify opportunities to improve the value of health care services. [ABSTRACT FROM AUTHOR]

Numerous studies in the United States have examined the association between quality and spending at the regional level. In this paper we evaluate this relationship at the level of individual hospitals, which are a more natural unit of analysis for reporting on and improving accountability. For all of the quality indicators studied, the association with spending is either nil or negative. The absence of positive correlations suggests that some institutions achieve exemplary performance on quality measures in settings that feature lower intensity of care. This finding highlights the need for reporting information on both quality and spending. [ABSTRACT FROM AUTHOR]

Compelling evidence suggests that the United States lags behind other developed nations in the health of its population and the performance of its health care system, partly as a result of a decades-long decline in primary care. This paper outlines the political, economic, policy, and institutional factors behind this decline. A large-scale, multifaceted effort-a new Charter for Primary Care-is required to overcome these forces. There are grounds for optimism for the success of this effort, which is essential to achieving health outcomes and health system performance comparable to those of other industrialized nations. [ABSTRACT FROM AUTHOR]

In the United States, the complex process of getting health care technologies into practice takes place in a competitive health system that is driven by technological innovation. Federal, state, and local governments' roles in the diffusion process are limited. In low-income countries, where competitive markets are not as prominent, diffusing medical innovations requires an alternative understanding of how new technologies are adopted. This paper describes how, in low-income countries, the lack of functioning markets serves as a barrier to the transfer of necessary health technologies, and why governments must act as stewards in promoting technologies there. [ABSTRACT FROM AUTHOR]

State hospitals were once the most prominent components of U.S. public mental health systems. But a major focus of mental health policy over the past fifty years has been to close these facilities. These efforts led to a 95 percent reduction in the country's state hospital population. However, more than 200 state hospitals remain open, serving a declining but challenging patient population. Using national and state-level data, this paper discusses the contemporary public mental hospital, the forces shaping its use, the challenges it faces, and its possible future role in the larger mental health system. [ABSTRACT FROM AUTHOR]

This paper analyzes the evolution of consumer-driven health care in terms of its original vision, its subsequent implementation, and the transformations it has endured as it moves into its second decade. The market is generating product designs that combine elements of consumerism with elements of managed care, but the trend is always toward a stronger role for consumer choice and a weaker role for management of those choices by physicians, insurers, employers, and regulators. [ABSTRACT FROM AUTHOR]

As the largest payer for health services in the United States, Medicare has the potential to use its payment policies to stimulate change in the organization of care to improve quality and mitigate cost growth. This paper proposes a framework in which Medicare would offer an array of new bundled payment options for physician group practices, hospitals, and delivery systems, with incentives to encourage greater integration in the organization of health care delivery and the provision of more coordinated care to beneficiaries. These changes could also serve as a model for other payers to improve quality and efficiency throughout the health system. [ABSTRACT FROM AUTHOR]

This paper analyzes the evolution of consumer-driven health care in terms of its original vision, its subsequent implementation, and the transformations it has endured as it moves into its second decade. The market is generating product designs that combine elements of consumerism with elements of managed care, but the trend is always toward a stronger role for consumer choice and a weaker role for management of those choices by physicians, insurers, employers, and regulators. [ABSTRACT FROM AUTHOR]

As the largest payer for health services in the United States, Medicare has the potential to use its payment policies to stimulate change in the organization of care to improve quality and mitigate cost growth. This paper proposes a framework in which Medicare would offer an array of new bundled payment options for physician group practices, hospitals, and delivery systems, with incentives to encourage greater integration in the organization of health care delivery and the provision of more coordinated care to beneficiaries. These changes could also serve as a model for other payers to improve quality and efficiency throughout the health system. [ABSTRACT FROM AUTHOR]

Health care reform has reemerged as a policy imperative. Congressional discussions regarding sizable federal investments in health information technology (IT) infrastructure have revitalized the vision of health IT as a critical component of accelerating improvements in the quality and value of health care for all Americans. Policymakers will be challenged to link investments in the health information infrastructure to the objectives of health care reform. The purpose of this paper is to articulate some near- and long-term steps that increase the likelihood of achieving high-value health care with the aid of health IT. [ABSTRACT FROM AUTHOR]

Health information technology (IT) has great potential to transform health care and inform population health goals in clinical research, quality measurement, and public safety. To fully realize the benefits of health IT for population health, we must focus on new models that maximize efficiency, encourage rapid learning, and protect patients' privacy. In this paper we explore the advantages of a networked model for analyzing population health information, providing several examples. Although broadening the use of networked models is challenging, the societal benefits of a networked model merit continued exploration and the development of workable solutions. [ABSTRACT FROM AUTHOR]

Innovation in health care requires new ideas and the capital to develop and commercialize those ideas into products or services. The necessary capital is often "venture capital," but the link between public policy and the venture capital industry has not been well examined. In this paper we explore the link between venture capital and innovation in health care, and we present new descriptive data from a survey of health care venture capital fund managers. Respondents generally viewed policy levers (for example, reimbursement and regulations) as important risks to venture capital investments, potentially affecting their ability to raise capital for early-stage investment funds. [ABSTRACT FROM AUTHOR]

Developed more than a decade ago, the Chronic Care Model (CCM) is a widely adopted approach to improving ambulatory care that has guided clinical quality initiatives in the United States and around the world. We examine the evidence of the CCM's effectiveness by reviewing articles published since 2000 that used one of five key CCM papers as a reference. Accumulated evidence appears to support the CCM as an integrated framework to guide practice redesign. Although work remains to be done in areas such as cost-effectiveness, these studies suggest that redesigning care using the CCM leads to improved patient care and better health outcomes. [ABSTRACT FROM AUTHOR]

The threat of mass-casualty disasters raises concern about the adequacy of hospitals' surge capacity. This paper measures surge capacity as the number of empty staffed beds per capita at the county level and compares it to a disaster-planning benchmark released by the federal government. The percentage of the U.S. population living in counties falling below the benchmark increased from 19 percent in 2000 to 30 percent in 2005. Limitations in surge capacity are associated with rapid population growth but not with higher rates of hospital use. Limitations appear to be most severe along the East Coast and in the West. [ABSTRACT FROM AUTHOR]

Anecdotal evidence suggests that innovative medical devices often arise from physicians' inventive activity, but no studies have documented the extent of such physician-engaged innovation. This paper uses patent data and the American Medical Association Physician Masterfile to provide evidence that physicians contribute to medical device innovation, accounting for almost 20 percent of approximately 26,000 medical device patents filed in the United States during 1990-1996. Moreover, two measures indicate that physician patents had more influence on subsequent inventive activity than nonphysician patents. This finding supports the maintenance of an open environment for physician-industry collaboration in the medical device discovery process. [ABSTRACT FROM AUTHOR]

From 2004 to 2007 the California HealthCare Foundation's Step by Step: Local Coverage Expansion initiative supported insurance coverage expansions for uninsured children and adults in thirty California counties. In this paper we describe the initiative and its achievements as well as challenges for grantees. Also, we discuss the implications of the initiative's outcomes for expanding coverage locally and more broadly. Implementing new insurance programs is possible in the most difficult settings. Although there are real challenges to sustaining these expansions and limits to what they can accomplish in the face of major unmet needs, they may lay useful groundwork for broader expansions later. [ABSTRACT FROM AUTHOR]

In this paper we explore whether increasing individuals' activation (self-management) levels could hold potential for reducing racial and ethnic disparities in health. A causal model is posited that assumes that social-environmental factors influence activation levels, which in turn influence health outcomes. Relationships are examined separately for whites and African Americans, and findings are supportive of the model for both groups. Simulations of what would happen to outcomes if there were racial parity in activation predict a narrowing of the racial gap in health and behavior. The findings suggest that a focus on increasing activation holds potential for addressing racial and ethnic disparities in health. [ABSTRACT FROM AUTHOR]

This paper assesses the evolving "facilitated consumerism" model of health care at the community level using data from the Community Tracking Study (CTS). We find that in a relatively short time, large employers and health plans have made notable progress in putting the building blocks in place to support their vision of consumerism. However, developments in the CTS communities suggest that the consumerism strategy evolving in local markets is more nuanced than implied by some descriptions of health care consumerism. [ABSTRACT FROM AUTHOR]

To achieve the diverse health care goals of the United States, health care value must increase. The capacity to create value through innovation is facilitated by an integrated delivery system focused on creating value, measuring innovation returns, and receiving market rewards. This paper describes the Geisinger Health System's innovation strategy for care model redesign. Geisinger's clinical leadership, dedicated innovation team, electronic health information systems, and financial incentive alignment each contribute to its innovation record. Although Geisinger's characteristics raise serious questions about broad applicability to nonintegrated health care organizations, its experience can provide useful insights for health system reform. [ABSTRACT FROM AUTHOR]

This paper examines variations in health spending by children, working-age adults, and seniors for selected years between 1987 and 2004. Seniors spent far more per person than children or working-age adults, but the relative gap between the age groups has not changed much since 1987 except for those age eighty-five and older. Since the inception of the State Children's Health Insurance Program (SCHIP) in 1997, the proportion of children's health spending financed by public sources has increased, while the share paid for out of pocket has decreased. The future age-mix is expected to have a major impact on nursing home spending growth while minimally affecting overall Medicare spending growth. [ABSTRACT FROM AUTHOR]

In 2003 the Indiana Office of Medicaid Policy and Planning implemented the Indiana Chronic Disease Management Program (ICDMP). This paper reports on the fiscal impact of the ICDMP from the state's perspective, as estimated from the outcomes of a randomized trial. Medicaid members with congestive heart failure (CHF) or diabetes, or both, were randomly assigned by practice site to chronic disease management services or standard care. The effect of the ICDMP varied by disease group and risk class: while cost savings were achieved in the CHF subgroup, disease management targeted to patients with only diabetes resulted in no significant fiscal impact. [ABSTRACT FROM AUTHOR]

For the first time since the early 1990s, the political environment in the United States offers the real possibility of fundamental reform of our fraying health care system. Although the current moment appears promising for reform, the opportunity could easily dissipate as it has in the past. In this paper, we offer seven observations on the key opportunities and pitfalls for health care reform advocates in this pivotal election year, based on our analysis of the current political dynamic and recent public opinion research. [ABSTRACT FROM AUTHOR]

In this paper we compare health insurance coverage for U.S. citizen children in all-citizen and mixed families in the fifteen states with the largest share of children in mixed families. Insurance coverage is lower and state variation in coverage is higher for children in mixed families vis-à-vis children in all-citizen families. The main challenges for states are tackling uninsurance among all low-income children and addressing the very low rates of employer-sponsored insurance for all low-income children and for children in all mixed families, regardless of income. We discuss state policy options to address the needs of children in mixed families. [ABSTRACT FROM AUTHOR]

Access to care for racial and ethnic minority groups, low-income populations, and the un- and underinsured has been problematic despite expansion in the health workforce. Workforce policies that improve access to care are needed, as is funding to support them. Reviewing evidence related to providers' patterns of service to the underserved, this paper concludes that underrepresented minority health professionals have consistently been more likely than those from Low socioeconomic backgrounds or the National Health Service Corps to deliver health care to the underserved. These findings have implications for policies and programs that might leverage the workforce to better meet the needs of disadvantaged patients. [ABSTRACT FROM AUTHOR]

Dental care is the largest unmet health need among low-income children, yet it garners relatively little attention from policymakers and grantmakers. Foundation giving for dental education and dental care totaled $55.6 million in 2005-a mere 1.6 percent of total health grant making and 0.34 percent of total foundation giving. Health foundations have played a critical role in advancing the U.S. health care system. The need for investments from grantmakers to spur innovation and change in the dental care system is great. This paper describes a range of ideas for strategic grant making to improve oral health in the United States. [ABSTRACT FROM AUTHOR]

The care of Americans with severe chronic illnesses is disorganized, unnecessarily costly, and undisciplined by sound clinical science. The federal government should in- vest in a crash program to improve the scientific basis of managing chronic illness, and the Centers for Medicare and Medicaid Services (CMS) should extend its pay-for-performance (P4P) agenda to ensure that within ten years all Americans with severe chronic illnesses have access to accountable health care organizations providing evidence-based prospective care. This paper recommends a strategy for achieving this goal. [ABSTRACT FROM AUTHOR]

The decision to undergo many discretionary medical treatments should be based on informed patient choice. Shared decision making is an effective strategy for achieving this goal. The Centers for Medicare and Medicaid Services (CMS) should extend its pay-for-performance (P4P) agenda to assure that all Americans have access to a certified shared decision-making process. This paper outlines a strategy to achieve informed patient choice as the standard of practice for preference-sensitive care. [ABSTRACT FROM AUTHOR]

When everyone is required to pay the same out-of-pocket amount for health care services whose benefits depend on patient characteristics, there is enormous potential for both under- and overuse. Unlike most current health plan designs, Value-Based Insurance Design (VBID) explicitly acknowledges and responds to patient heterogeneity. It encourages the use of services when the clinical benefits exceed the cost and likewise discourages the use of services when the benefits do not justify the cost. This paper makes the case for VBID and outlines current VBID initiatives in the private sector as well as barriers to further adoption. [Health Affairs 26, no. 2 (2007): w195-w203 (published online 30 January 2007; 10.1377/hlthaff.26.2.w195)] [ABSTRACT FROM AUTHOR]

In this paper we argue that there is a real need for Medicaid reform primarily because of the large differences among states in coverage and benefits and because of the program's high and rising costs. We describe and develop several options for Medicaid reform that would expand coverage, provide fiscal relief to states, shift responsibility for some or all of the care of dual eligibles to the federal government, and eliminate or restructure disproportionate-share hospital (DSH) payments. We conclude with a discussion on a number of other issues, particularly Medicaid cost containment and the federal matching payment structure. [Health Affairs 26, no. 2 (2007): w254-w270 (published online 23 February 2007; 10.1377/hlthaff.26.2.w254)] [ABSTRACT FROM AUTHOR]

Using multiple databases, this paper examines recent trends in the affordability and comprehensiveness of small-group and individual health insurance markets in California. Both became less affordable over the study period. In 2006, a single person age 32-52 earning the median income who purchased individual insurance spent on average 16 percent of income on premiums and out-of-pocket medical expenses. For individual insurance, the share of medical expenses paid by insurance as opposed to patients declined from 2002 to 2006. In the small-group market, premiums rose more than 50 percent from 2003 to 2006, but the proportion of claims paid by insurers for a standardized population remained constant. [ABSTRACT FROM AUTHOR]

This paper discusses the meaning of the term risk from the economic perspective. It argues that some consumer decisions about insurance and the use of medical care are consistent with the economic model, but many are not. When decisions are inconsistent, real-world democratic governments' ability to intervene is limited by politicians' desire to please voters. The choice of incomplete insurance coverage in private markets is often said to present a case for governmental intervention, but the choice of insurance design in the Medicare drug benefit shows that the political process also may fail to select insurance that is optimal from an economic viewpoint. [ABSTRACT FROM AUTHOR]

The Census Bureau produces annual state-level estimates of health insurance coverage using the Current Population Survey (CPS) Annual Social and Economic Supplement. Many states also conduct their own population surveys of health insurance status; in most cases, the state survey estimates of uninsurance are lower than the estimates produced by the CPS. This discrepancy fuels debate about the true count of uninsured Americans and changes in that number overtime. This paper compares state survey and CPS estimates of uninsurance, highlights key reasons for these differences, and discusses the policy implications of this persistent discrepancy. [ABSTRACT FROM AUTHOR]

Americans have been urged for several decades to view Social Security and Medicare as political relics—both unaffordable and unfair in light of contemporary demographic and fiscal circumstances and the practices of modern financial markets and modern medicine. Proposals abound for ‘modernizing’ both systems to emphasize choice, competition, and individual ownership. This paper contends that critics of Social Security and Medicare have misanalyzed the problems of both programs and are urging misdirected reforms. The critics, we argue, are often wrong factually and sometimes confused conceptually. More fundamentally, these critiques and proposals are either ignorant of or hostile to the fundamental logic of social insurance. [ABSTRACT FROM AUTHOR]