Comment on the Lewin Report on the Impact of SB 921
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Comment on the Lewin Report on the Impact of SB 921

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Economic and Policy Analysis of California’s Proposed 1Single-Payer Health Care System (SB 840) Project Director and Contact: John E. Schneider, PhD 2Health Economics Consulting Group LLCjschneider@hecg-llc.com February 2006 © 2006 by Health Economics Consulting Group LLC 1 This report was funded in part by the California Association of Health Underwriters. The authors would like to acknowledge the valuable assistance of Jeff Miles, Alexis Barbour, Janet Benton, Christopher Decker, Robert Ohsfeldt, Robin Flagg, Jeff Lemieux, and Jim Capretta. The views expressed in this document are those of the authors and do not necessarily reflect the views of the funding organizations. 2 LLC The Health Economics Consulting Group is group of academic health economists and health services researchers providing research consulting services in a number of subject areas in health economics, including cost impact and cost-effectiveness analyses, patterns of care and estimates of treatment effects using claims data, and economic impact of health sector regulation, including antitrust, managed care regulation, licensure and capacity regulation, and administered pricing. For more information, visit www.hecg-llc.com. HECG / Schneider et al. Page 2 of 38 EXECUTIVE SUMMARY The primary objective of this report is to ...

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Economic and Policy Analysis of Californias Proposed Single-Payer Health Care System (SB 840)1 Project Director and Contact: John E. Schneider, PhD Health Economics Consulting Group LLC2 jschneider@hecg-llc.com  February 2006  © 2006 by Health Economics Consulting Group LLC
1This report was funded in part by the California Association of Health Underwriters. The authors would like to acknowledge the valuable assistance of Jeff Miles, Alexis Barbour, Janet Benton, Christopher Decker, Robert Ohsfeldt, Robin Flagg, Jeff Lemieux, and Jim Capretta. The views expressed in this document are those of the authors and do not necessarily reflect the views of the funding organizations. 2The Health Economics Consulting Group LLC is group of academic health economists and health services researchers providing research consulting services in a number of subject areas in health economics, including cost impact and cost-effectiveness analyses, patterns of care and estimates of treatment effects using claims data, and economic impact of health sector regulation, including antitrust, managed care regulation, licensure and capacity regulation, and administered pricing. For more information, visitwww.hecg-llc.com.
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EXECUTIVE SUMMARYThe primary objective of this report is to review the theory and evidence on centralized health care systems and apply those findings to the specific case of the California Health Insurance Reliability Act (SB 840) and the proposed California Health Insurance System (CHIS). We examine the performance attributes of centralized health plans in general and CHIS in particular, focusing on eight criteria: 1) access; 2) quality; 3) administrative costs; 4) technology and adaptation; 5) regulatory instruments; 6) tax-based financing; 7) costs; and 8) implementation.  1. Access.objective of the proposalto extend health careThe foremost nominal coverage to allis laudable. More than one in five (6.5 million) non-elderly Californians lack health insurance. There is consistent evidence that those without health insurance tend to use fewer and different types of health care services than those with insurance, resulting in either no care (especially for preventive care) or lower-quality care. According to Schoen et al., the underinsured experience health access problems remarkably similar to those of the uninsured, including failure to fill prescriptions, forgoing tests and treatment, and forgoing visits to regular doctors and specialists (Schoen, Doty et al. 2005). Single-payer systems in other countries appear to have achieved the basic objective of extending some level of coverage to the vast majority of residents. However, centrally-planned systems, by design, require rationing, typically in the form of waiting lists. Waiting lists, together with increasing tax burdens, are often cited as the principal drivers of discontent with centrally-planned systems, and are also susceptible to fraud and abuse. 
2. Quality.There is insufficient evidence to suggest that centrally-planned systems result in better quality of care than private systems. Both types of systems appear to be good at some things and worse at others.  According to a recent study of 21 quality indicators from Australia, Canada, New Zealand, England, and the United States (Hussey et al. 2004), the U.S. ranked either best or second-best in more than half of the indicators. The U.S. was first or second in more than half of the indicators, leading the authors to conclude that no country scores consistently the best or worst overall, and each country has at least one area where it could learn from international experience. Each country also has an area where it could teach others. (pp. 91-92). In addition, single-payer plans imply some degree of regression to the mean in the scope of benefits and, perhaps, the quality of care. According to Newhouse and Reischauer (2004), If the single-payer plan has benefits that are around the current average, roughly half of people with above-average coverage now will have less coverage under reform, something that they are unlikely to take kindlyand if the single plan is much better than the current average, costs explode (p.181). 
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3. Administrative Costs.is that a single payer system will resultA common argument in cost savings by reducing redundant and unnecessary administrative costs. This argument has two limitations. First, defining administrative costs as waste requires the assumption that administration (as well as management) is essentially a superfluous function that produces nothing of value in terms of helping an organization achieve its objectives. However, the managerial function is essential to the operation of any organization, and can serve to assure access to needed services while reducing utilization of less valuable services. For example, Kahn et al. (2005) found that the administrative costs of commercial health insurance plans in California were 9.9% of premiums, more than one-third (3.7 percentage points) of which were attributed to customer service, information systems, and major clinical activities (e.g., case management). Administrative functions are the primary defense against health care fraud and abuse, the vast majority of which consists of fraudulent billing. The Federal Bureau of Investigation estimates that the total costs of health care fraud in the U.S. each year ranges from $70 billion to $200 billion, representing between 3% and 10% of total health care expenditures. Second, data on administrative costs are very limited in interpretability. Accountants have a fair amount of discretion over the allocation of costs to different functions within an organization, and allocations differ substantially by organizational structure. This is especially pertinent in the accounting of capital costs. It is likely that a non-trivial proportion of capital costs in countries with government-run health plans is not counted as administrative costs to the program; similar arguments have been made regarding the U.S. Medicare program. Thus, the assumption that CHIS will be able to achieve 1.8% administrative costs is weak. The estimated savings from the statewide reduction in administrative costs is inaccurate because the Lewin report overstates private health insurance administrative expenses, estimating them to be $9.7 billion in 2006 whereas other estimates typically fall between $5-6 billion and have been shown to be declining over the past several years. 4. Technology and Adaptation.For a given organizational problem or issue (e.g., extending health care to all), the pivotal question should be what does public administration have to offer? Government bureaucracies such as the U.S. Postal Service are relatively good at performing certain tasks, but they have clearly been followers in the delivery industry, as innovative and adaptive firms like Federal Express and United Parcel Service captured large market shares by out-innovating their government counterpart. All else equal, gains from bureaucratic coordination, which the U.S. Postal Service does well, are often offset by incentive attenuation. Incentive attenuation includes reduced incentives to attract new customers, reduced incentives to invest in up-to-date capital and equipment, reduced incentives to innovate (processes and products), and reduced productivity (i.e., from reduced ability of decision-makers and risk takers to share in entrepreneurial returns). The health care system is dynamic and evolving. The evidence suggests that the vast
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majority of new health and medical care innovations have positive economic value, the total value of which exceeds the costs. For example, the most expensive and in many cases valuable prescription drugs in the U.S. are newer drugs that are under patent. The CHIS is at risk for failing to adapt quickly enough to innovation and changes in consumer demand. Health care is a moving target; consumer preferences and the menu of treatment options evolve and change frequently. How will a state-run program handle changes in consumer demand, changes in medical technology, and changes in input prices, such as wages? How will a state program handle geographic variations in charges? Will more concentrated provider groups command higher reimbursement rates? Will rural physicians be paid less than urban physicians? 
5. Regulatory Instruments.The CHIS relies extensively on the use of public-utility regulatory (PUR) mechanisms. The standard set of PUR mechanisms, also referred to as economic regulation, are typically aimed at controlling the prices, profits, output, and capacity of private firms. Throughout the text of the legislation, references are made to the role of CHIS as the regulator of price and capacity. However, the cumulative knowledge on economic regulation suggests, consistently across studies and industries, that the imposition of economic regulation on an industry results in higher costs and prices than would have been observed in the absence of regulation. In the wake of regulatory reform, many of these industries experienced 10-30% decreases in real prices and net operating costs. In addition to efficiency gains, many of the industries subjected to economic regulation achieved improvements in quality, safety, and access following deregulation. Economic regulation has been shown to have similar effects in the U.S. hospital industry. Hospitals in markets with comparatively less rate regulation or more competition have lower operating costs than their regulated or less competitive counterparts. Capacity regulation, which appears to be a critical component of CHIRA, has also been shown to have deleterious affects on efficiency. Studies of the impact of Certificate-of-Need (CON) programs have consistently found the programs to be ineffective at controlling costs and enhancing access, and in some cases have been shown to increase costs. Protecting incumbent hospitals from competitive entry may help achieve planning goals, but the same insulation from competition is likely to allow incumbent firms to maintain higher prices and higher costs. 
6. Tax-Based Financing.The financing of single-payer plans typically relies on tax revenue, either from general collections or targeted taxes, as have been proposed under CHIRA. In a private system, increases in demand for medical services (including new technologies and procedures) will be countered with a supply-side response to adapt to those changes in demand. If consumers want it, they are generally willing to pay for it. A public system must also find a way to adapt to changes in consumer demand, but the financing necessary for adaptation flows from a single state government source. There is no guarantee that bureaucrats and
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politicians will be able to finance the system at levels aligned with consumer demand, nor is there and guarantee that, in the aggregate, consumers would be willing to vote in favor of tax increases sufficient to fund adaptation and growth. A related issue, which has been voiced by residents of single-payer countries, is the extent to which medical decision-making becomes politicized. Some of the idiosyncrasies of public administration invariably will enter into health care allocation decisions; who gets what will be a matter of someone or some committee to decide. Elected leaders can win voter approval by using the health care system to further political agendas. A final comment on CHIS financing has to do with the public financing climate in California. It would be difficult to argue that K-12 primary education is of less value than health care. Nevertheless, California has systematically under-funded K-12 education, choosing instead to maintain unusually strict limits on growth in property taxes. Since the passage in 1978 of Proposition 13, which limited property tax increases to a maximum of 2% per year, Californias public school system has degraded and currently ranks among one of the worst in the nation in terms of funding and performance. Although there is no direct evidence to suggest that CHIS financing will be similarly constrained, it is reasonable to ask the question whether CHIS financing will somehow be immune to the forces that passed and continue to uphold current public education funding levels in California. 
7. Costs.The proposed single-payer plan is not immune to the cost inflation problems common to the existing health care system. There are a number of reasons why the existing cost estimates for CHIS are overly optimistic, including: 1) the systems administrative costs are likely to be higher than expected; 2) the system will have to deal with provider market power, moral hazard and new technology, all of which apply significant upward pressure on cost; and 3) the systems mechanisms to limit adverse selection are insufficient. are likely to be some reductions in overallThere administrative costs, but those reductions will be small if the single-payer plan continues to provide a reasonable level of value-added organizational and patient-care management, including such activities as disease management, patient education, provider management, quality control, and fraud and abuse monitoring. In addition, bulk purchasing is often touted as a cost saver, but the savings from bulk purchasing are most likely exaggerated. Estimates assume that it is possible to pressure manufacturers of patented products to offer deep discounts. In order for bulk purchasing to work, the state has to be willing to walk away from the table when a large pharmaceutical manufacturer refuses to lower the price of a patented drug. Is the state prepared to withdraw popular drugs from the formulary or cease coverage for other popular products, such as cardiovascular stents?  These factors, and others, have resulted in cost pressure in virtually all of the single-payer systems internationally, particularly Canada and the U.K., causing the systems to undergo significant reform against a backdrop of considerable consumer and provider discontent. Another potential health expenditure issue is adverse selection. The
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proposed plan is only partially protected from adverse selection, mainly because it does not explicitly call for a mandatory waiting period for new-resident eligibility. The Lewin simulation models assume a three-month residency requirement as a condition of eligibility, but then further assume (correctly) that the plan would have to make an exception for those relocating to California for the purposes of employment. Low-wage out-of-state workers relocating to California would receive a subsidy equivalent to roughly 25% of the individuals annual incomea potentially powerful incentive to relocate. 
8. Implementation.Virtually absent from the Lewin report or any other analyses of SB 840 are estimates of the economic impact of the elimination (or drastic reduction in size) of the private health insurance industry in California; according to the Act, no health care service plan contract or health insurance policy, except for the [CHIS] plan, may be sold in California for services provided by the system. Thus, the only legal form of health insurance sold in California, if CHIRA were to be enacted, would be limited to policies that only cover the relatively small array of services not covered by CHIS. Given that CHIRA is nominally designed to cover an exceptionally generous array of services, there would be little business left for private health insurance companies and many would be forced to close, discontinue service to the California market (in the case of national firms), or drastically reduce their size in order to cater to the small CHIS supplemental market. Each of these exit options would result in a substantial economic impact on the California economy. According to our simulation analyses, replacing the private system with a government system will result in a net loss of $33 billion over the 5-year post-CHIRA enactment period. This loss comes close to offsetting the $40 billion net gains estimated by the Lewin report for the same time period. 
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1. INTRODUCTION  Reform of the U.S. health care system has been a perennial topic ever since disparities in access and rapidly rising costs attracted attention in the mid 1960s. Since then, there have been a number of reform proposals put forth at the state and federal levels, ranging from employer mandates, direct subsidies, Medicare and Medicaid expansions, high-deductible health plans (HDHPs) and Health Savings Accounts (HSAs), managed competition, quality incentives, personal mandates, insurance pools, and government-administered single-payer systems (Bodenheimer 2003; Fuchs and Emanuel 2005; Curtis and Neuschler 2005). To date, however, the most politically and economically feasible reform policies have been incremental reforms, such as employer mandates, managed competition, and quality incentives.  Comprehensive systems, such as government-administered single-payer plans, have been largely kept off the table of feasible reform alternatives. However, in California long the breeding ground for innovations in health care management and organization a proposal to create a large-scale, comprehensive single-payer government health system, much like those created in Canada and Great Britain, has surfaced in the form of Senate Bill 840 (SB 840). The California proposal promises to extend health care coverage to all California residents, administered and funded centrally through state government. The foremost nominal objective of the proposalto extend health care coverage to all3 nearly 46 million non-elderly individuals (18% of allis laudable. Nationally, non-elderly residents) lack even the most basic coverage for health care (Hoffman et al. 2005). In California, the problem of the uninsured appears to be somewhat worse: 20.5% (6.5 million) non-elderly Californians lack health insurance (California Health Care Foundation 2005). These data are particularly important because there is reliable evidence that those without health insurance tend to use fewer and different types of health care services than those with insurance, resulting in either no care (especially for preventive care) or lower-quality care (Hadley and Reschovsky 2002; Schoen, Doty et al. 2005). According to Schoen et al. (2005), the underinsured4experience health access problems remarkably similar to those of the uninsured, including failure to fill prescriptions, forgoing tests and treatment, and forgoing visits to regular doctors and specialists. In addition, rising health insurance premiums can result in a larger number of uninsured as people drop coverage entirely (Kronick and Gilmer 1999). 3According towww.healthcareforall.org(accessed November 30, 2005), the leading reported feature of the bill is that Everyone is covered. No one will ever lose coverage for any reason. 4is based on cost-exposure to family income.The definition of underinsured  Underinsured were defined as those with at least one of three indicators: (1) out-of-pocket medical expenses10% of income; (2) out-of-pocket medical expenses5% of income if income < 200% of the federal poverty level; and (3) health plan deductibles5% of income.
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 All health care reform proposals are associated with tradeoffsincentives versus access, innovation versus stability, and adaptation versus control. These tradeoffs are complex and interrelated, and given that the U.S. has not adopted all of the various forms of state and national health reforms, much of the knowledge concerning how various reforms would work in the U.S. is based on applications of theory from the disciplines of economics, political science, and organizational sociology, coupled with the experiences of countries that have systems resembling the various kinds of reforms. For example, Japans system is akin to employer mandates, and Canada and Great Britain rely on single-payer government-run systems. Taken together, the literature on the international experiences of health systems and reform initiatives is quite extensive. The primary objective of this report is to highlight, rather than comprehensively review, the main findings of these literatures as they pertain to government-administered single-payer health plans. We discuss these findings in the context of the current single-payer proposal in the state of California.  This report is organized into four sections. Section 2 briefly outlines the structure, scope, and financing of SB 840.5 Section 3 reviews the state of knowledge on government-administered single-payer plans, including some discussion of the British and Canadian systems, which are most closely aligned with the mechanisms of SB 840. Section 3 also evaluates SB 840 in the context of the general state of knowledge on single-payer plans, basing much of the evaluation on the most comprehensive evaluation of SB 840 to datea report by The Lewin Group (Sheils and Haught 2005) commissioned by the Health Care for All Education Fund.6Single payer programs in general and CHIS in particular are evaluated across eight dimensions of performance: We examine the performance attributes of centralized health plans in general and CHIS in particular, focusing on eight criteria: 1) access; 2) quality; 3) administrative costs; 4) technology and adaptation; 5) regulatory instruments; 6) tax-based financing; 7) costs; and 8) implementation. Section 4 offers some concluding comments. 2. OVERVIEW OF THE CALIFORNIA PROPOSAL2.1 Structure  The single-payer bill, referred to as The California Health Insurance Reliability Act (CHIRA, also referred to as the Act), would establish the California Health Insurance System (CHIS), which would be administered by the newly created California Health Insurance Agency (CHIA) under the control of an elected Health Insurance Commissioner (California Health Insurance Reliability Act 2005).7 The 5As of July 12, 2005 (the most recent date the bill was amended, as of this writing). 6Refer towww.healthcareforall.org. 7The Act confers substantial powers on the elected Health Insurance Commissioner; e.g., These broad powers shall include, but are not limited to, the powerto set rates; to
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bill would make all California residents eligible for a generous range of services, including inpatient and outpatient services, durable medical equipment, hearing aids, rehab care, preventive care, home health care, prescription drugs, mental health care, and many others.8 Providers of these services would negotiate with CHIS on acceptable fees and minimum quality standards.9 Interestingly, the Act emphasizes that CHIS will use its monopsony buying power to negotiate lower prices with pharmaceutical companies, but does not use the same language when discussing physician and hospital service procurement.10  A number of support agencies would also be created, including a health insurance policy board, an Office of Consumer Advocacy, an Office of Health Planning, and an Office of Health Care Quality. These organizations would share responsibilities for technology assessment, coverage decisions, capital allocations, and minimum quality thresholds. The Office of Health Care Quality would be led by a Chief Medical Officer (CMO), who would be responsible for helping doctors and other health care providers deliver the most appropriate and effective medicines and procedures [and] sets standards of best practice, recommends an evidence-based formulary for pharmaceuticals and durable medical equipment, identifies treatments that are safe and effective, and recommends means to achieve an appropriate ratio of general practitioners to specialists.5The Act would create up to 10 health planning regions throughout the state. Regional planning directors are responsible for working with CHIS to establish, for example, global operating budgets for physician establish [CHIS] goals, standards and priorities; [and to] make allocations and reallocations to the health planning regions and promulgate generally binding regulations concerning any and all matters related to the implementation of the division and its purposes [§140101 (b) 25-33] 8Refer to SB 840 §140500-§140502 for a list of covered benefits, and §140503 for a list of excluded benefits (California Health Insurance Reliability Act 2005). Also refer to Features of SB 840 California Health Insurance Reliability Actwww.healthcareforall.org, accessed November 30, 2005) 9It is unclear whether providers would be permitted to bargain as a unit, which would require a waiver from existing antitrust laws. The language of the bill is somewhat vague: the state shall actively supervise and regulate a system of payments whereby groups of fee-for-service physicians are authorized toselect representatives of their specialtiesto negotiate with [CHIS], pursuant to §140209. Nothing in this division shall be construed to allow collective action against [CHIS] [§140000.1(b) 16-21; emphasis added] (California Health Insurance Reliability Act 2005). 10As outlined in the powers of the Commissioner (§140102), the language broadly states that the Commissioner will negotiate for or set rates, fees and prices involving any aspect of the [CHIS] and establish procedures thereto [§140102 (y) 7-9]. In the same section, the language regarding pharmaceuticals reads differently, stating that the Commissioner will utilize the purchasing power of the state to negotiate price discounts for prescription drugs and durable and nondurable medical equipment for use by the [CHIS] system [§140102 (dd) 22-25]
       
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groups and hospitals, capital budget targets for the region (including review of providers proposed capital projects) and physician specialty mixes.  The plan would effectively eliminate the private health insurance industry in California: No health care service plan contract or health insurance policy, except for the [CHIS] plan, may be sold in California for services provided by the system (§140000.6). The Act, as of the July 2005 amendments, does not appear to make any provisions for the effects on the California economy of eliminating a $64 billion industry. 2.2 Financing  The total annual costs of CHIS are expected to be $166.8 billion (Sheils and Haught 2005). Financing is based on two direct sources: (1) continued funding of existing government programs for Californians, including federal, state, and local programs ($72.2 billion); and (2) new dedicated taxes ($94.6 billion). The bulk of the continued funding is Medicare and Medi-Cal ($54.9 billion). Newly created taxes will likely include an 8.2% employer payroll tax ($55.7 billion), a 3.8% employee payroll tax, a 12% self-employed business income tax ($8.3 billion), a 4% non-wage/non-business tax, ($3.5 billion), and a 1% surcharge on incomes over $200,000 ($1.3 billion). The justification for the new taxes is that there will be significant savings to employers and employees in the form of shifting health care costs to state government, as well system-wide savings attributable to greater efficiency and reductions in administrative costs (Kuehl 2005; Sheils and Haught 2005) 3. EVALUATION OF SINGLE-PAYER SYSTEMS  The next sections discuss the pros and cons of single-payer government administered health systems. The discussion is based on an extensive review of the literature and the application of some basic theory from economics, political science, and organizational sociology. The discussion includes general knowledge of single-payer plans as well as specific aspects of the proposed CHIS. Single payer programs in general and CHIS in particular are evaluated across eight dimensions of performance: We examine the performance attributes of centralized health plans in general and CHIS in particular, focusing on eight criteria: 1) access; 2) quality; 3) administrative costs; 4) technology and adaptation; 5) regulatory instruments; 6) tax-based financing; 7) costs; and 8) implementation. 3.1 Access  One of the obvious advantages of centralized single-payer plans is that they can, by administrative design, extend coverage to the uninsured and underinsured, thereby
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increasing access.11 As mentioned earlier, there is ample evidence showing the positive relationship between access to health care services and subsequent health outcomes (Hadley and Reschovsky 2002; Schoen, Doty et al. 2005). However, single-payer plans in some cases generate their own access problems. Access to health care services in these systems is limited by the availability of physicians, equipment, supplies, and policies defining necessary or appropriate care. Few of these systems make use of financial incentives to control use (e.g., individual deductibles or co-insurance). The lack of price rationing and often limited availability of specialized personnel and equipment results in waiting lists for many types of services in many health systems, some of which are exceptionally long, at least by U.S. norms. For example, the mean waiting time for a magnetic resonance imaging (MRI) of the head in Canada in 1997 was 150 days, compared to 3 days in the U.S. (Bell et al. 1999).12 Schoen, Osborn, Huynh, Doty et al. (2005) report that among sicker adults, only 8% had to wait four months or more for non-emergency surgery in the U.S., compared to 33% in Canada and 41% in the United Kingdom. Similarly, in the U.S., 23% had to wait more than four weeks for an appointment with a specialist, compared to 57% for Canada and 60 percent for the UK. Blendon et al. (2002) report similar findings for hospitalizations for elective surgery in five countries. The percentage of survey respondents reporting waiting times of four months or more for elective surgery ranged from 23% (Australia) to 38% (UK), compared to only 5% in the U.S. (p.188).  Mechanisms for managing waiting lists vary across health systems and by type of service. In some cases no explicit criteria are used to prioritize individual patients in the queue, while in others clinical criteria are used in an attempt to place those with a more immediate need for service closer to the front of the queue (Alter et al. 1999). The latter approach often is hampered by a lack of consensus among experts concerning specific clinical criteria for prioritization (Naylor et al. 1990), but even in the absence of explicit criteria, in practice those patients with at least some characteristics suggestive of more proximate need tend to be assigned higher priority (Hemingway et al. 2000). Nonetheless, an individuals placement on the waiting list is to a degree also influenced 11The reason most often given for not purchasing health insurance is that it is too expensive (Kaiser Family Foundation 2004). But meaning of this response is unclear; if these young individuals perceive themselves to be at low risk, they may view health insurance at prevailing premiums as a poor value, even if they have the financial means to pay. In this sense, some of the uninsured choose to be uninsured (Pauly and Nichols 2004; Schur, Feldman, and Zhao 2004). State insurance regulations that mandate health insurers to cover numerous types of services may exacerbate the problem. These regulations in effect prohibit low-cost bare-bones or catastrophic health insurance policies (Jensen and Morrisey 1999). But even when regulations permitted bare-bones policies, traditionally they did not fare well in individual or small-group markets. This is beginning to change as insurers are more actively marketing new low-cost policies with benefit designs intended to appeal to the low-risk healthy uninsured (Fuhrmans 2005). 12list issue in Canada is also provided by Patel and RushefskyA review of the waiting (2002).
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