From Massachusetts to Hawaii, many states, counties and cities are working on ways to provide new health insurance options to the 45 million Americans who lack health coverage.
But the devil's in the details: Which treatments and preventive measures will the new plans cover? How much will they charge for doctor's visits and trips to the emergency room? Which doctors and hospitals will accept them? How much will they cost?
A new study published in the November issue of the journal Health Affairs reveals a promising way to deal with this thorny problem: Let the public decide.
In fact, the study suggests, grassroots decisions about what's fair, and what's affordable, may lead to coverage that will be acceptable to participants even though they are less costly than average health plans.
The study involved nearly 800 California residents from diverse backgrounds who took part in a project that asked them to design the best possible health plan for the uninsured, using a limited amount of dollars. The project, funded by the California HealthCare Foundation and organized by the nonprofit Sacramento Healthcare Decisions, used a game-like computer program called CHAT (Choosing Healthplans All Together) developed by University of Michigan and National Institutes of Health researchers.
Individually, and in small and large groups, the 798 participants picked from a range of options – including different coverage levels for preventive, chronic and last-hope care; different options for access to doctors; a variety of co-pays for appointments, hospital stays and ER visits; options for dental and vision care, different premium levels, and more.
Each of the options "cost" them a certain number of points, which were calculated based on actuarial estimates of the real-world costs of those coverage options. Just like in the real world, the amount of points (dollars) available to spend was limited.
In the end, the participants came to agreement on what to cover, what kinds of tradeoffs to make, and how much would be reasonable for participants to pay out of their own pockets. The result was a package that, for example, would pay for the least-expensive medicines first for chronic diseases like diabetes; give basic care for pregnancy, mental health, and rehabilitation; and cover only proven preventive tests and exams. But it wouldn't cover last-ditch catastrophic care, extraordinary end-of-life care, and conditions that interfere with quality of life but aren't seriously disabling.
In all, the authors calculate, the plan would cost two-thirds of the average cost for insurance plans in California. But still, the study participants didn't elect to make participants pay the maximum out-of-pocket costs.
"They made many trade-offs to avoid saddling individuals with high co-pays and deductibles," says lead author Marge Ginsburg, executive director of SHD. "They also chose comprehensiveness of coverage over choice of doctor, and made a clear distinction between health care needs that are vital to basic living, and those that are less essential to productivity and longevity."
Ginsburg's organization conducted the project, called Just Coverage, to solicit public input on the elements of basic health insurance coverage – in other words, if everyone had health insurance, what would be the minimum they would need?
The CHAT game is designed so that individuals progress from designing a plan on their own, to working in small groups, and then to a larger group. A number of sessions lasting two and a half hours, and each involving 10 to 12 people, were held in 2005 and 2006. Half of participants were from Sacramento County. The participants varied in age, economic and educational background, and insurance status, though they were not fully representative of the California population.
Although the researchers report the general consensus achieved by most participants, there were some major differences in the insurance choices made by people of different backgrounds. For instance, people with lower incomes and lower levels of education were more likely to include a category of coverage called "quality of life care" which included coverage for infertility, impotence coverage, and coverage for injuries that only affected athletic performance, not daily ability to function. The authors note that more research needs to be done on this kind of difference in viewpoints about the "necessity" of coverage for this kind of care.
Another aspect of the findings is that people seemed largely willing to forego coverage for "last hope" long-shot types of treatment. However, this kind of limit would represent a major change, because doctors and patients currently have a lot of discretion in choosing such options.
"We anticipate that by making basic coverage more affordable, it will be more possible to expand coverage to the uninsured." says co-author Marion Danis, co-inventor of CHAT and head of the Section on Health Ethics and Policy at the National Institutes of Health.
"When the public participates in designing basic benefit plans for the uninsured, they make well-reasoned tradeoffs," says co-author Susan Dorr Goold, M.D., MHSA, MA, an associate professor of internal medicine and health management and policy, director of the Bioethics Program at the U-M Medical School and co-inventor of CHAT. "This kind of participation may be key to developing plans that prospective participants will choose and will accept, especially when coverage is mandated as in Massachusetts' recently enacted health reform. A publicly-designed plan that limits coverage may be more acceptable to them than one designed from the top down."
The Massachusetts reform will require all state residents to have health insurance, and will offer a variety of public and private plans and subsidies depending on age, health status and income. The individual mandate is subject to the availability of affordable, credible coverage, but the details of affordability and what counts as credible coverage have not yet been decided.
In fact, Goold and a graduate student, Nancy Baum, address that very issue in a new essay in the Hastings Center Report, a leading medical ethics journal. The essay examines the potential impact on individuals depending on how "affordable" is defined -- and how insurance premiums, deductibles and co-pays are set -- by the Massachusetts board called the Connector. Although the Connector board includes representatives from "stakeholder" groups, it may benefit from seeking further public input into the plans it designs before finalizing them, the authors say.
Kara Gavin | EurekAlert!
Europe’s Demographic Future. Where the Regions Are Heading after a Decade of Crises
10.08.2017 | Berlin-Institut für Bevölkerung und Entwicklung
Scientists reveal source of human heartbeat in 3-D
07.08.2017 | University of Manchester
Whether you call it effervescent, fizzy, or sparkling, carbonated water is making a comeback as a beverage. Aside from quenching thirst, researchers at the University of Illinois at Urbana-Champaign have discovered a new use for these "bubbly" concoctions that will have major impact on the manufacturer of the world's thinnest, flattest, and one most useful materials -- graphene.
As graphene's popularity grows as an advanced "wonder" material, the speed and quality at which it can be manufactured will be paramount. With that in mind,...
Physicists at the University of Bonn have managed to create optical hollows and more complex patterns into which the light of a Bose-Einstein condensate flows. The creation of such highly low-loss structures for light is a prerequisite for complex light circuits, such as for quantum information processing for a new generation of computers. The researchers are now presenting their results in the journal Nature Photonics.
Light particles (photons) occur as tiny, indivisible portions. Many thousands of these light portions can be merged to form a single super-photon if they are...
For the first time, scientists have shown that circular RNA is linked to brain function. When a RNA molecule called Cdr1as was deleted from the genome of mice, the animals had problems filtering out unnecessary information – like patients suffering from neuropsychiatric disorders.
While hundreds of circular RNAs (circRNAs) are abundant in mammalian brains, one big question has remained unanswered: What are they actually good for? In the...
An experimental small satellite has successfully collected and delivered data on a key measurement for predicting changes in Earth's climate.
The Radiometer Assessment using Vertically Aligned Nanotubes (RAVAN) CubeSat was launched into low-Earth orbit on Nov. 11, 2016, in order to test new...
A study led by scientists of the Max Planck Institute for the Structure and Dynamics of Matter (MPSD) at the Center for Free-Electron Laser Science in Hamburg presents evidence of the coexistence of superconductivity and “charge-density-waves” in compounds of the poorly-studied family of bismuthates. This observation opens up new perspectives for a deeper understanding of the phenomenon of high-temperature superconductivity, a topic which is at the core of condensed matter research since more than 30 years. The paper by Nicoletti et al has been published in the PNAS.
Since the beginning of the 20th century, superconductivity had been observed in some metals at temperatures only a few degrees above the absolute zero (minus...
16.08.2017 | Event News
04.08.2017 | Event News
26.07.2017 | Event News
18.08.2017 | Life Sciences
18.08.2017 | Physics and Astronomy
18.08.2017 | Materials Sciences