Edwine Barasa, Anthony Muchai Manyara, Sassy Molyneux, Benjamin Tsofa
BACKGROUND: In 2013, Kenya transitioned into a devolved system of government with a central government and 47 semi-autonomous county governments. In this paper, we report early experiences of devolution in the Kenyan health sector, with a focus on public county hospitals. Specifically, we examine changes in hospital autonomy as a result of devolution, and how these have affected hospital functioning. METHODS: We used a qualitative case study approach to examine the level of autonomy that hospitals had over key management functions and how this had affected hospital functioning in three county hospitals in coastal Kenya. We collected data by in-depth interviews of county health managers and hospital managers in the case study hospitals (n = 21). We adopted the framework proposed by Chawla et al (1995) to examine the autonomy that hospitals had over five management domains (strategic management, finance, procurement, human resource, and administration), and how these influenced hospital functioning. FINDINGS: Devolution had resulted in a substantial reduction in the autonomy of county hospitals over the five key functions examined. This resulted in weakened hospital management and leadership, reduced community participation in hospital affairs, compromised quality of services, reduced motivation among hospital staff, non-alignment of county and hospital priorities, staff insubordination, and compromised quality of care. CONCLUSION: Increasing the autonomy of county hospitals in Kenya will improve their functioning. County governments should develop legislation that give hospitals greater control over resources and key management functions.
This chapter examines the evolution of health care system in Kazakhstan since its independence. The Soviet health system, which emphasized centralized planning with the principle of free universal health coverage for all, has been adopted by Kazakhstan. To bring major improvements in the health system, the reform measures have altered the institutional and procedural aspects of health care delivery as well as the behavioral aspects of health care providers. In analyzing the health reform programs, four elements in the reform have been examined, namely, decentralization, efficiency and quality, expenditure and financing, and competition. The health financing system consolidates funds at the oblast level, where oblast health departments serve as the single health purchaser or single payer for all state health funds. The National Program of Health Care Reform and Development incorporates a new health financing policy, which aims to improve the linkage between different levels of care, reinvest resources saved through rationalization and decrease regional differences in health financing.
This paper entitled "Public expenditure on health in local budgets" aims analysing and deepening major spending categories that public authorities finance at local level, namely health expenditure. In the first part of the article we have specified the content and role of this category of expenditure in local budgets and also made some feedback on decentralization in health. In the second part of the work, based on data available in Statistical Yearbook of Romania, we have carried out an analysis of the dynamics of health spending from local budgets to emphasize their place and role in the health care expenses. The research carried out follows that the evolution and structure of health expenditure financed from local budgets is determined, along with the legislative framework in the field, by several variables that differ from one territorial administrative unit to another: the existence of sanitary units, their type, the involving of local public authorities in their development and modernization, the number and the social structure of the population. The research shows that over the period 1993-2015, the dynamics of the share of health spending in total expenditures of local budgets is sinusoidal, with a minimum threshold in 2000 of only 0.3%.Journal: The USV Annals of Economics and Public Administration
Global Health Care Issues
Fiscal Policy and Economic Growth
Sustainable Development and Environmental Management
Hilaire Zon, Milena Pavlova, Koiné Maxime Drabo, Wim Groot
'Four' types of decentralization are distinguished in health care: deconcentration when the shift in authority is to regional or district offices; devolution when the shift is to state, provincial or municipal governments; delegation when semi-autonomous agencies are granted new powers; and privatization when ownership is granted to private entities. This article systematically reviews the experiences of local governments of Sub-Saharan African countries with the provision of health services during and after decentralization reforms. The article highlights the achievements, challenges and issues associated with decentralization. The review shows that most countries have mainly focused on the process by enacting numerous policies, regulations and standards with mixed outcomes for health services delivery. Decentralization in general, and resource transfer from the central to local governments in particular, are a highly political issue that influences the health reform strategy on decentralization. The literature shows the complexity of implementing decentralization schemes which strongly impact the health service organization and delivery. The theory of decision space applied in a comparative analysis found that some functions, particularly financing, remain under the control of the central state. Despite the numerous challenges, this review identifies some good practices in resources transfer, key determinants being the type of decentralization and the government's will to make legislative and administrative changes required for the effectiveness of decentralization. The literature search, even though systematic, resulted in a limited number of relevant publications with evidence on the link between decentralization and health services delivery. This is a largely unexplored research area, especially the use of financial resources by local governments, the factors that drive local decision-making processes and the effects of decentralization on health care sector performance.
Like many countries, the health care industries of England 1 and the United States consume large amounts of resources and struggle to achieve equity and efficiency. They attempt to reach these goals in quite different ways, exhibiting common challenges familiar to reformers throughout the world. Recent activities in England and the United States suggest that significant changes being discussed in the United States or implemented in the United Kingdom could upset previously accepted policies and threaten some or many of the gains made to provide more equal and timely accessible care to all individuals. Policy makers in both countries wrestle with similar problems of redistribution and system design. Although in the United States, the issues of equity and expenditure controls do not have the same importance as in England, both countries seek the “Holy Grail” of limiting spending both by government and the private sector by redesigning institutions that manifest inefficiency and contribute to inflationary pressures. Yet competing value systems permeate the political debate about how to accomplish these aims. These value systems underlie political preferences for regulation and markets. Although a minority in the United States advocates for universal care funded by a single payer, private employer-based insurance remains the bedrock mechanism. Unlike the United Kingdom and most Organisation for Economic Cooperation and Development (OECD) countries, the United States has never shown a political willingness to have government responsible for financial protection for all inhabitants against the cost of medical care. The United States has, however, accepted this responsibility for major components of society, namely, the aged, disabled, and low-income families and children (e.g., via Medicare, Medicaid, and the State Children's Health Insurance Program). This commitment was expanded with the Affordable Care Act (ACA) in 2010, commonly known as Obamacare. The outcomes of the two health care systems reflect a preference for collectivism in funding and access in the United Kingdom and for pluralism in funding (less third-party coverage) and a greater role for privately delivered care in the United States. But the battle continues in both countries as important groups advocate for the reversal of these preferences. Policy makers continually try to change their health care systems. Some of these changes seek to develop greater efficiency in how care is delivered as a means of controlling the burdens imposed on society by ever-increasing public and private expenditure. Both countries face common problems that have been well identified for decades but have proven difficult to resolve. Reformers face three common problems. First, unwarranted variations in clinical practice (Wennberg, 2008, Wennberg, 2012) are produced by price variations in insurance systems and volume variations elsewhere (Institute of Medicine, 2013). Second, both systems have been slow to develop measures of the value of health care outcomes, that is, improvements in the length and quality of life. Third, both health care systems have perverse incentives that inhibit efficiency-inducing change; for example, they use hospital pricing or tariff systems that incentivise activity with little regard to patient value. Inadequate evaluation and political resistance to change continue to produce inefficiency. The end result is unnecessary spending and unethical deprivation of beneficial care for some populations. The English single payer system is characterised by frugality and cycles of famine and plenty, with attendant bouts of supply side reform (Street & Maynard, 2007). Constrained funding in the 1980s led to the Thatcher reforms and the creation of the “quasimarket” of purchaser and providers contracting for public and private care. These structural reforms received increased funding in the early 1990s. By the end of the 1990s, financial parsimony was creating renewed performance problems, for example, increased waiting times for elective surgery. As a consequence, the Blair government financed a large increase in funding. Since 2010, the Coalition and now Conservative government has exerted extreme expenditure controls, and current plans will result in real per capita funding falling by 2018. Since the Thatcher era, the often violent fluctuations in NHS funding have been accompanied by the “redisorganisation” of structures and processes of care whilst maintaining universal cover age free at the point of use. The purchaser side of the National Health Service (NHS) market has evolved from health authorities to primary care trusts and now to clinical commissioning groups, all with similar functions and uncertain impact. The provider side of the market remains dominated by public institutions as private providers have made only marginal inroads to public funding. The current chronic underfunding of the NHS and social care, manifested currently by increased waiting times for elective procedures, has produced inevitable pursuit of the “Holy Grail” of increased productivity. The Five Year Forward View (NHS, 2014) involved the acceptance of government parsimony and for the 2015–2020 period. Its authors argued that the NHS would require £30 billion to meet demographic and technological demands, of which only £8 billion was to be provided from tax revenues. The additional £22 billion was to be funded from productivity increases. Current NHS spending is £110 billion. Currently, a frenzy of structural reform proposals range from integration of currently fragmented hospital, primary and social care systems to hospital mergers to the abolition of the purchaser-provider “market” with the creation of accountable care organisations. These proposals involve unevidenced merger plans and deskilling of nursing and other workforce changes. The Sustainability and Transformation Plans (https://www.england.nhs.uk/stps/) are radical but unlikely to yield £22 billion of productivity gains in 5 years. There is little available funding to finance the change process, and its duration is likely to take many years to free up resources. Both options assume that healthcare is much more expensive in the United States than in any OECD country because American patients use too much medical care. Yet the evidence does not support this assumption. Americans are less likely to be admitted to a hospital and have a lower length of stay once in a hospital than many OECD countries. Americans also are less likely to see a doctor or use fewer pharmaceuticals than patients in OECD countries. U.S. patients do use more very expensive medical devices such as MRIs or new and expensive drugs, but on net, the pluses and minus may cancel out. What separates United States spending from that in OECD countries are the prices charged for all medical activities. The reasons for the higher prices are complicated and due to a myriad of factors including the higher wages paid to most participants in the healthcare system (not only physicians); the much higher prices Americans pay for drugs and medical devices; and the fact that the complexity of the U.S. system has evolved in a way that requires the use of many more lawyers, consultants, and administrators, all of whom are well paid. The latter consideration is possibly more central because some key providers such as primary care physicians receive relatively low compensation relative to education costs and work conditions. Additional efforts within the United States that are sometimes related to the ACA include a broad interest in insurance redesign, emphasis on value from services provided, and a focus on patient-centred outcomes. Value-based cost-sharing approaches are being implemented in the United States as well as other OECD countries (Thomson, Schang, & Chernew, 2013), though these approaches are more easily implemented for certain services such as pharmaceuticals. The Medicare program is testing a number of value-based payment innovations and incentive payments. The Patient-Centered Outcomes Research Institute is a nongovernmental institute created under ACA that was charged with assessing the effectiveness and appropriateness of medical treatments. However, the Patient-Centered Outcomes Research Institute is not able to mandate coverage or reimbursement for any treatments and infamously is prohibited from considering cost per quality-adjusted life years in its recommendations despite widespread interest in this measure in many other countries. The American and the English health and social care systems differ greatly, but they are surprisingly similar in some dimensions. Key differences pertain to who pays for care and how it is delivered, with the United States having a more decentralized and fragmented system leading to inequalities in the provision of care and its funding. The English system is universal and largely free at the point of consumption system but constrained by limited funding (which also generates inequalities in access to timely care). The supply side problems are more similar for both countries. Increasingly, U.S. reform in terms of payment mechanisms is being emulated by the English. Both systems seek better measurement and management of “value,” that is, the effects of health care on the length and quality of patients' lives. The hospital systems of both countries are attempting to integrate care function and move away from “fee for service” to bundled or incentive payments. The American system is the product of producer incentives producing grossly inflated costs. Concomitantly, a growing proportion of the U.S. population has a limited view about who should be eligible for government-supported health care services and the types of services that should be supported. Despite greater underlying consensus in favour of universal coverage, the English system's crisis is a product of parsimony and fragmentation of funding and provision. Both systems are permeated by organisational inertia and the defence of political values and self-interest. The United States is grappling with more than a sea change given political restructuring and the very uncertain future of most expansions of insurance or medical cost coverage under the ACA. England faces potentially revolutionary structural changes in supply and a real political challenge in its single payment system. Although current trends are not positive, the authors maintain hope that both countries will prevent further deterioration in health care coverage and return towards more progressive policies to protect their inhabitants' access to care when subjected to the misfortunes of medical illness.
Background Mechanisms for and levels of financing for public health services in Europe are insufficiently documented and understood. Concerns have been raised in a number of countries over recent budget cuts. Methods Our study draws on (i) a review of grey and published evidence, (ii) detailed descriptions of the financing of public health services in nine European countries (England, France, Germany, Italy, Moldova, the Netherlands, Poland, Slovenia and Sweden) using a structured data collection template, and (iii) a review of WHO, Eurostat and OECD datasets as well as national statistics. Results Levels of financing for public health services remain difficult to assess, but available data suggest that funding is low as a percentage of total health expenditure. Available data differ between international and national databases, further complicating a detailed assessment. Public budgets at national, regional and local levels (financed mainly through taxation and social health insurance) are the main source of financing for public health services. In some countries, such as Poland, private sources also play an important role. Allocation mechanisms frequently do not allow for medium- to long-term planning. Approaches that bring together health and other sectors for the funding of public health programmes remain rare, as does the use of taxes dedicated to public health. Countries such as England and the Netherlands have seen major budget cuts for public health services in recent years, while others (Italy, Germany) saw increases in funding, sometimes linked to new policy developments, such as the new Prevention Law in Germany. There are also major differences in financing levels and mechanisms within countries, in particular in decentralized systems. Conclusions The lack of sufficient and sustainable resources is a challenge for public health services in several countries, but there are also positive examples that can be emulated.
-Within the last two decades, the Nigerian government has committed to strengthening its primary health care system, through reforms addressing institutional restructuring, deepening decentralized governance, and the incorporation of an alternative health care financing strategy. One of these reforms prescribed the establishment of state primary health care agencies/boards (SPHCDBs) as an integral part of the national health system, with the principal responsibility "for the coordination of planning, budgeting, provision and monitoring of all primary health care services that affect residents of the state." Central to this reform is the integration of primary health care (PHC) governance and management, popularly called primary health care under one roof. Another reform, piloting results-based financing, has been implemented since 2011 in three states under the Nigeria State Health Investment Project. This study assesses the implementation of the Primary Health Care Under One Roof (PHCUOR) policy as part of the broader PHC reforms, with a specific focus on how this policy has been strengthened through the Nigeria State Health Investment Project (NSHIP) in Adamawa, Nasarawa, and Ondo states, documenting the evolution of SPHCDB and PHC service delivery, with a focus on management, accountability, and incentives. The study shows that, in the above-mentioned states, significant milestones were achieved in the establishment of the SPHCDB, the strengthening of PHC systems, the improvement of accountability linkages, and an increase in service utilization. The authors therefore argue that integrated PHC systems through SPHCDBs, as enshrined in the PHCUOR guidelines, are a panacea for effective provision of primary health care and a potential game changer for health outcomes, especially when reinforced with a results-based financing approach.
This analysis of the Romanian health system reviews recent developments in organization and governance, health financing, health care provision, health reforms and health system performance. The Romanian health care system is a social health insurance system that has remained highly centralized despite recent efforts to decentralize some regulatory functions. It provides a comprehensive benefits package to the 85% of the population that is covered, with the remaining population having access to a minimum package of benefits. While every insured person has access to the same health care benefits regardless of their socioeconomic situation, there are inequities in access to health care across many dimensions, such as rural versus urban, and health outcomes also differ across these dimensions. The Romanian population has seen increasing life expectancy and declining mortality rates but both remain among the worst in the European Union. Some unfavourable trends have been observed, including increasing numbers of new HIV/AIDS diagnoses and falling immunization rates. Public sources account for over 80% of total health financing. However, that leaves considerable out-of-pocket payments covering almost a fifth of total expenditure. The share of informal payments also seems to be substantial, but precise figures are unknown. In 2014, Romania had the lowest health expenditure as a share of gross domestic product (GDP) among the EU Member States. In line with the government's objective of strengthening the role of primary care, the total number of hospital beds has been decreasing. However, health care provision remains characterized by underprovision of primary and community care and inappropriate use of inpatient and specialized outpatient care, including care in hospital emergency departments. The numbers of physicians and nurses are relatively low in Romania compared to EU averages. This has mainly been attributed to the high rates of workers emigrating abroad over the past decade, exacerbated by Romania's EU accession and the reduction of public sector salaries due to the economic crisis. Reform in the Romanian health system has been both constant and yet frequently ineffective, due in part to the high degree of political instability. Recent reforms have focused mainly on introducing cost-saving measures, for example, by attempting to shift some of the health care costs to drug manufacturers by claw-back and to the population through co-payments, and on improving the monitoring of health care expenditure.
For more than three decades healthcare decentralization has been promoted in developing countries as a way of improving the financing and delivery of public healthcare. Decision autonomy under healthcare decentralization would determine the role and scope of responsibility of local authorities. Jalal Mohammed, Nicola North, and Toni Ashton analyze decision autonomy within decentralized services in Fiji. They conclude that the narrow decision space allowed to local entities might have limited the benefits of decentralization on users and providers. To discuss the costs and benefits of healthcare decentralization this paper uses the U-form and M-form typology to further illustrate the role of decision autonomy under healthcare decentralization. This paper argues that when evaluating healthcare decentralization, it is important to determine whether the benefits from decentralization are greater than its costs. The U-form and M-form framework is proposed as a useful typology to evaluate different types of institutional arrangements under healthcare decentralization. Under this model, the more decentralized organizational form (M-form) is superior if the benefits from flexibility exceed the costs of duplication and the more centralized organizational form (U-form) is superior if the savings from economies of scale outweigh the costly decision-making process from the center to the regions. Budgetary and financial autonomy and effective mechanisms to maintain local governments accountable for their spending behavior are key decision autonomy variables that could sway the cost-benefit analysis of healthcare decentralization.
This paper aims at investigating the impact of fiscal decentralization on two key social services: education and healthcare outcomes. We use both a simple time series data set and panel data set covering four provinces of Pakistan over the period from 1975 to 2009 to empirically test the impact of fiscal decentralization on infant mortality rate, crude death rate and literacy rate. Besides Ordinary Least Square method we use Generalized Method of Moment econometric technique to obtain robust and consistent results. The empirical findings of this paper indicate that fiscal decentralization is effective in enhancing the delivery and augmenting the quality of education and healthcare services. These findings are important because they suggest, contrary to the traditional public finance theory, that provincial governments can play a far better role in improving the social services delivery like basic education and healthcare compare to federal government.
Análise da capacidade de autofinanciamento e da dependência financeira dos municípios fluminenses para custear o gasto municipal no Sistema Único de Saúde (SUS). Estudo descritivo, seccional e analítico com dados do Sistema de Informações sobre Orçamentos Públicos em Saúde (Siops). A receita per capita própria municipal foi utilizada como medida da capacidade de autofinanciamento. O Índice de Capacidade de Autofinanciamento (ICA) permitiu o ordenamento dos municípios por graus de capacidade de autofinanciamento. As medidas estatísticas utilizadas foram a média, desvio padrão, intervalo de confiança e o coeficiente de correlação de Pearson. Os valores de receita e gasto em saúde foram deflacionados pelo Índice Geral de Preços (IGP-DI). Os resultados evidenciaram que houve aumento da capacidade de autofinanciamento entre os anos de 2002 e 2013, com decréscimo a partir de 2014. Na distribuição por graus de capacidade de autofinanciamento identificou-se entre os aos 2002 e 2008 uma continua ascensão dos municípios para graus mais elevados e, a partir do ano de 2009 em diante, todos se encontraram no grau 4, demonstrando maior aproximação das receitas municipais. Por outro lado, verificou-se permanência de desigualdades de receita própria para gasto em saúde. Houve elevação da despesa total em saúde durante todo o período com participação dos dois subcomponentes de receita (receita própria e de transferências SUS) neste crescimento. O gasto próprio deteve a maior participação na despesa total em que pese a relevância das transferências SUS, em especial da União, onde 80 por cento dos municípios apresentaram uma dependência de recursos de transferências do SUS acima de 20 por cento na execução de sua despesa total em saúde
Aku Kwamie, Han van Dijk, Evelyn Ansah, Irène Akua Agyepong
The district health system in Ghana today is characterized by high resource-uncertainty and narrow decision-space. This article builds a theory-driven historical case study to describe the influence of path-dependent administrative, fiscal and political decentralization processes on development of the district health system and district manager decision-space. Methods included a non-exhaustive literature review of democratic governance in Ghana, and key informant interviews with high-level health system officials integral to the development of the district health system. Through our analysis we identified four periods of district health system progression: (1) development of the district health system (1970-85); (2) Strengthening District Health Systems Initiative (1986-93); (3) health sector reform planning and creation of the Ghana Health Service (1994-96) and (4) health sector reform implementation (1997-2007). It was observed that district manager decision-space steadily widened during periods (1) and (2), due to increases in managerial profile, and concerted efforts at managerial capacity strengthening. Periods (3) and (4) saw initial augmentation of district health system financing, further widening managerial decision-space. However, the latter half of period 4 witnessed district manager decision-space contraction. Formalization of Ghana Health Service structures influenced by self-reinforcing tendencies towards centralized decision-making, national and donor shifts in health sector financing, and changes in key policy actors all worked to the detriment of the district health system, reversing early gains from bottom-up development of the district health system. Policy feedback mechanisms have been influenced by historical and contemporary sequencing of local government and health sector decentralization. An initial act of administrative decentralization, followed by incomplete political and fiscal decentralization has ensured that the balance of power has remained at national level, with strong vertical accountabilities and dependence of the district on national level. This study demonstrates that the rhetoric of decentralization does not always mirror actual implementation, nor always result in empowered local actors.
This paper considers an overlapping-generations model with pay-as-you-go social security and retirement decision making by an old agent. In addition, the paper assumes that labor productivity depreciates. Under this setting, socially optimal allocations are examined. The first-best allocation is an \nallocation that maximizes welfare when a social planner \ndistributes resources and forces an old agent to work and \nretire as she wants. The second-best allocation is an allocation that maximizes welfare when she can use only pay-as-you-go social security in a decentralized economy. The paper finds a range of an old agent’s labor productivity such \nthat the first-best allocation is achieved in the decentralized economy. This differs from the finding in Micheland Pestieau [“Social security and early retirement in an overlapping-generations growth model”, Annals of Economics & Finance, 2013] that the first-best allocation cannot be achieved in the decentralized economy.
The main purpose of this article was to present the most important organizational, supervisory and financial competences of local government units (LGUs) in Poland relating to public health care institutions (medical entities, a non-entrepreneurs). One of the goals of article was also evaluated the involvement of the various levels of local government in Poland in the financing of the tasks related to the health care and evaluated the effects of decentralization in health care. The article has been prepared on the basis of literature study, including the current legislation, as well as papers of various organizations, institutions and scientific journals.
Renate Hartwig, Robert Sparrow, Sri Budiyati, Athia Yumna · 7 authors
We exploit variation in the design of subnational health-care financing initiatives in Indonesian districts to assess the effects of these local schemes on maternal care from 2004 to 2010. The analysis is based on a district pseudopanel, combining data from a unique survey among District Health Offices with the Indonesian Demographic and Health Surveys, the national socioeconomic household surveys, and the village census. Our results show that these district schemes contribute to an increase in antenatal care visits and the probability of receiving basic recommended antenatal care services for households that are not targeted by the national health insurance programs. We observe a decrease in home births. However, there is no effect on professional assistance at birth. We also observe variation in scheme design across districts as well as constraints to the effectiveness of local schemes. Including antenatal and delivery services explicitly in benefits packages and contracting local rather than national health-care providers increases the effects on maternal care. Increasing population coverage reduces effectiveness, delineating limitations to local funding and risk pooling. Furthermore, we do not find any effects for districts outside Java and Bali, where access to basic health care remains a key policy concern.
White House Conferences on Aging, held roughly every 10 years since 1961, have “generated ideas and momentum prompting the establishment of and/or key improvements in … programs that represent America’s commitment to older Americans” (The White House, 2015a). In terms of economic security, notably, the 1961 conference gave a push to the enactment of Medicare by recommending the provision of medical care for the aged through Social Security (Senate Special Committee on Aging, 1961). In 1971, President Nixon advocated inflation-proofing Social Security benefits, saying “It does not make sense to have … benefits constantly behind inflation” (Nixon, 1971), language backed-up when he signed the 1972 amendments to the Social Security Act implementing automatic cost of living adjustments (the “COLA”). While unlikely that this year’s conference will see the fruits of its labor enacted into sweeping policy change in the near term, it could play an important agenda-setting role for future congresses and presidents if conference planners and delegates: Explicitly reject the “entitlement crisis frame” and language; Advance the intergenerational understanding of Social Security; Highlight economic insecurity among today’s seniors Sound the alarm on the looming retirement income crisis; Consider benefit increases in Social Security as a critical option Once a neutral budget term, “entitlement” has taken on new meaning in policy, media and even everyday discourse—one that diminishes the dignity of the old and contributes to the mis-framing of policy discussions about the economic consequences of the aging of America. Conference planners and participants should reject “entitlements” language and urge politicians and the press to do likewise. Here’s why. Americans properly understand Social Security and Medicare as benefits they have earned through lifelong contributions from their (or a family member’s) earnings, not as a “hand-out.” Medicaid, in turn, ensures that the poor as well as many very sick Americans obtain needed health care. Subtle or not, “entitlement” terminology implies that somehow such benefit protections are not deserved. Intended or not, the language chips away at the self-esteem and reinforces negative stereotypes that somehow the old—like spoiled, overly entitled children or adults—are demanding and taking more than they deserve (Altman & Kingson, 2015). The terminology of entitlement is functional for those wanting to scale-back or otherwise radically change—Social Security, Medicare, and Medicaid. Rather than frontally attacking these popular programs, it allows them to obfuscate their intentions by attacking “entitlements.” Lumping these programs together as a “unified entitlement problem” provides a convenient frame for advancing and reinforcing the claim that entitlement spending is the largest cause of federal deficits and the national debt, and that left unchecked this spending will bankrupt the nation. As William Greider writes in The Nation, the political consequences of this shift in meaning are not benign: For many years, the smug elites of Wall Street have peddled “entitlement reform” as a sly euphemism for cutting Social Security. And Washington’s political elites, including President Obama, bought into the propaganda. Social Security, not to mention Medicare and Medicaid, was driving the nation into ruinous debt if government did not act to curb this venerable New Deal program. Think tanks and editorial writers, political reporters and TV talkers, witlessly embraced the big lie and promoted it as indisputable truth (Greider, 2014). Equally problematic, the terminology of “entitlement,” “entitlement problem,” and “entitlement crisis” distracts attention from tax spending sprees (e.g., profligate tax cuts and expenditures primarily benefitting well-off constituencies), two wars paid for with credit cards, financial mismanagement leading to the near collapse of our economy, and widening inequalities of income and wealth. Whatever the problem, this frame offers cuts to spending on Social Security, Medicare, and Medicaid as solution. At any one point in time Social Security serves all age groups and, over time, all generations. Princeton economist J. Douglas Brown, an architect of the Social Security Act, spoke eloquently of Social Security as a covenant reaching across generations and arising from a commitment to mutual responsibility that undergirds civilization. This covenant “underlies the fundamental obligation of the government and citizens of one time and the government and citizens of another time to maintain a contributory social insurance system” (Brown, 1977, 31–32). The most important source of income for retirees, Social Security is also working American’s most reliable disability insurance and the nation’s largest children’s program. Indeed, 3.4 million dependent young children and one million dependent adults disabled before age 22 receive benefits each month. The most significant source of income flowing into the homes of 7.4 million children being raised by grandparents or other older relatives, Social Security is also the most important life and disability insurance working parents have, protecting nearly all of the nation’s 74 million children. As important as Social Security is for today’s old, it is likely to be even more so for today’s young- and middle-aged workers. Indeed, it is they who have more at stake if benefits are cut or expanded (Altman & Kingson, 2015). Unfortunately, in policy discourse Social Security is often presented—by both friends and foes—as if it is only a program for the old. And, the prime sponsor of this year’s WHCOA contributes to this mischaracterization. The President’s 2007–2008 presidential primaries and general election campaigns and the White House website provide case in point. Unionists, women, religious groups, environmentalist, and the like were listed among the 25 or so groups providing special support for candidate Obama (e.g., “_____ for Obama”). “Seniors for Obama” was nowhere to be found on this list. Instead, seniors were assigned to the “Issues” section of the website under “Seniors and Social Security.” The problem here is that “Seniors” are not issues, and, “Social Security” benefits and policy concerns everyone, not just seniors. A one-time occurrence would be of little concern. But in spite of requests by supporters engaged in the campaign and followed by similar requests at White House meetings, “Seniors” and “Social Security” remain joined under the “Issues” tab on The White House (2015b) website (see Figure 1). Seniors are not issues. Like the contemporary use of the word “entitlement,” intended or not, defining seniors as “an issue” is, at best, inaccurate, and, at worst, disrespectful. And presenting Social Security narrowly as an issue primarily of concern to the old misframes policy discussions. So, it is time for the White House to push the “reset” button… Language frames issues and conveys attitudes. Like the contemporary use of the word “entitlement,” intended or not, defining seniors as “an issue” is, at best, inaccurate, and, at worst, disrespectful. And presenting Social Security narrowly as an issue primarily of concern to the old misframes policy discussions. So, it is time for the White House to push the “reset” button with regard to how it talks about older Americans and Social Security. Failing this, the WHCOA delegates could perform an important service by raising such concerns. By virtually any measure, the economic status of the old has, on average, improved since the 1950s, with, for example, poverty rates declining under the official poverty measure from roughly 35% in 1959 to 9% today (15% when the Census Bureau’s new Supplemental Poverty measure is used). But contrary to stereotypes, most seniors are not living on easy street. A small percentage is wealthy, while many more live in poverty or near the margin of economic insufficiency. Indeed 48% of seniors are economically vulnerable when 200% of the New Supplemental Poverty Measure is used as the standard. Others—including many among the one out of four senior households with annual incomes in excess of $50,000—are comfortable but often only one shock away from serious financial problems (Altman & Kingson, 2015). Monthly Social Security benefits for seniors are modest, averaging just $1,328 in January 2015. Yet, two thirds of beneficiaries, 65 and over, receive at least half of their income from Social Security (U.S. Social Security Administration, 2014). While the struggle to make ends meet is a burden many seniors face, this pattern of economic stress is generally more pronounced among particular demographic groups—notably Latinos, African Americans, unmarried women, and the oldest old—who are very much at risk for living in poverty based on their limited access to resources and societal limitations that have prevented many from accumulating wealth over their lifetimes. Also, a large numbers of older workers, with health limitations and/or little opportunity to work, accept Social Security retired worker benefits at early ages (e.g., 62), thus sustaining large, permanent reductions in their monthly benefits. Social Security has helped maintain a standard of living for many families of color in America that may otherwise not be possible. People of color rely more heavily on survivor and disability benefits, reflecting lower educational attainment and higher incidence of poverty and morbidity (Martin, 2007). While non-Hispanic whites are more likely to possess wealth outside of their Social Security retirement benefits, many people of color rely solely on what they earned from Social Security for financial stability (Rockeymoore & Lui, 2011). Many people of color have also been unable to obtain wealth through their lifetimes due to past racial discrimination in American policies, yielding a disproportionate reliance on Social Security benefits to ensure that they are able to meet basic monthly expenses. While acknowledging the heterogeneity of economic circumstance among today’s old, the 2015 WHCOA provides opportunity to highlight the very real financial insecurities facing the majority of seniors today, especially those who are most vulnerable. American workers face a looming retirement income crisis, where far too many will find themselves unable to maintain their standards of living when they grow old. Allianz Life Insurance Company reported, from its 2010 survey of 3,257 people, that “an overwhelming 92%” answered that they absolutely (44%) or somewhat (48%) believe that the nation faces a retirement income crisis, with “more than half (54%)” of persons ages 44–49 saying they are “totally unprepared” for retirement (Allianz Life Insurance Company, 2010). In their 2013 retirement confidence survey, the Employee Benefit Research Institute found that only “13 percent are very confident they will have enough money to live comfortably in retirement,” the lowest ever reported in the 23 years of conducting this annual survey. This lack of confidence is not surprising as the past 35 years have not been good to most American workers. Only the top 10% of the income distribution have seen aggregate gains in household income (Picketty, 2014). From 1979 until the eve of the Great Recession in 2007, almost two fifths of all gains in household income were received by the top 1% (Hacker & Pierson, 2010), while men in the bottom 60% saw their real wages decline (Economic Policy Institute, 2012). Further, traditional private sector defined benefits are rapidly disappearing, public sector plans under political attack, and 401K and related retirement vehicles primarily benefit the well-off. And changes enacted in the 1983 (e.g., raising retirement ages, taxing benefits) have reduced benefits by roughly 24% for persons born after 1959 (Altman & Kingson, 2015). The economic crash furthered the deterioration of retirement prospects for countless individuals. Since 2008, many people in their 40s and 50s have been balancing substantial losses of 401(k), IRA and other savings, pension protection, housing equity, and job security with the rising cost of health care and college tuitions. The median income of households headed by persons 55–64 dropped from $61,700 in 2009 to $58,626 in 2012 (Kingson, 2013). Post-crash in 2013—after the stock market increased and housing prices improved—52% of households were on a glide path to an inadequate retirement income (Munnell, Hou, & Webb, 2014), presumably as much as two thirds more if health and long-term-care costs were included in this risk assessment (Altman & Kingson, 2015). According to the Pension Rights Center there is a $6.6 trillion deficit between what Americans have saved for retirement and what they should have saved in order to maintain their current standard of living. According to the National Institute on Retirement Security 38.3 million working-age households (45%) do not have any retirement account assets (National Institute on Retirement Security, 2013). Even among working households with retirement savings, “Four out of five working households have … less than one times their annual income” (National Institute on Retirement Security, 2013, 11). Thus, the WHCOA has an important opportunity to sound the alarm on the retirement income crisis. … the WHCOA has an important opportunity to sound the alarm on the retirement income crisis. Responding to the looming retirement income crisis of today’s workforce and tenuous economic circumstances of many among today’s retirees, legislative proposals are being advanced which increase Social Security’s modest, though vital, protections while simultaneously strengthening program financing. These proposals include revenue measures such as lifting the payroll contribution ceiling, gradually increasing the contribution rate over 20 years, and diversifying trust fund investments. With respect to today’s and tomorrow’s retirees, on the benefit side, they include such proposals as modest across the board increase in benefits, larger minimum benefit payments for low wage-workers, caregiver credits, and use of the Consumer Price Index for the Elderly (CPI-E) to calculate COLAs. A poll by the National Academy of Social Insurance (NASI) indicates that our Social Security system is supported across all political groups; self-reported Democrats, Republicans, and Tea-Partiers alike agree that Social Security benefits should be expanded because they understand the importance of the system to their families and communities (Tucker, Reno, & Bethell, 2013). Americans favor having millionaires and billionaires pay the same rate by raising the payroll contribution cap, currently set at $118,500 for 2015 (U.S. Social Security Administration, 2015). Of course, many disagree with the proposition that it is time to expand Social Security, but that should not stop the WHCOA from recommending that very serious consideration be given to such proposals. Whatever the outcome, the nation will benefit from a full and open debate and the WHCOA can serve as vehicle to facilitate such debate. The 2015 White House Conference on Aging has the opportunity to delve into diverse issues affecting older Americans, their families, and caregivers. As 2015 begins, we look forward to the 80th Anniversary of the Social Security Act as well as the 50th Anniversaries of Medicare and Medicaid—institutions that have reduced poverty, helped families sustain their standard of living and strengthened the national community. Addressing the retirement income crisis and significant income problems of today’s retirees in a way that recognizes the importance of intergenerational commitments and supports the expansion of the nation’s most successful and popular domestic policy will resonate most effectively with the American people. E. Kingson, Professor of Social Work at Syracuse University is Founding Co-director, Social Security Works and Co-chair of the Strengthen Social Security Coalition. M. Checksfield is Legislative Director of Social Security Works and the Strengthen Social Security Coalition. Partial support for the writing of this article was provided from a grant received by Social Security Works from The Atlantic Philanthropies.
Cinzia Di Novi, Massimiliano Piacenza, Silvana Robone, Gilberto Turati
This paper aims at investigating empirically the impact of fiscal decentralization reforms on inequality in well-being. In particular, we look at the effects on health inequalities following the assignment of larger tax power to the Italian Regions for financing their health expenditure, starting from the end of the Nineties. Exploiting large differences in the size of the tax base across Regions, we find that fiscal decentralization processes that attribute a greater tax power to lower government tiers, besides reducing inefficiencies of healthcare policies, seem to be effective in reducing also within-regional disparities in health outcomes. However, the degree of economic development � on which depends the actual fiscal autonomy from Central government � significantly affects the effectiveness of these reforms and highlights the importance to take properly into account the specific features of the context where the decentralization of power is implemented.
Carlo De Pietro, Paul Camenzind, Isabelle Sturny, Luca Crivelli · 8 authors
This analysis of the Swiss health system reviews recent developments in organization and governance, health financing, health care provision, health reforms and health system performance. The Swiss health system is highly complex, combining aspects of managed competition and corporatism (the integration of interest groups in the policy process) in a decentralized regulatory framework shaped by the influences of direct democracy. The health system performs very well with regard to a broad range of indicators. Life expectancy in Switzerland (82.8 years) is the highest in Europe after Iceland, and healthy life expectancy is several years above the European Union (EU) average. Coverage is ensured through mandatory health insurance (MHI), with subsidies for people on low incomes. The system offers a high degree of choice and direct access to all levels of care with virtually no waiting times, though managed care type insurance plans that include gatekeeping restrictions are becoming increasingly important. Public satisfaction with the system is high and quality is generally viewed to be good or very good. Reforms since the year 2000 have improved the MHI system, changed the financing of hospitals, strengthened regulations in the area of pharmaceuticals and the control of epidemics, and harmonized regulation of human resources across the country. In addition, there has been a slow (and not always linear) process towards more centralization of national health policy-making. Nevertheless, a number of challenges remain. The costs of the health care system are well above the EU average, in particular in absolute terms but also as a percentage of gross domestic product (GDP) (11.5%). MHI premiums have increased more quickly than incomes since 2003. By European standards, the share of out-of-pocket payments is exceptionally high at 26% of total health expenditure (compared to the EU average of 16%). Low and middle-income households contribute a greater share of their income to the financing of the health system than higher-income households. Flawed financial incentives exist at different levels of the health system, potentially distorting the allocation of resources to different providers. Furthermore, the system remains highly fragmented as regards both organization and planning as well as health care provision.
Spain’s Transition to Democracy set the stage for the organization of a national healthcare system. The adoption of the Spanish Constitution of 1978 was a political milestone that led to the recognition of every citizen’s right to healthcare and the right of autonomy of the different regions that make up the SpanishState. The most distinctive characteristic of the healthcare model set up in those early years of political transition was the decentralization of the healthcare system which transferred political and administrative power on matters of public health to the 17 autonomous communities. It took more than 20 years to complete this decentralization process. Due to the economic crisis and the election of a conservative government, the National Healthcare System is being seriously questioned, its very sustainability in doubt as reform measures are being taken that are considered a threat by many institutions and organizations to public welfare.
The purpose of this article is to present the main directions of changes in the Estonian health care system following the transformation of the national economy and the accession of Estonia to the European Union. Special attention has been paid to the ways of sourcing, and the collection and redistribution of financial resources allocated to health care in different periods of the transformation. The initial changes introduced far-reaching decentralization of the health system, while further reforms led to his re-centralization. The intensity of the re-centralization of finance and health management processes was accelerated after 2008, when the impact of the global financial crisis on the condition of the economy of Estonia was significant. As a result of the introduced changes, Bismarck’s mixed system – a hybrid system – has been formed.