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If U.S. health care spending growth continues unchecked, the nation will have far less in the future to purchase other essentials, including education, infrastructure, and consumer goods. The point at which nonhealth spending could begin a precipitous decline was previously projected in a paper by Michael Chernew and colleagues to be 2050, unless the rate of health cost growth can be lowered (that is, "bending the curve"). This paper evaluates alternative approaches. First, it looks at the effect on health and nonhealth spending of a one-time reduction in health costs--for example, through a sharp reduction in overuse of medical services in higher-cost regions of the country. It concludes that a one-time reduction in the range of 20-35 percent would delay Chernew's projected decline in nonhealth spending by ten to twenty years. Second, it looks at the effect of combining up-front spending reductions of this size with a longer-range cut in the rate of growth of health spending from 2 percentage points to 1.5 percentage points annually. It finds that this scenario would postpone a major drop in nonhealth spending almost until the twenty-second century. The paper argues that substantial up-front reductions in health spending are therefore worth pursuing to protect the nation's long-term economic growth. [ABSTRACT FROM AUTHOR]

The American Recovery and Reinvestment Act (ARRA) of 2009 will soon provide billions of dollars to small physician practices nationwide to encourage adoption of electronic health records. Although shifting from paper to computers should lead to better and cheaper care, the transition is complex. In this paper we describe our struggles to adapt a commercial electronic health record to an innovative practice serving high-cost patients with chronic diseases. Limitations in the technology gave rise to medication errors, interruptions in work flow, and other problems common to paper systems. Our experience should encourage providers and policy makers to consider alternative software and informatics models before investing in currently available systems. [ABSTRACT FROM AUTHOR]

This paper reviews the happiness-health relationship from an economics perspective, highlighting the role of adaptation. People's expectations for health standards influence their reported health and associated happiness, a finding that roughly mirrors the Easterlin paradox in income and happiness. Research on unhappiness and obesity shows that norms and stigma vary a great deal across countries and cohorts, mediating the related well-being costs. Better understanding this variance and its effects on incentives for addressing the condition is important to policy design. More generally, the paper discusses how happiness surveys can-and cannot-inform public health policy. [ABSTRACT FROM AUTHOR]

Payers point to the lack of unbiased evidence for making coverage decisions for new and often costly technologies. This paper provides a case study of a new approach to developing information to meet the needs of a payer: Medicare's coverage with evidence development (CED) policy. Medicare's decision to condition coverage of cancer therapies on clinical trial participation is an early application of CED and signals Medicare's interest in developing evidence on new technologies for beneficiaries. This paper reviews the rationale and challenges Medicare faces in applying its CEO policy and discusses the implications of payers' using and generating evidence. [ABSTRACT FROM AUTHOR]

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

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

This paper reviews recent reports that demonstrate disparities in health care for children and current federal efforts to eliminate them. Instead of simply describing disparities, this paper also presents recommendations that can reduce disparities. By reviewing current problems, practices, and recommendations in health care coverage, quality, and provider training, the author maps out a plan for reducing disparities in child health that complements existing efforts. The fragmentation of current and proposed initiatives would benefit from an oversight body based at the U.S. Department of Health and Human Services that would monitor progress and coordinate efforts for eliminating disparities. [ABSTRACT FROM AUTHOR]

This paper uses the latest data from the Organization for Economic Cooperation and Development (OECD) to compare the health systems of the thirty member countries in 2000. Total health spending—the distribution of public and private health spending in the OECD countries—is presented and discussed. U.S. public spending as a percentage of GDP (5.8 percent) is virtually identical to public spending in the United Kingdom, Italy, and Japan (5.9 percent each) and not much smaller than in Canada (6.5 percent). The paper also compares pharmaceutical spending, health system capacity, and use of medical services. The data show that the United States spends more on health care than any other country. However, on most measures of health services use, the United States is below the OECD median. These facts suggest that the difference in spending is caused mostly by higher prices for health care goods and services in the United States. [ABSTRACT FROM AUTHOR]

Two papers in this volume review efforts worldwide to control the growth of drug spending and discuss the potential role for the U.S. government with respect to rationing of prescription drugs. I put the roles given to government in the two papers in context by focusing on the role of government as a partner with the pharmaceutical industry. I concentrate on the unique features of the prescription drug market, coupled with the fact that government is a payer, regulator, and provider in the health sector. I conclude that the federal government should exercise caution when attempting to regulate prescription drug prices. [ABSTRACT FROM AUTHOR]

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

The framework for reaching near-universal coverage outlined in this paper combines tax credits for private insurance and public program expansions. It illustrates how a series of incremental steps could be phased in to achieve near-universal coverage. Hallmarks include creation of a Congressional Health Plan; use of the income tax system to provide tax credits and enroll uninsured people; creation of a state Family Health Insurance Program open to everyone below 150 percent of poverty; and creation of a Medicare Part E, open to the disabled and uninsured older adults. The paper provides coverage and cost estimates and identifies potential sources of revenue to finance coverage. [ABSTRACT FROM AUTHOR]

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

The US health care system is in the midst of an enormous change in the way health care providers and hospitals document, monitor, and share information about health and care delivery. Part of this transition involves a wholesale, but currently uneven, shift from paper-based records to electronic health record (EHR) systems. We used the most recent longitudinal survey of US hospitals to track how they are adopting and using EHR systems. Only 44 percent of hospitals report having and using what we define as at least a basic EHR system. And although 42.2 percent meet all of the federal stage 1 "meaningful-use" criteria, only 5.1 percent could meet the broader set of stage 2 criteria. Large urban hospitals continue to outpace rural and nonteaching hospitals in adopting EHR systems. The increase in adoption overall suggests that the positive and negative financial incentives currently in place across the US health care system are working as intended. However, achieving a nationwide health information technology infrastructure may require efforts targeted at smaller and rural hospitals. [ABSTRACT FROM AUTHOR]

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

In response to increasing abuse of prescription drugs, forty- four states have implemented-and five more states will soon adopt- monitoring programs to track prescriptions of controlled medications. Although these programs were originally designed to help law enforcement officials and regulatory agencies spot possible illegal activity, health care providers have begun to use data from them to help improve patient safety and quality of care. For this article we reviewed government documents, expert white papers, articles from the peer-reviewed medical literature, and reports of the experiences of local health officials. We found some evidence that prescription drug monitoring programs are a benefit to both law enforcement and health care delivery. However, the programs have strengths and weaknesses, and their overall impact on drug abuse and illegal activity remains unclear. We believe that improving the efficacy of prescription drug monitoring programs will require such changes as more standardization and interstate cooperation, better training of providers, more secure funding, and further evaluation. [ABSTRACT FROM AUTHOR]

The pending Supreme Court decision on the Affordable Care Act and the fall presidential election raise concerns about what would happen if the insurance expansion promised by the landmark health reform law were to be curtailed. This paper's analysis of national survey estimates found that access to health care and use of health services for adults ages 19-64--the primary targets of the Affordable Care Act--deteriorated between 2000 and 2010, particularly among those who were uninsured. More than half of uninsured US adults did not see a doctor in 2010, and only slightly more than a quarter of these adults were seen by a dentist. We also found that children--many of whom qualify for public coverage through Medicaid and the Children's Health Insurance Program--generally maintained or improved their access to care during the same period. This provides a reason for optimism about the ability of the coverage expansion in the Affordable Care Act to improve access for adults, but it suggests that eliminating the law or curtailing the coverage expansion could result in continued erosion of adults' access to care. [ABSTRACT FROM AUTHOR]

Public reports of provider performance on measures of the quality, costs, and outcomes of health care can spur improvement and help patients find the best providers. However, the likelihood that these benefits will materialize depends on the methods underlying each performance report. This paper presents a five-point methodological checklist to guide those who want to improve their performance reporting methods. The central goal is to help report makers minimize the frequency and severity of provider performance misclassification and avoid adverse unintended consequences of reporting. We believe that if those who produce the reports publicly explain how they address each checklist item, this increased transparency will encourage more rigorous methods and improve the chances that reports will lead to better, more efficient care. [ABSTRACT FROM AUTHOR]

Electronic health records have the potential to improve the environmental footprint of the health care industry. We estimate that Kaiser Permanente's electronic health record system, which covers 8.7 million beneficiaries, eliminated 1,000 tons of paper records and 68 tons of x-ray film, and that it has lowered gasoline consumption among patients who otherwise would have made trips to the doctor by at least three million gallons per year. However, the use of personal computers resulted in higher energy consumption and generated an additional 250 tons of waste. We conclude that electronic health records have a positive net effect on the environment, and that our model for evaluating their impact can be used to determine whether their use can improve communities' health. [ABSTRACT FROM AUTHOR]

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

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

The United States may advance toward a high-performing health care system that offers long-term services and supports for people with disabilities and chronic conditions, or it may retreat from gains achieved in recent years. Since the 1980s, policy makers and advocates for the disabled have sought to move from a system that emphasizes nursing homes and institutional care to one that includes a broader range of care options. The Affordable Care Act of 2010 gives this movement a considerable boost by offering states timely new options and enhanced federal funding to create a care system that meets the diverse needs and preferences of people with disabilities and that also recognizes the role of family caregivers. In this paper we outline the five key characteristics of a high-performing system of long-term services and supports. We describe an emerging "scorecard" that could help measure states' progress toward this goal. And we itemize aspects of the Affordable Care Act intended to support the creation of such a high-performing system for the disabled and those with chronic conditions. [ABSTRACT FROM AUTHOR]

What are the respective roles of the public and private sectors in drug development? This question is at the heart of some policy proposals, such as those that would give the government a share of profits from drugs at least partly developed with federal research dollars. This paper provides empirical data on these issues, using information included in the patents on drugs approved between 1988 and 2005. Overall, we find that direct government funding is more important in the development of "priority-review" drugs--sometimes described as the most innovative new drugs--than it is for "standard-review" drugs. Government funding has played an indirect role--for example, by funding basic underlying research that is built on in the drug discovery process--in almost half of the drugs approved and in almost two-thirds of priority-review drugs. Our analyses should help inform thinking about the returns on public research funding--a topic of long-standing interest to economists, policy makers, and health advocates. [ABSTRACT FROM AUTHOR]

The fifty states will play a critical role in implementing the Affordable Care Act, and California is one of the states at the forefront of reform. The act can provide coverage to millions of currently uninsured Californians and offers important benefits in terms of more-affordable coverage, improved access to services, and better health outcomes. As the paper by Peter Long and Jonathan Gruber in this issue of Health Affairs notes, the ultimate effects of health reform in California will be influenced by the policy and program decisions that state lawmakers and administrators make during the next three years. Key issues include revamping cumbersome eligibility determination and enrollment processes that could prevent rapid enrollment in expanded public health insurance-but also affording that expansion in the face of large state budget deficits. California policy makers need to move thoughtfully and strategically to ensure that the potential of federal health reform becomes a reality for state residents. [ABSTRACT FROM AUTHOR]

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

Some orthopedists and neurologists acquired their own magnetic resonance imaging (MRI) equipment during the early 2000s. This paper examines changes in imaging use and in overall spending by patients of orthopedists and neurologists who began billing for MRI scans between 1999 and 2005. Results show that physicians ordered substantially more scans once they began billing for MRI. For example, after orthopedists began billing for MRI, the number of MRI procedures used within thirty days of a first visit increased by about 38 percent. Not only did MRI spending increase for their patients, but spending for other aspects of care rose as well. Attention should be paid to ensuring that advanced medical equipment acquired in physician practices is used appropriately. [ABSTRACT FROM AUTHOR]

This paper presents updated national health spending projections for 2009-2019 that take into account recent comprehensive health reform legislation and other relevant changes in law and regulations. Relative to our February 2010 projections under prior law, average annual growth in national health spending over the projection period is estimated to be 0.2 percentage point higher than our previous estimate. The health care share of gross domestic product (GDP) is expected to be 0.3 percentage point higher in 2019. Within these net overall impacts are larger differences for trends in spending and spending growth by payer, attributable to reform's many major changes to health care coverage and financing. [ABSTRACT FROM AUTHOR]

Kathleen Sebelius, secretary of health and human services, has issued a challenge to enroll the millions of uninsured children eligible for public insurance in Medicaid or the Children's Health Insurance Program (CHIP). This paper provides estimates of the rates at which children in the various states participated in these programs in 2008 as well as the number who were eligible for them but uninsured. According to our coverage estimates, an estimated 7.3 million children were uninsured on an average day in 2008, of whom 4.7 million (65 percent) were eligible for Medicaid or CHIP but not enrolled. Participation rates varied across states from 55 percent to 95 percent, and ten states had participation rates close to or above 90 percent. Thirty-nine percent of eligible uninsured children (1.8 million) live in just three states--California, Texas, and Florida--and 61 percent (2.9 million) live in ten states. Meeting Secretary Sebelius's challenge means achieving success in these populous states, in part through tools and resources available under the 2009 CHIP reauthorization law. [ABSTRACT FROM AUTHOR]

The Patient Protection and Affordable Care Act established a new Patient-Centered Outcomes Research Institute to identify and address research priorities for comparative effectiveness research. Among its many responsibilities, the institute has been charged with setting priorities, developing methodological standards, and communicating research results to decision makers. In this paper we consider how the institute can support the different standards for acceptable evidence used by various government agencies, providers, patients, and other decision makers. We argue that the public interest will best be served if the institute develops a balanced and flexible approach to deciding which types of studies to fund. [ABSTRACT FROM AUTHOR]

The Patient Protection and Affordable Care Act established a new public-private entity for comparative effectiveness research: the Patient-Centered Outcomes Research Institute. The institute is charged with identifying priorities, establishing an agenda, and carrying out comparative effectiveness research. The political process through which the institute was formalized greatly influenced its scope and charge, including the organization's goals, its unique private-public composition, and its funding. In this paper I highlight key moments and offer background and insights into what did and did not end up in the final legislation. [ABSTRACT FROM AUTHOR]

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

Provisions of the American Recovery and Reinvestment Act authorize incentive payments to hospitals and clinicians who become "meaningful users" of health information technology (IT). We argue that various private-sector entities--commercial payers, employers, consumer groups, health care ratings organizations, large provider organizations, and regulatory bodies--can further accelerate health IT adoption by implementing strategies that are complementary to the Medicare and Medicaid incentive programs. This paper describes these strategies and potential approaches to implementation. [ABSTRACT FROM AUTHOR]

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

In this paper we present the costs of defensive medicine in thirty-five clinical specialties to determine whether malpractice liability reforms would greatly reduce health care costs. Defensive medicine includes tests and procedures ordered by physicians principally to reduce perceived threats of medical malpractice liability. The practice is commonly assumed to increase health care costs. The results of studies of the costs of defensive medicine have been inconsistent. We found that estimated savings resulting from a 10 percent decline in medical malpractice premiums would be less than 1 percent of total medical care costs in every specialty. These savings are lower than most previous estimates, and they suggest that the presumed impact of tort reform on health care costs may be overstated. [ABSTRACT FROM AUTHOR]

The health reform legislation signed into law by President Barack Obama contains numerous payment reform provisions designed to fundamentally transform the nation's health care system. Perhaps the most noteworthy of these is the establishment of a Center for Medicare and Medicaid Innovation within the Centers for Medicare and Medicaid Services. This paper presents recommendations that would maximize the new center's effectiveness in promoting reforms that can improve the quality and value of care in Medicare, Medicaid, and the Children's Health Insurance Program, while helping achieve health reform's goals of more efficient, coordinated, and effective care. [ABSTRACT FROM AUTHOR]

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

Numerous reports predict U.S. primary care physician shortages, with deficits of 20,000-46,000 doctors projected by 2020-25. Doctors of osteopathic medicine (DOs) could help fill some of the gap alongside their medical doctor (MD) colleagues. Many osteopathic schools haife undertaken initiatives to reinvigorate primary care career choices among students. This paper describes these developments, and it highlights as examples early-stage innovations at Lake Erie College of Osteopathic Medicine and A.T. Still University School of Osteopathic Medicine in Arizona. It will be several years before the changes can be assessed. The final outcome awaits coordinated national design changes in primary care support and training and in health care coverage. [ABSTRACT FROM AUTHOR]

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

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

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

Although the physician assistant (PA) profession was created to bolster the primary care workforce, PAs have assumed increasing roles in subspecialties. This paper compares specialty prevalence between physicians and physician assistants, analyzes trends in PM' specialty choices from 1997 to 2006, and suggests options for influencing these specialty choices in the future. The number of PM is growing more rapidly in surgical and medical subspecialties than in primary care. Salaries loosely correlate with specialty choice, especially among specialties with the highest income. If there is a societal interest in encouraging PAs to practice in primary care, new economic or educational policies may be required. [ABSTRACT FROM AUTHOR]

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

Implementing health information technology (IT) is a major strategic objective for providers. To pinpoint considerations that tie to success, the Premier health care alliance surveyed hospitals to develop an electronic health record best-practices library. Compiled from diverse health care organizations, the library outlines considerations to support "meaningful use" in the areas of computerized physician order entry, medication management, clinical documentation, reporting of measures, privacy, information exchange, management of populations' health, and personal health records. Best practices also uncovered strategies for securing executive leadership, culture change, communication, and support for clinicians. This paper summarizes lessons from the library, providing recommendations to speed up health IT implementation. [ABSTRACT FROM AUTHOR]

Policy makers generally agree that childhood obesity is a national problem. However, it is not always clear whether enough is being spent to combat it. This paper presents nine scenarios that assume three different degrees of reduction in obesity/overweight rates among children in three age groups. A mathematical model was then used to project lifetime health and economic gains. Spending $2 billion a year would be cost-effective if it reduced obesity among twelve-year-olds by one percentage point. The analysis also found that childhood obesity has more profound economic consequences than previously documented. Large investments to reduce this major contributor to adult disability may thus be cost-effective by widely accepted criteria. [ABSTRACT FROM AUTHOR]

Almost one-third of American children and adolescents are now either overweight or obese. One contributing factor may be the foods and beverages sold outside of the U.S. Department of Agriculture (USDA) school meal programs, which are often called "competitive foods." These foods, such as cookies, chips, and sodas, are often available through vending machines, snack bars, and other outlets on school premises. They are not required to conform to the nutritional standards of the USDA school meal programs. This paper looks at the research into whether these competitive foods may be affecting students' dietary intake or contributing to their risk of obesity. [ABSTRACT FROM AUTHOR]

To address the obesity crisis, public health experts recommend major reductions in the marketing of unhealthy food to youth. However, policies to restrict food marketing are not currently viewed as politically feasible. This paper examines attitudes and knowledge about food marketing and support for restricting unhealthy food marketing among one group of constituents: parents. A survey of 807 parents found that those most likely to support food marketing restrictions were also more likely to have negative views of current food practices. These findings suggest that increased public education about the harm caused by food marketing may increase public support for policy interventions. [ABSTRACT FROM AUTHOR]

In the past few decades, obesity rates among American children have skyrocketed. Although many factors have played a part in this unhealthy increase, this paper focuses on how economic policies may be contributing to our children's growing girth and how these policies might be altered to reverse this trend. It examines the economic causes and consequences of obesity, the rationales for government intervention, the cost-effectiveness of various policies, and the need for more research funding. [ABSTRACT FROM AUTHOR]

For thirty-five years, U.S. agriculture has operated under a "cheap food" policy that spurred production of a few commodity crops, not fruit or vegetables, and thus of the calories from them. A key driver of childhood obesity is the consumption of excess calories, many from inexpensive, nutrient-poor snacks, sweets, and sweetened beverages made with fats and sugars derived from these policy-supported crops. Limiting or eliminating farm subsidies to commodity farmers is wrongly perceived as a quick fix to a complex agricultural system, evolved over decades, that promotes obesity. Yet this paper does set forth a series of policy recommendations that could help, including managing commodity crop oversupply and supporting farmers who produce more fruit and vegetables to build a healthier, more balanced agricultural policy. [ABSTRACT FROM AUTHOR]

In this paper we explore whether uninsured Americans with three chronic conditions were less likely than the insured to be aware of their illness or to have it controlled. Among those with diabetes and elevated cholesterol, the uninsured were more often undiagnosed. Among hypertensives and people with elevated cholesterol, the uninsured more often had uncontrolled conditions. Undiagnosed and uncontrolled chronic illness, which is common among insured people, is even more frequent among the uninsured. [ABSTRACT FROM AUTHOR]

In this paper we explore whether uninsured Americans with three chronic conditions were less likely than the insured to be aware of their illness or to have it controlled. Among those with diabetes and elevated cholesterol, the uninsured were more often undiagnosed. Among hypertensives and people with elevated cholesterol, the uninsured more often had uncontrolled conditions. Undiagnosed and uncontrolled chronic illness, which is common among insured people, is even more frequent among the uninsured. [ABSTRACT FROM AUTHOR]

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