Prefunding Medicare without individual accounts.

It has recently been proposed that Medicare be prefunded through the creation of individual medical retirement accounts. There is a strong case for prefunding Medicare in anticipation of the retirement of the numerous baby boomers. But the creation of individual accounts would involve a new departure for Medicare with serious potential shortcomings. This paper shows how Medicare can be prefunded without the creation of individual accounts--through a Medicare trust fund reform.

Health Card: a new reform plan.

Health Card is a new reform plan. Every household, regardless of employment of health status, would receive a government-issued health credit card to use at the doctor's office or hospital like MasterCard. Later, it would be billed a percentage of the provider's charge--a percentage scaled to its last income tax return; its annual burden would never exceed a designated percentage of its income. Health Card would simply and directly achieve universal coverage and equitable patient cost-sharing. Like MasterCard, government would pay bills, not regulate providers. Each household would choose its medical provider (fee-for-service or HMO), bearing a percentage of the charge. Provider competition for cost-sharing consumers would help contain health care costs.

A cost-effective weight loss program at the worksite.

A major focus of Lockheed Missiles and Space Company's wellness program (Sunnyvale, Calif.) was to motivate weight loss in a cost-effective manner. The educationally based "Take It Off '83" campaign was created using the concepts of competition and self-responsibility. Seventy percent of the initial 2,499 participants completed the program, and 90% of these lost weight. Program completion rates and weight lost were higher for men than for women and higher for those who participated as team members rather than as individuals. Encouraging the formation of supportive/competitive teams proved to be a very effective means of promoting weight loss. The cost-effective motivation of weight loss in an industrial setting was accomplished successfully through this program (the cost to the company per initial participant was +5.40). Because of these results, the program will be repeated annually.

Impaired steroidogenesis in the luteal phase of the reproductive cycle and during pregnancy in rhesus monkeys immunized with the beta-subunit of ovine luteinizing hormone.

Monkeys immunized with the beta-subunit of ovine luteinizing hormone (oLH beta) develop antibodies which cross react with rhesus chorionic gonadotropin (rhCG) and luteinizing hormone (rhLH). Immunization causes shortened menstrual cycles and reduced fertility. Fertility can be restored by administration of medroxyprogesterone acetate (MPA) during the first 5 weeks of pregnancy. In the present study, we have measured the effects of circulating oLH beta-antibodies on peripheral estradiol, progesterone and 17 alpha OH-progesterone (17OH-P) concentrations throughout the menstrual cycle and during gestation in monkeys which became pregnant following MPA-treatment. Progesterone concentrations were markedly reduced during the luteal phase in cycling animals and the luteal phase of the cycle was significantly shorter as compared to non-immunized controls. Concentrations of estradiol and 17OH-P in the peripheral circulation were not affected by the oLH beta-antibodies. In immunized monkeys which became pregnant following MPA-treatment, progesterone and 17OH-P levels were consistently lower and estradiol concentrations were increased during the second and third trimesters. Our results show that circulating antibodies to oLH beta have multiple endocrinological effects. Corpus luteum function is impaired in cycling monkeys and during the early part of pregnancy. In addition, the pattern of steroid secretion remains abnormal in pregnant monkeys even after the luteal-placental shift.

Human chorionic gonadotropin maintains plasma progesterone at pregnancy levels in rhesus monkeys.

Peripheral plasma progesterone (P) levels in the rhesus monkey remain relatively constant both during the latter half of pregnancy and for long periods after fetectomy (removal of the fetus with the placenta left in situ) or ovariectomy. The constancy is maintained despite what appears to be reciprocal changes in the relative contributions of ovary and placenta. Placental regulation of the corpus luteum is likely, but it is not known if the corpus luteum responds to a gonadotropic stimulus in the later stages of pregnancy. In this study, we have investigated the effects of hCG administration in postdelivery monkeys (normally pregnant, fetectomized, ovariectomized and sham ovariectomized animals) and have determined if hCG administration maintains plasma P at pregnancy levels. hCG maintained P at pregnancy levels after surgical removal of the conceptus near term in both normally pregnant and previously fetectomized monkeys over a 7-day treatment period. hCG treatment after normal delivery maintained P levels in sham-ovariectomized but not in ovariectomized monkeys over an 8-day treatment period. The magnitude of the response to hCG declines over the treatment period in all groups except fetectomized monkeys, although hCG levels in the peripheral plasma are quite constant. These results indicate that the ovary of late pregnancy is fully capable of producing P at normal values and is responsive to this gonadotropin.

Effects of immunization with the beta-subunit of ovine luteinizing hormone on corpus luteum function in the rhesus monkey.

Rhesus monkeys immunized with the beta-subunit of ovine luteinizing hormone (oLHbeta) developed circulating antibodies which cross-reacted strongly with rhesus monkey chorionic gonadotropin. Normal ovulatory cycles continued, but the fertility of immunized monkeys as compared with that of controls was significantly reduced. Thus, the rhesus monkey represented a useful animal model for the study of certain aspects of an "antifertility vaccine." We investigated the effects of circulating antibodies to oLHbeta on corpus luteum function by measuring production rates (PRs) and peripheral concentrations of progesterone during the luteal phase of the menstrual cycle. Both parameters were significantly lower in immunized animals than in control animals. The length of the menstrual cycle was also significantly reduced. Progesterone PRs were also determined on days 10 and 15 after mating to test the assumption that the antifertility vaccine prevents pregnancy by interfering with "corpus luteum rescue" (the increase in PRs of progesterone usually occurring on day 15 after mating in fertilized animals). PRs increased from days 10 to 15 in pregnant controls, were unchanged in nonpregnant controls, and were significantly lower on day 15 in immunized monkeys as compared with nonpregnant and pregnant controls. These results suggest that "corpus luteum rescue" is suppressed in immunized animals.

A cash-equivalent option under "major-risk" national health insurance.

A central purpose of proposed "major-risk" ("catastrophic") national health insurance would be to provide an incentive to economize by requiring most households to pay, out of pocket, at least a fraction of the cost of all medical care they use. To help ensure the success of this cost-conscious strategy, the author asserts, a cash-equivalent option for workplace supplementary private health insurance should be legally required.

The Aroman food crisis: a fable with a lesson for national health insurance.

An analogy is always imperfect. Nevertheless, at times it is an effective way to communicate an insight. This paper uses an analogy to examine the consequences of attempting to achieve health sector efficiency through regulation, instead of consumer cost-sharing. It is suggested that as long as hospital care continues to be virtually "free" to patients at the time of use, such regulation may well do more harm than good. Moreover, a national health insurance plan that would make all medical care "free" to patients, and would pay for all health care through taxes (the proposed Health Security Act), would not only generate significant inefficiency; but, in contrast to the intentions of its supporters, would prove harmful to the poor and the elderly, by shifting scarce Federal tax dollars away from the programs that assist them in order to pay the medical bills of middle and upper income households. It is therefore urged that we enact income-related catastrophic national health insurance, that would place a ceiling, which varies with household income, on the financial burden a household must bear; but at the same time, would require most families to pay part of their own medical cost out-of-pocket, so that consumer cost-consciousness can help promote health sector efficiency.