Paying for graduate medical education: the debate goes on.

The debate over Medicare payments for graduate medical education has been conducted under the premise that such payments cover the added costs of training. Standard economic theory suggests that residents bear the costs of their training, implying that the additional costs of teaching hospitals are not attributable to training per se but to some combination of a different patient care product, unmeasured case-mix differences, and the costs of clinical research. As a result, payment for the additional patient care costs at teaching hospitals should come from the Medicare trust fund; any subsidies for training should come from general revenues.

Medicare: what's right? What's wrong? What's next?

Although future Medicare costs are highly uncertain, reasonable projections of those costs suggest a major financing problem. The Balanced Budget Act of 1997 will provide temporary relief, although it introduced some new problems, including its geographic adjustment of Medicare+Choice rates. For the future we propose a premium-support system and an expanded benefits package. Such a system would provide a more flexible means to adjust the division of the financing burden between the elderly and the nonelderly, potentially gain some efficiencies from greater price competition and less reliance on administered pricing, and partly address the issue of uninsured early retirees.

Medicare managed care. Why is it coming?

The fear that managed care is making inroads into Medicare has struck a note of near panic in the minds of many American physicians. Making more options available to seniors, including many types of managed care plans, and reforming the way Medicare makes payments to such plans, however, may be more attractive to physicians than the continued reliance on the direct control system that has been traditionally associated with Medicare. This article discusses the changing private sector, the present structure of Medicare, how plans are paid, what physicians can expect in the near-term, and future fiscal pressures on Medicare.

What happened, what next?

Many physicians and other health care professionals breathed a collective sigh of relief when the 103rd Congress adjourned without passing the Clinton Health Security Act or any other health care reform legilsation. The ambition of this brief paper is to describe why health care reform did not pass in 1994, the issues that need to be resolved if we are to pass legislation, the political forces that will need to be addressed before legislation is passed, and the type of struggles we can expect to see in the coming session of Congress.

Health reform: what will it take to pass?

The health care reform debate has begun in earnest, but the outcome for 1994 is highly uncertain. Divisions among Democrats on health care reform are very serious, with conservative Democrats closer to mainstream Republicans than to their own congressional leadership on the key issues of spending limits, price controls, and employer mandates. Because 1994 is an election year, and given the commitment of the president to reform, passage of legislation that is somewhere between a less regulatory form of managed competition and incremental reform is possible. But because of the divisions within Congress and the president's overly ambitious starting point, near-term passage is not inevitable.