Financing reform for long-term care: strategies for public and private long-term care insurance

The way the nation provides for the financing and delivery of long-term care is badly in need of reform. The principal options for change are private insurance, altering Medicaid, and public long-term care insurance. This article uses the Brookings-ICF Long-Term Care Financing Model to evaluate each of these options in terms of affordability, distribution of benefits, and ability to reduce catastrophic out-of-pocket costs. So long as private insurance is aimed at the elderly, its market penetration and ability to finance long-term care will remain severely limited. Affordability is a major problem. Selling to younger persons could solve the affordability problem, but marketing is extremely difficult. Liberalizing Medicaid could help solve the problems of long-term care, but there is little public support for means-tested programs. Finally, universalistic public insurance programs do well in meeting the goals of long-term care reform, but all social insurance programs are expensive and seem politically infeasible in the current political environment.     

The Value of Information in Decision‐Analytic Modeling for Malaria Vector Control in East Africa

Decision analysis tools and mathematical modeling are increasingly emphasized in malaria control programs worldwide to improve resource allocation and address ongoing challenges with sustainability. However, such tools require substantial scientific evidence, which is costly to acquire. The value of information (VOI) has been proposed as a metric for gauging the value of reduced model uncertainty. We apply this concept to an evidenced‐based Malaria Decision Analysis Support Tool (MDAST) designed for application in East Africa. In developing MDAST, substantial gaps in the scientific evidence base were identified regarding insecticide resistance in malaria vector control and the effectiveness of alternative mosquito control approaches, including larviciding. We identify four entomological parameters in the model (two for insecticide resistance and two for larviciding) that involve high levels of uncertainty and to which outputs in MDAST are sensitive. We estimate and compare a VOI for combinations of these parameters in evaluating three policy alternatives relative to a status quo policy. We find having perfect information on the uncertain parameters could improve program net benefits by up to 5–21%, with the highest VOI associated with jointly eliminating uncertainty about reproductive speed of malaria‐transmitting mosquitoes and initial efficacy of larviciding at reducing the emergence of new adult mosquitoes. Future research on parameter uncertainty in decision analysis of malaria control policy should investigate the VOI with respect to other aspects of malaria transmission (such as antimalarial resistance), the costs of reducing uncertainty in these parameters, and the extent to which imperfect information about these parameters can improve payoffs.     

Coordination of benefits reduces double payments.

As a means of reducing the cost of duplicate health care coverage, the health insurance industry utilizes a mechanism called coordination of benefits (COB). The main purposes of COB are to limit recovery to 100 percent of actual charges and to assign insurers primary and secondary responsibilities to pay these charges. Nearly all health plans, including HMOs, Blue Cross/Blue Shield plans, and commercial insurers, coordinate benefits, mostly for group coverage, often on the basis of procedures found in state insurance codes. While COB provides an effective cost reduction mechanism to health insurers, several issues remain in its administration, including difficulties that arise when carriers refuse to pay, when HMO members self-refer, and when coordination is attempted with an uninsured plan.     

Search for a majority element

A new short proof of a theorem of Saks and Werman is given about the number of weighings necessary and sufficient to determine a majority type coin among n coins of two possible weights by comparisons. A lower bound on the number of good algorithms is proved and further questions are posed about determining the majority in different weighing models.     

Learning to Manage the Multirisk World

Risk assessment, perception, and management tend to focus on one risk at a time. But we live in a multirisk world. This essay in honor of the 40th anniversary of the Society for Risk Analysis (SRA) and the journal Risk Analysis suggests that we can—and have already begun to—strengthen risk analysis and policy outcomes by moving from a focus on the single to the multiple—multiple stressors, multiple impacts, and multiple decisions. This evolution can improve our abilities to assess actual risks, to confront and weigh risk-risk trade-offs and innovate risk-superior moves, and to build learning into adaptive regulation that adjusts over time. Recognizing the multirisk reality can help us understand complex systems, foresee unintended consequences, design better policy solutions, and learn to improve.     

Making sense of the new geography of citizenship: Fragmented citizenship in the European Union

Theory and Society -     

“I Didn't Leave Y'all on Purpose”: HIV-Infected Mothers' Videotaped Legacies for Their Children

The authors analyzed twelve videotapes made by HIV-infected women for their children. Using grounded theory methods the concept of eternal mothering provides a framework to study the interactive aspects of mothering, and the significance of impending maternal death from a stigmatizing illness. In creating these videotape legacies, the mothers drew on personal experiences of gender, class, race, ethnicity, family configurations, and other social conditions. There is tension between women's self-presentation in an attempt to control the impressions they make on their children, and their decision to disclose stigmatizing secrets with the potential consequential loss of maternal authority and children's loyalty, as well as inherited shame by association.     

The CLASS Act: is it dead or just sleeping?

The Affordable Care Act (ACA) established a voluntary public insurance program for long-term care: the Community Living Assistance Services and Supports (CLASS) Act. In October 2011, the Obama Administration announced that the program would not be implemented because of the high risk of fiscal insolvency. Under the legislative design, adverse selection was a major risk and premiums would have been very high. This article discusses several CLASS Act design and implementation issues, including the design features that led to the decision not to implement the program: the voluntary enrollment, the weak work requirement, the lifetime and cash benefits, and the premium subsidy for low-income workers and students.     

Estimates of the Health Risk Reductions Associated with Attainment of Alternative Particulate Matter Standards in Two U.S. Cities

As part of its periodic re-evaluation of particulate matter (PM) standards, the U.S. Environmental Protection Agency estimated the health risk reductions associated with attainment of alternative PM standards in two locations in the United States with relatively complete air quality data: Philadelphia and Los Angeles. PM standards at the time of the analysis were defined for particles of aerodynamic diameter less than or equal to 10 microm, denoted as PM-10. The risk analyses estimated the risk reductions that would be associated with changing from attainment of the PM-10 standards then in place to attainment of alternative standards using an indicator measuring fine particles, defined as those particles of aerodynamic diameter less than or equal to 2.5 microm and denoted as PM-2.5. Annual average PM-2.5 standards of 12.5, 15, and 20 microg/m3 were considered in various combinations with daily PM-2.5 standards of 50 and 65 microg/m3. Attainment of a standard or set of standards was simulated by a proportional rollback of "as is" daily PM concentrations to daily PM concentrations that would just meet the standard(s). The predicted reductions in the incidence of health effects varied from zero, for those alternative standards already being met, to substantial reductions of over 88% of all PM-associated incidence (e.g., in mortality associated with long-term exposures in Los Angeles, under attainment of an annual standard of 12.5 microg/m3). Sensitivity analyses and integrated uncertainty analyses assessed the multiple-source uncertainty surrounding estimates of risk reduction.