Enforcement Options Considered for Proposed California Health Insurance Mandate

California Gov. Arnold Schwarzenegger's (R) administration on Tuesday proposed using state and private databases to locate residents without health insurance, an approach that also could be used to enforce penalties against uninsured people, the Los Angeles Times reports. The plan was presented at a meeting of representatives from insurers, hospitals, physicians, business organizations and consumer advocacy groups (Rau, Los Angeles Times, 4/11).

Schwarzenegger in January announced a proposal that would require all state residents to obtain health insurance and would share the cost among employers, individuals, health care providers, health insurers and the government (Kaiser Daily Health Policy Report, 1/9). Schwarzenegger said the proposed system could be modeled after a system that the state Department of Motor Vehicles uses to track drivers without car insurance and another state system that tracks residents who do not pay child support. Under the plan, residents who lacked coverage for at least 60 days would be located through state or private databases.

The Schwarzenegger administration said that the proposal initially would be intended to notify uninsured residents that they must have insurance and help identify insurance options. Residents who do not obtain coverage after being notified would be subject to penalties. California Health and Human Services Agency Secretary Kim Belshe said the tracking system "represents one approach to enforcement," but she added that "nothing is set in stone." Other proposals under consideration would "attach the wages of people who don't buy insurance and ... increase the amount they owe in state income taxes," according to the Times. Some present at the meeting said they oppose penalties for the uninsured

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NHS DANGEROUS FOR SICK BABIES

Care for premature or seriously ill babies has fallen even farther below acceptable standards, the baby charity Bliss has found. In a report prepared for it by two researchers at the National Perinatal Epidemiology Unit, it finds that units are understaffed, often have to close to new admissions, and that babies often need to be driven hundreds of miles to the nearest empty intensive care cot.

The report shows that, on average, baby units are understaffed by a third and suitably qualified nurses are in particularly short supply. Two thirds of units, not wishing to turn babies away, admitted more than they could care for properly. Many babies needing the highest levels of intensive care had to be treated in units capable of providing only lower levels. Ideally, said Bliss, there should be one nurse for every baby in intensive care, a staffing figure agreed by ministers. The research for its report shows that if this target were achieved infant deaths could be reduced by 48 per cent. At present less than 4 per cent of units achieve this staffing ratio.

Andy Cole, the chief executive of Bliss, said: "The first few days after birth are absolutely critical for babies born premature or sick, and the care they receive during this period shapes not only their chances of survival but also their future health. "Bliss is concerned that the Government gives less priority to intensive care for babies than for adults and children and that it is only thanks to the goodwill and commitment of doctors and nurses that babies are being cared for in some cases. "We are calling on the Government to make one-to-one nursing care mandatory for intensive care babies, and to commit the necessary resources to get this essential service back on track."

The new report, Special Delivery or Second Class, was based on data provided by almost 80 per cent of the 224 units in hospitals for the care of newborn babies. Demand for such services is increasing. Last year 80,000 babies were admitted to the units, which are classifed into three categories: intensive-care units, high-dependency units, and special-care units. The babies needing care were born prematurely (less than 37 weeks of gestation), of low birth weight (less than 5.5lb) or had other medical problems. The number of babies who survive such an unpromising start in life is increasing, so the demand for the units is increasing.

Between 60 and 70 per cent of units said that demand for cots exceeded capacity last year across all three levels of care. As a result, some babies were being given care in inappropriate units: 1,233 were given breathing support in special-care units, for example, which are equipped to deliver such care only in the short-term.

Some transfers of babies between units are inevitable and can be justified if, for example, they need surgery. Transfers simply because units are full (called inappropriate transfers) should not exceed 10 per cent. Last year the figure was 22.6 per cent. In one in four cases twins or triplets were separated and sent to units that may be hundreds of miles apart, a traumatic experience for mothers. "It is hard to imagine having the stress of one child in an intensive care unit," Mr Cole said. "Imagine having two, split by 150 miles."

Three years ago the Department of Health committed 70 million pounds to improving the service but the money has now almost run out, and Bliss believes that at least 20 million of it disappeared into other budgets because it was not ring-fenced. It calculates that to meet the full requirement of one-to-one nursing, the present numbers need to rise from 5,863 whole-time equivalents to 8,147, an increase of almost 2,300 nurses, which would cost 75 million a year.

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For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

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