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Show where there will simply not be enough trained providers to serve as primary care givers even if we can restore incentives for them to be able to do so. A second major means of judging the health care reform proposal thus must be how successfully it addresses and reverses the incentives which have led to the demise of the primary care provider by changing incentives to encourage physicians, students, and other providers to turn to primary care fields for their professional careers. Cost Control/ Allocation of Resources We recognize that given a finite limitation of financial resources, we cannot as a society provide all care possible to all members of our communities who may want or need it. We must thus decide some means to allocate health care services to best meet the needs of individuals and communities, yet fit within the resources available. Currently, these allocation decisions are made principally by erecting barriers progressively to access for care until demand fits within the available resource supply. Those barriers can be financial, resulting through some of the incentives discussed above, which continue to increase the proportion of the population who are unable or unwilling to have health insurance coverage. Barriers may also be administrative, or due to paperwork, as in the extensive processes required to qualify for governmental support through Medicare or Medicaid programs, or through utilization controls and procedures for patients or providers requiring pre-authorization, written justification, repeated applications for approval, etc., for services provided by health insurance companies or a health care system. These barriers may also be cultural or language barriers, manifest in the inability of the health care provider community to understand or appreciate members of the broader community from different ethnic and cultural backgrounds. Regardless of what the barriers are or where they are erected, by their very nature they limit access to care or coverage in ways which are usually neither equitable nor rational. The current proposals for health care reform could also be judged on the basis of how effectively and equitably they remove barriers to health care access and how effectively and equitably they address the conflict between limited economic resources and unlimited demand for health care services. It has been suggested that any system of allocation, or "rationing" of care must meet at least the following criteria, and thus we judge our proposals based on if or how well they meet them (Cassell, 1993): 1. There must be universal access to a basic minimum level of care. 2. The income of providers must not be directly tied to treatment choices. 3. There must be a closed financial system within which meaningful tradeoffs can be made. 4. There must be an ethically acceptable framework for decision making (allocation decisions). How Does Utah HealthPrint Measure Up? Insurance Reform: Utah HealthPrint does begin to address the incentives necessary to return insurance to its original purpose. The 1994 Legislature's "first step" begins to return insurance premiums to a modified community-based rating, which will redirect insurance towards managing risk rather than avoiding it. There are many risk-basing "loopholes," however. One of these loopholes is allowing premium variation still on the basis of age, gender, geographic area, family composition, industry and size of group covered. These are planned for gradual elimination in subsequent years as we slowly move to full community based rating. If we succeed in doing so, then HealthPrint will have succeeded at least in this area. Utah HealthPrint, by mandating renewability of insurance coverage for small group plans, puts some limitation on the ability of insurance companies to eliminate risk. However, without a corresponding requirement to reasonably limit the cost of coverage for small groups, it is unlikely that this piece of HealthPrint will do much to stop small businesses or groups from dropping coverage as renewal time comes around and premium costs go up. Again, unless the costs are at least better distributed through full community based rating, we will not likely see much improvement in the practice of avoiding risk or much increase in the numbers of insured Utahns. Incentives for Primary Care: To put it simply, Utah HealthPrint does not address this issue, nor does it even seem to recognize it as a problem. Rural health care is noted as an item for study by the Health Policy Commission created by Utah HealthPrint. Primary care incentives are an important part of Rural Health concerns, yet primary care is much more than just a rural health issue. Many other states are taking a strong role in primary care, ranging from at least looking at the issue to directing their medical education facilities to increase primary care providers and distributing state education funds to reward them for doing so. Hopefully, Utah will address this issue more directly as Utah HealthPrint moves forward. 114 HEALTHPRINT COMMENTARY |