Original Research

@article{woolhandler_correction_1994,

title = {Correction: The deteriorating administrative efficiency of the UṠ. health care system.},

author = {S. Woolhandler and D. U. Himmelstein},

doi = {10.1056/nejm199408043310520},

issn = {0028-4793},

year  = {1994},

date = {1994-08-01},

journal = {The New England journal of medicine},

volume = {331},

number = {5},

pages = {336},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{willcox_inappropriate_1994,

title = {Inappropriate drug prescribing for the community-dwelling elderly.},

author = {S. M. Willcox and D. U. Himmelstein and S. Woolhandler},

issn = {0098-7484},

year  = {1994},

date = {1994-07-01},

journal = {JAMA},

volume = {272},

number = {4},

pages = {292–296},

abstract = {OBJECTIVE: To examine the amount of inappropriate drug prescribing for Americans aged 65 years or older living in the community. DESIGN: Cross-sectional survey of a national probability sample of older adults. SETTING: The 1987 National Medical Expenditure Survey, a national probability sample of the US civilian noninstitutionalized population, with oversampling of some population groups, including the elderly. SUBJECTS: The 6171 people aged 65 years or older in the National Medical Expenditure Survey sample, using appropriate weighting procedures to produce national estimates. MAIN OUTCOME MEASURES: Incidence of prescribing 20 potentially inappropriate drugs, using explicit criteria previously developed by 13 United States and Canadian geriatrics experts through a modified Delphi consensus technique. Three cardiovascular drugs identified as potentially inappropriate were analyzed separately since they may be considered appropriate for some noninstitutionalized elderly patients. RESULTS: A total of 23.5% (95% confidence interval [CI], 22.4% to 24.6%) of people aged 65 years or older living in the community, or 6.64 million Americans (95% CI, 6.28 million to 7.00 million), received at least one of the 20 contraindicated drugs. While 79.6% (95% CI, 77.2% to 82.0%) of people receiving potentially inappropriate medications received only one such drug, 20.4% received two or more. The most commonly prescribed of these drugs were dipyridamole, propoxyphene, amitriptyline, chlorpropamide, diazepam, indomethacin, and chlordiazepoxide, each used by at least half a million people aged 65 years or older. Including the three controversial cardiovascular agents (propranolol, methyldopa, and reserpine) in the list of contraindicated drugs increased the incidence of probably inappropriate medication use to 32% (95% CI, 30.7% to 33.3%), or 9.04 million people (95% CI, 8.64 million to 9.44 million). CONCLUSION: Physicians prescribe potentially inappropriate medications for nearly a quarter of all older people living in the community, placing them at risk of drug adverse effects such as cognitive impairment and sedation. Although most previous strategies for improving drug prescribing for the elderly have focused on nursing homes, broader educational and regulatory initiatives are needed.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{hellander_health_1994,

title = {Health care paper chase, 1993: the cost to the nation, the states, and the District of Columbia.},

author = {I. Hellander and D. U. Himmelstein and S. Woolhandler and S. Wolfe},

doi = {10.2190/TXXQ-P955-E61G-ME9J},

issn = {0020-7314},

year  = {1994},

date = {1994-01-01},

journal = {International journal of health services : planning, administration, evaluation},

volume = {24},

number = {1},

pages = {1–9},

abstract = {The U.S. health care payment system is an elaborate and increasingly wasteful paper chase. This article presents new state-by-state estimates of health care administrative costs in the United States, and savings that could be realized with single-payer reform. In 1993, health care bureaucracy will consume 24.7 cents of every health care dollar, a total of $232.3 billion. Administration's share of health spending is up from 23.9 percent in 1987, and from 21.9 percent in 1983. Reducing the cost of administration to Canadian levels by adopting a single-payer health care system would cut U.S. health care bureaucracy by more than half (50.7 percent), saving at least $117.7 billion in 1993. The savings achievable with a single-payer system could fund universal access for the uninsured and improve benefits for the tens of millions of Americans who currently have only partial coverage, without any increase in overall health spending. Reform measures such as electronic billing, insurance industry consolidation, and increased competition (including "managed competition") would save little or nothing on administration. Only a single-payer reform that incorporates the "macro-management" approach to cost control, as in Canada, can achieve significant administrative savings.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{woolhandler_administrative_1993,

title = {Administrative costs in UṠ. hospitals.},

author = {S. Woolhandler and D. U. Himmelstein and J. P. Lewontin},

doi = {10.1056/NEJM199308053290606},

issn = {0028-4793},

year  = {1993},

date = {1993-08-01},

journal = {The New England journal of medicine},

volume = {329},

number = {6},

pages = {400–403},

abstract = {BACKGROUND: Previous estimates of administrative costs in U.S. hospitals have been based on figures for California, and nationwide extrapolation has been controversial. If the costs of bureaucracy are high, major policy reforms may yield substantial savings. METHODS: We obtained detailed data on hospital expenses for fiscal year 1990 from reports submitted to Medicare by 6400 hospitals. We calculated each hospital's administrative costs by summing expenses in the following Medicare cost-accounting categories: administrative and general, nursing administration, central services and supply (excluding the purchase cost of supplies), medical records and library, utilization review, and the salary costs of the employee benefits department. We classified costs in most other categories as clinical. Some small categories of expenses (e.g., gift shop) were excluded from both our clinical and administrative groupings, and for others (e.g., plant operations), a proportional share was allocated between the two groupings. RESULTS: Nationwide, administration accounted for an average of 24.8 percent of each hospital's spending in fiscal 1990. Average hospital administrative costs ranged from 20.5 percent in Minnesota to 30.6 percent in Hawaii. Administrative salaries accounted for 22.4 percent of the average hospital's salary costs. Administrative costs were similar in states with high and low rates of enrollment in health maintenance organizations (HMOs). CONCLUSIONS: Hospital administrative costs in the United States are higher than previous estimates and more than twice as high as those in Canada. Greater enrollment in HMOs, with more competitive bidding by hospitals for managed-care contracts, an important element of proposed managed-competition health care reforms, does not seem to lower hospital administrative costs.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{himmelstein_end_1993,

title = {The end stage renal disease program.},

author = {D. U. Himmelstein and S. Woolhandler},

issn = {0028-4793},

year  = {1993},

date = {1993-07-01},

journal = {The New England journal of medicine},

volume = {329},

number = {2},

pages = {139–40; author reply 140–141},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{himmelstein_american_1993,

title = {The American Health Care System–Medicare.},

author = {D. U. Himmelstein and S. Woolhandler},

issn = {0028-4793},

year  = {1993},

date = {1993-06-01},

journal = {The New England journal of medicine},

volume = {328},

number = {24},

pages = {1789; author reply 1790},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{clancy_questions_1993,

title = {Questions and answers about managed competition.},

author = {C. M. Clancy and D. U. Himmelstein and S. Woolhandler},

issn = {0017-9051},

year  = {1993},

date = {1993-01-01},

journal = {Health PAC bulletin},

volume = {23},

number = {1},

pages = {30–32},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{clancy_questions_1993-1,

title = {Questions and answers about managed competition.},

author = {C. M. Clancy and D. U. Himmelstein and S. Woolhandler},

issn = {0025-4800},

year  = {1993},

date = {1993-01-01},

journal = {Journal of the Massachusetts Dental Society},

volume = {42},

number = {2},

pages = {81–84},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{clancy_questions_1993-2,

title = {Questions and answers about managed competition.},

author = {C. M. Clancy and D. U. Himmelstein and S. Woolhandler},

doi = {10.2190/DJA5-CGCB-M4RJ-3VW9},

issn = {0020-7314},

year  = {1993},

date = {1993-01-01},

journal = {International journal of health services : planning, administration, evaluation},

volume = {23},

number = {2},

pages = {213–218},

abstract = {The Managed Competition strategy for health care financing reform would push most people into cut-rate versions of health maintenance organizations chosen for them by their employer and owned by an insurance company. Many of those who currently enjoy good coverage would be forced into bare bones plans, and would forfeit the right to choose their health care provider. There is little evidence that the rigidly multi-tiered system created by Managed Competition would be more efficient or less expensive than the current U.S. system, and administrative costs would likely rise. Promises to expand coverage for the uninsured are likely to fall by the wayside if cost containment fails, and no current Managed Competition proposals address long-term care. In rural areas including at least 30 percent of the U.S. population, price competition central to the Managed Competition strategy is untenable since a long hospital or other provider cannot compete with itself. Managed Competition would empower vertically integrated corporate health care insurer/providers and disempower patients and the clinical work force.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{himmelstein_bias_1992,

title = {Bias in, bias out: a reply to Sheils, Young, and Rubin.},

author = {D. U. Himmelstein and S. Woolhandler},

doi = {10.1377/hlthaff.11.2.235-a},

issn = {0278-2715},

year  = {1992},

date = {1992-01-01},

journal = {Health affairs (Project Hope)},

volume = {11},

number = {2},

pages = {235–238},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{himmelstein_perils_1992,

title = {Perils of prediction in UṠ./Canadian comparisons.},

author = {D. U. Himmelstein and S. Woolhandler},

doi = {10.1377/hlthaff.11.4.255},

issn = {0278-2715},

year  = {1992},

date = {1992-01-01},

journal = {Health affairs (Project Hope)},

volume = {11},

number = {4},

pages = {255–257},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{himmelstein_vanishing_1992,

title = {The vanishing health care safety net: new data on uninsured Americans.},

author = {D. U. Himmelstein and S. Woolhandler and S. M. Wolfe},

doi = {10.2190/5FBA-VEKK-K2DK-JF8V},

issn = {0020-7314},

year  = {1992},

date = {1992-01-01},

journal = {International journal of health services : planning, administration, evaluation},

volume = {22},

number = {3},

pages = {381–396},

abstract = {New data obtained from the Census Bureau shows that the number of Americans without any health insurance increased by 1.3 million between 1989 and 1990, bringing the total number of uninsured to 34.7 million, more than at any time since the passage of Medicare and Medicaid 25 years ago. This increase coincided with a 10.5 percent increase in health spending, the second largest in the past three decades. The number of people covered by Medicaid grew by 3.1 million, due to a one-time expansion of eligibility mandated by Congress, but this was more than counter-balanced by a population growth of 3 million and a decrease of 1.3 million in people covered by private insurance. Had Medicaid not been expanded, the number of uninsured would have increased by 4.4 million. The increase in the uninsured affected virtually all parts of the nation. Seven states had increases of more than 100,000 persons each. Only Texas experienced a decrease of that magnitude, but still had the second highest rate of uninsurance of any state. Of the 1.3 million additional uninsured in 1990, 77 percent were male, 32 percent had family incomes in excess of $50,000 per year, and 74 percent had annual family incomes above $25,000. Fewer than 9 percent had incomes below the poverty line. The numbers of uninsured children and senior citizens fell slightly (but not significantly), while the number of uninsured working-age adults rose by 1.4 million. The number of uninsured workers in each of four of 20 major industry groups increased by more than 100,000 in 1990. None of the industry groups showed a significant decline in the number of uninsured. Among professionals, there were substantial numbers of uninsured doctors, engineers, teachers, college professors, clergy, and others, but all legislators and judges were insured. The data presented here largely predate the recession and understate current problems. In 1991 the number of uninsured will likely reach nearly 40 million. Also, these estimates are based on the number of people uninsured at a single time during 1990; a far higher number were temporarily uninsured at some point during the year. Moreover the Census Bureau survey ignores the problem of the underinsurance of at least 50 million insured Americans. Patchwork public programs are grossly inadequate to plug the holes. A national health program covering all Americans could assure access to care and contain costs.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{harrington_national_1991,

title = {A national long-term care program for the United States. A caring vision. The Working Group on Long-term Care Program Design, Physicians for a National Health Program.},

author = {C. Harrington and C. Cassel and C. L. Estes and S. Woolhandler and D. U. Himmelstein},

issn = {0098-7484},

year  = {1991},

date = {1991-12-01},

journal = {JAMA},

volume = {266},

number = {21},

pages = {3023–3029},

abstract = {The financing and delivery of long-term care (LTC) need substantial reform. Many cannot afford essential services; age restrictions often arbitrarily limit access for the nonelderly, although more than a third of those needing care are under 65 years old; Medicaid, the principal third-party payer for LTC, is biased toward nursing home care and discourages independent living; informal care provided by relatives and friends, the only assistance used by 70% of those needing LTC, is neither supported nor encouraged; and insurance coverage often excludes critically important services that fall outside narrow definitions of medically necessary care. We describe an LTC program designed as an integral component of the national health program advanced by Physicians for a National Health Program. Everyone would be covered for all medically and socially necessary services under a single public plan, federally mandated and funded but administered locally. An LTC payment board in each state would contract directly with providers through a network of local public agencies responsible for eligibility determination and care coordination. Nursing homes, home care agencies, and other institutional providers would be paid a global budget to cover all operating costs and would not bill on a per-patient basis. Alternatively, integrated provider organizations could receive a capitation fee to cover a broad range of LTC and acute care services. Individual practitioners could continue to be paid on a fee-for-service basis or could receive salaries from institutional providers. Support for innovation, training of LTC personnel, and monitoring of the quality of care would be greatly augmented. For-profit providers would be compensated for past investments and phased out. Our program would add between $18 billion and $23.5 billion annually to current spending on LTC. Polls indicate that a majority of Americans want such a program and are willing to pay earmarked taxes to support it.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{himmelstein_who_1991,

title = {Who cares for the care givers? Lack of health insurance among health and insurance personnel.},

author = {D. U. Himmelstein and S. Woolhandler},

issn = {0098-7484},

year  = {1991},

date = {1991-07-01},

journal = {JAMA},

volume = {266},

number = {3},

pages = {399–401},

abstract = {OBJECTIVE: –To analyze the health insurance status of physicians, other health personnel, and insurance industry personnel. DESIGN: –The study was based on data collected by the US Bureau of the Census in the March 1991 Current Population Survey for six groups of workers in health care occupations and three classifications of insurance employees. This survey included 6182 civilian health personnel and 1498 insurance workers under the age of 65 years. RESULTS: –Of civilian health personnel under the age of 65 years, 9% (90% confidence interval [CI], 8.2% to 9.8%) are uninsured, equivalent to 834,000 persons, including 15,000 (90% CI, 5000 to 25,000) physicians. Among insurance workers, 5.1% (90% CI, 3.9% to 6.2%) are uninsured. While 6% (90% CI, 4.2% to 7.9%) of those working in physicians' offices are uninsured, 52.2% (90% CI, 48.2% to 56.3%) receive no employer contribution toward their coverage. More than a fifth of nursing home employees lack insurance coverage, as do nearly a quarter of the 1.868 million health care workers with annual incomes less than $10,000. CONCLUSION: –Nearly a million health care and insurance workers are themselves uninsured and at high risk for being unable to obtain needed care.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{wolfe_invitation_1991,

title = {Invitation to hospitals: join the push for a single-payer, waste-avoiding health system.},

author = {S. M. Wolfe and D. U. Himmelstein and S. J. Woolhandler},

issn = {0160-7480},

year  = {1991},

date = {1991-05-01},

journal = {Modern healthcare},

volume = {21},

number = {19},

pages = {22},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{woolhandler_deteriorating_1991,

title = {The deteriorating administrative efficiency of the UṠ. health care system.},

author = {S. Woolhandler and D. U. Himmelstein},

doi = {10.1056/NEJM199105023241805},

issn = {0028-4793},

year  = {1991},

date = {1991-05-01},

journal = {The New England journal of medicine},

volume = {324},

number = {18},

pages = {1253–1258},

abstract = {BACKGROUND AND METHODS: In 1983 the proportion of health care expenditures consumed by administration in the United States was 60 percent higher than in Canada and 97 percent higher than in Britain. To assess the effects of recent health policy initiatives on the administrative efficiency of health care, we examined four components of administrative costs in the United States and Canada for 1987: insurance overhead, hospital administration, nursing home administration, and physicians' billing and overhead expenses. Most data were provided by the two nations' federal health and statistics agencies, supplemented by state and provincial data and published sources. Because data on physicians' billing costs were limited, we estimated a range for these costs by two methods that rely on different sources of data. All figures are reported in 1987 U.S. dollars. RESULTS: In 1987 health care administration cost between $96.8 billion and $120.4 billion in the United States, amounting to 19.3 to 24.1 percent of total spending on health care, or $400 to $497 per capita. In Canada, between 8.4 and 11.1 percent of health care spending ($117 to $156 per capita) was devoted to administration. Administrative costs in the United States increased 37 percent in real dollars between 1983 and 1987, whereas in Canada they declined. The proportion of health care spending consumed by administration is now at least 117 percent higher in the United States than in Canada and accounts for about half the total difference in health care spending between the two nations. If health care administration in the United States had been as efficient as in Canada, $69.0 billion to $83.2 billion would have been saved in 1987. CONCLUSIONS: The administrative structure of the U.S. health care system is increasingly inefficient as compared with that of Canada's national health program. Recent health policies with the avowed goal of improving the efficiency of care have imposed substantial new bureaucratic costs and burdens.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{himmelstein_debating_1991,

title = {Debating national health insurance alternatives.},

author = {D. U. Himmelstein and S. Woolhandler},

doi = {10.1377/hlthaff.10.2.223-a},

issn = {0278-2715},

year  = {1991},

date = {1991-01-01},

journal = {Health affairs (Project Hope)},

volume = {10},

number = {2},

pages = {223–4, 227–228},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{himmelstein_patchwork_1990,

title = {Patchwork not perestroika. The promise and problems of UNY*Care.},

author = {D. U. Himmelstein and S. Woolhandler},

issn = {0017-9051},

year  = {1990},

date = {1990-01-01},

journal = {Health PAC bulletin},

volume = {20},

number = {2},

pages = {22–26},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{himmelstein_beyond_1990,

title = {Beyond our means: patterns of variability of physiological traits.},

author = {D. U. Himmelstein and R. Levins and S. Woolhandler},

doi = {10.2190/BKDL-N7DB-BDW8-DPYY},

issn = {0020-7314},

year  = {1990},

date = {1990-01-01},

journal = {International journal of health services : planning, administration, evaluation},

volume = {20},

number = {1},

pages = {115–124},

abstract = {Epidemiologists usually employ measures of variability of physiological traits such as blood pressure and cholesterol only to determine confidence intervals or statistical significance. For evolutionary biologists population variability per se has proven of interest. This article explores the applicability of this perspective to the analysis of human physiology, using data from the Framingham Heart Disease Study and the National Health and Nutrition Examination Surveys. The nonrandom patterns of variability observed suggest that examination of the degree and pattern of heterogeneity within a population may provide information not evident from the analysis of mean values.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{pels_dipstick_1989,

title = {Dipstick urinalysis screening of asymptomatic adults for urinary tract disorders. II. Bacteriuria.},

author = {R. J. Pels and D. H. Bor and S. Woolhandler and D. U. Himmelstein and R. S. Lawrence},

doi = {10.1001/jama.262.9.1221},

issn = {0098-7484},

year  = {1989},

date = {1989-09-01},

journal = {JAMA},

volume = {262},

number = {9},

pages = {1221–1224},

abstract = {Using criteria adopted by the US Preventive Services Task Force, we evaluated use of the dipstick urinalysis to screen for bacteriuria. When the leukocyte esterase and nitrite dipstick tests are combined, the positive predictive value for detecting bacteriuria exceeded 12% in groups with a 5% or higher prevalence of bacteriuria: women who are pregnant, diabetic, or over 60 years of age and all institutionalized elderly. Conventional antimicrobial regimens for asymptomatic bacteriuria have proved efficacious only for pregnant women. We conclude that pregnant women should be screened for bacteriuria, but with the more sensitive urine culture, because treatment prevents serious fetal and maternal sequelae. Dipstick screening may be justified in women who are over 60 years of age or diabetic. The prevalence of bacteriuria in other groups is too low to justify screening.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{woolhandler_dipstick_1989,

title = {Dipstick urinalysis screening of asymptomatic adults for urinary tract disorders. I. Hematuria and proteinuria.},

author = {S. Woolhandler and R. J. Pels and D. H. Bor and D. U. Himmelstein and R. S. Lawrence},

issn = {0098-7484},

year  = {1989},

date = {1989-09-01},

journal = {JAMA},

volume = {262},

number = {9},

pages = {1214–1219},

abstract = {We review evidence on the value of dipstick urinalysis screening for hemoglobin and protein in asymptomatic adults. In young adults, evidence from five population-based studies indicates that fewer than 2% of those with a positive heme dipstick have a serious and treatable urinary tract disease, too few to justify screening and the risks of subsequent workup. For older populations, evidence is contradictory and no recommendation can presently be made for or against hematuria screening. A population-based randomized, controlled trial of hematuria screening in the elderly is urgently needed. Proteinuria screening is not recommended in any healthy, asymptomatic adult population, since four population-based studies have found that fewer than 1.5% of those with positive dipsticks have serious and treatable urinary tract disorders.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{woolhandler_ideology_1989,

title = {Ideology in medical science: class in the clinic.},

author = {S. Woolhandler and D. U. Himmelstein},

doi = {10.1016/0277-9536(89)90013-0},

issn = {0277-9536},

year  = {1989},

date = {1989-01-01},

journal = {Social science & medicine (1982)},

volume = {28},

number = {11},

pages = {1205–1209},

abstract = {The class character of medicine is most easily discerned in the inequitable organization of health services. Capital's shaping of the patterns of disease and our medical/scientific responses is less apparent but equally strong. We illustrate this point by reviewing some recent history of cardiovascular diseases and therapies. Hitherto unknown afflictions have become commonplace. Our diagnostic and therapeutic concepts are the crystallization of a long history of scientific effort–an effort dominated and directed by capitalist imperatives. The work of the clinician rests on this scientific substrate, and recognition or rejection of its class nature provides a potential basis for a new medical science but not the needed results. The socialist transformation of medicine will require a recognition of the capitalist specificity of current science, and the painstaking construction of alternative modes of thought.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{navarro_jackson_1989,

title = {The Jackson National Health Program.},

author = {V. Navarro and D. U. Himmelstein and S. Woolhandler},

doi = {10.2190/NHEP-LN4M-D85R-ERB9},

issn = {0020-7314},

year  = {1989},

date = {1989-01-01},

journal = {International journal of health services : planning, administration, evaluation},

volume = {19},

number = {1},

pages = {19–44},

abstract = {In this position paper we outline the major problems that exist in the U.S. health care system and present a proposal for addressing them. This paper contains the major health proposal put forward by the Jesse Jackson 1988 Campaign, calling for the establishment in the United States of a universal and comprehensive National Health Program (NHP) that will be federally funded and administered and be equitably financed. We also discuss how the NHP will affect patients, unions, corporations and employers, practitioners and other health workers, hospitals, and the insurance industry. Specific proposals are made for the transition from the current system to the proposed NHP, with a discussion of the major differences between national health proposals put forward by the two major Democratic contenders for the U.S. Presidency. This position paper also includes a brief appendix sketching some of the major differences between the U.S. and the Canadian medical care systems.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{himmelstein_corporate_1988,

title = {The corporate compromise: a Marxist view of health maintenance organizations and prospective payment.},

author = {D. U. Himmelstein and S. Woolhandler},

doi = {10.7326/0003-4819-109-6-494},

issn = {0003-4819},

year  = {1988},

date = {1988-09-01},

journal = {Annals of internal medicine},

volume = {109},

number = {6},

pages = {494–501},

abstract = {Recent developments in health care are strikingly congruent with a Marxist paradigm. For many years small scale owner producers (physicians) dominated medicine, and the corporate class supported the expansion of services. As health care expanded, corporate involvement in the direct provision of services emerged. This involvement is reflected not only in the rise of for-profit providers, but also in the influence of hospital administrators, utilization review organizations, insurance bureaucrats, and other functionaries unfamiliar with the clinical encounter, but well versed on the bottom line. Corporate providers' quest for increasing revenues has brought them into conflict with corporate purchasers of care, whose employee benefit costs have skyrocketed. This intercorporate conflict powerfully shapes health policy and has caused the rapid proliferation of health maintenance organizations and other forms of prospective payment. Corporate purchasers of care favor the incentives under prospective payment for providers to curtail care and its costs. For corporate providers, prospective payment has allowed increased profits even in the face of constrained revenues, because reimbursement is disconnected from resource use. Unfortunately, this corporate compromise serves patients and physicians poorly. Alternative policy options that challenge corporate interests could save money while improving care.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{woolhandler_reverse_1988,

title = {Reverse targeting of preventive care due to lack of health insurance.},

author = {S. Woolhandler and D. U. Himmelstein},

issn = {0098-7484},

year  = {1988},

date = {1988-05-01},

journal = {JAMA},

volume = {259},

number = {19},

pages = {2872–2874},

abstract = {We analyzed patterns of receipt of preventive services among middle-aged women, with particular attention to health insurance coverage, based on data from the National Health Interview Survey. Lack of insurance was most prevalent among socioeconomically disadvantaged women at high risk for disease and was the strongest predictor of failure to receive screening tests. The relative risk of inadequate screening for uninsured compared with insured women was 1.60 (95% confidence interval [Cl], 1.40 to 1.83) for blood pressure checkups, 1.55 (95% Cl, 1.43 to 1.68) for cervical smears, 1.52 (95% Cl, 1.41 to 1.63) for glaucoma testing, and 1.42 (95% Cl, 1.33 to 1.51) for clinical breast examination. Controlling for demographic and health status variables did not diminish the effect of insurance coverage. We conclude that inadequate insurance coverage leads to "reverse targeting" of preventive care–that is, populations at highest risk are least likely to be screened. This compromises both the effectiveness and the cost-effectiveness of screening.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{woolhandler_free_1988,

title = {Free care: a quantitative analysis of health and cost effects of a national health program for the United States.},

author = {S. Woolhandler and D. U. Himmelstein},

doi = {10.2190/78J9-BWXL-Y6AL-45RA},

issn = {0020-7314},

year  = {1988},

date = {1988-01-01},

journal = {International journal of health services : planning, administration, evaluation},

volume = {18},

number = {3},

pages = {393–399},

abstract = {We estimate the health and cost effects of instituting a National Health Program (NHP) in the United States that would provide universal, comprehensive free care. Based on empiric studies of the relationship of health service use to cost and health outcomes, we estimate that an NHP would increase use of health services by 14.6 percent and save between 47,000 and 106,000 lives annually. Because the United States faces a growing surplus of hospital beds and physicians, additional services could be provided at low cost. Simplifying the health bureaucracy that currently enforces unequal access to care would also result in substantial savings. Consequently, an NHP would actually decrease costs 2.4 percent, $10.2 billion annually, since the $35.7 billion spent for additional services would be offset by $45.9 billion saved on bureaucracy.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{himmelstein_will_1988,

title = {Will cost effectiveness analysis worsen the cost effectiveness of health care?},

author = {D. U. Himmelstein and S. Woolhandler and D. H. Bor},

doi = {10.2190/VDAK-9MFH-1VWN-G1LR},

issn = {0020-7314},

year  = {1988},

date = {1988-01-01},

journal = {International journal of health services : planning, administration, evaluation},

volume = {18},

number = {1},

pages = {1–9},

abstract = {Cost effectiveness analysis is increasingly advocated as a basis for health policy. Analysts often compare expensive interventions with highly cost-effective programs such as hypertension screening, implying that if the former were curtailed resources would be reallocated to the latter and the efficiency of health care would improve. However, in practice, savings are unlikely to be targeted in this way. We present refined policy models that take into account actual patterns of resource allocation in the United States, and provide more realistic estimates of the likely uses of savings. We illustrate the implications of these models in an analysis of the effects of diverting funds from an expensive but effective practice. Eliminating such a practice would actually worsen the overall cost-effectiveness of U.S. health care unless there are radical changes in health policy. Cost effectiveness analysis incorrectly predicts health and cost outcomes of policy initiatives because it ignores the political constraints to health care decision-making.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{himmelstein_cost_1986,

title = {Cost without benefit. Administrative waste in UṠ. health care.},

author = {D. U. Himmelstein and S. Woolhandler},

doi = {10.1056/NEJM198602133140710},

issn = {0028-4793},

year  = {1986},

date = {1986-02-01},

journal = {The New England journal of medicine},

volume = {314},

number = {7},

pages = {441–445},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{woolhandler_militarism_1985,

title = {Militarism and mortality. An international analysis of arms spending and infant death rates.},

author = {S. Woolhandler and D. U. Himmelstein},

doi = {10.1016/s0140-6736(85)91795-7},

issn = {0140-6736},

year  = {1985},

date = {1985-06-01},

journal = {Lancet (London, England)},

volume = {1},

number = {8442},

pages = {1375–1378},

abstract = {Examination of data from 141 countries showed that infant mortality rates for 1979 were positively correlated with the proportion of gross national product devoted to military spending (r = 0.23, p less than 0.01) and negatively correlated with indicators of economic development, health resources, and social spending. In a multivariate analysis controlling for per caput gross national product, arms spending remained a significant positive predictor of infant mortality rate (p less than 0.0001), while the proportion of the population with access to clean water, the number of teachers per head, and caloric consumption per head were negative predictors. The multivariate model accounted for much of the observed variance in infant mortality rate (R2 = 0.78, p less than 0.0001), and showed good fit to similar data for the year 1972 (R2 = 0.80, p less than 0.0001). The model was also predictive of infant mortality rates in subgroup analysis of underdeveloped, middle developed, and developed nations. Analysis of time trends confirmed that an increase in military spending presages a poor record of improvement in infant mortality rate. These findings support the hypothesis that arms spending is causally related to infant mortality.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{woolhandler_medical_1985,

title = {Medical care and mortality: racial differences in preventable deaths.},

author = {S. Woolhandler and D. U. Himmelstein and R. Silber and M. Bader and M. Harnly and A. A. Jones},

doi = {10.2190/90P3-LEFF-WNU0-GLY6},

issn = {0020-7314},

year  = {1985},

date = {1985-01-01},

journal = {International journal of health services : planning, administration, evaluation},

volume = {15},

number = {1},

pages = {1–22},

abstract = {We analyzed deaths of blacks and whites in Alameda County, California where previous studies have documented consistent racial inequalities in health services. We classified each death during 1978 as due to preventable and manageable conditions or as "non-preventable" according to lists compiled by the Working Group on Preventable and Manageable Diseases chaired by Dr. David Rutstein. The total death rate for blacks 0-65 years of age exceeded that of whites by 58 percent (p less than .01). Rates of death due to preventable and manageable conditions for persons aged 0-65 years were 77 percent higher for blacks than for whites (p less than .01). More than one-third of the excess total death rate of blacks relative to whites could be explained by the excess of potentially preventable deaths. Our findings suggest that inequalities in health services reinforce broader social inequalities and are in part responsible for disparities in health status. Improvements in the health and longevity of blacks and other oppressed groups might be achieved by improved access to existing medical, public health, and other preventive measures.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{lang_yugoslavia_1984,

title = {Yugoslavia: equity and imported ethical dilemmas.},

author = {S. Lang and S. Woolhandler and Z. Bantic and D. U. Himmelstein},

issn = {0093-0334},

year  = {1984},

date = {1984-12-01},

journal = {The Hastings Center report},

volume = {14},

number = {6},

pages = {26–27},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{himmelstein_free_1984,

title = {Free care, cholestyramine, and health policy.},

author = {D. U. Himmelstein and S. Woolhandler},

doi = {10.1056/NEJM198412063112311},

issn = {0028-4793},

year  = {1984},

date = {1984-12-01},

journal = {The New England journal of medicine},

volume = {311},

number = {23},

pages = {1511–1514},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{himmelstein_yugoslav_1984,

title = {The Yugoslav health system: public ownership and local control.},

author = {D. U. Himmelstein and S. Lang and S. Woolhandler},

issn = {0197-5897},

year  = {1984},

date = {1984-09-01},

journal = {Journal of public health policy},

volume = {5},

number = {3},

pages = {423–431},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{himmelstein_elevated_1984,

title = {Elevated SGOT/SGPT ratio in alcoholic patients with acetaminophen hepatotoxicity.},

author = {D. U. Himmelstein and S. J. Woolhandler and R. D. Adler},

issn = {0002-9270},

year  = {1984},

date = {1984-09-01},

journal = {The American journal of gastroenterology},

volume = {79},

number = {9},

pages = {718–720},

abstract = {Two alcoholic patients with acetaminophen hepatotoxicity are described. Both patients had very high SGOT levels and SGOT/SGPT ratios. It is suggested that a high SGOT/SGPT ratio is not specific for alcoholic hepatitis. Extreme elevations of this ratio, especially in association with SGOT levels greater than five times normal, should suggest nonalcoholic causes of hepatocellular necrosis in alcoholic patients.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{woolhandler_terms_1984,

title = {Terms of endowment. Prospective hospital reimbursement in Massachusetts.},

author = {S. Woolhandler and D. U. Himmelstein},

issn = {0017-9051},

year  = {1984},

date = {1984-04-01},

journal = {Health PAC bulletin},

volume = {15},

number = {2},

pages = {13–16},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{himmelstein_medicine_1984,

title = {Medicine as industry: the health-care sector in the United States.},

author = {D. U. Himmelstein and S. Woolhandler},

doi = {10.14452/mr-035-11-1984-04_2},

issn = {0027-0520},

year  = {1984},

date = {1984-01-01},

journal = {Monthly review (New York, N.Y. : 1949)},

volume = {35},

number = {11},

pages = {13–25},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{himmelstein_interferon_1983,

title = {Interferon for prevention of cytomegalovirus reactivation in renal-transplant recipients.},

author = {D. U. Himmelstein and S. Woolhandler},

doi = {10.1056/NEJM198311103091918},

issn = {0028-4793},

year  = {1983},

date = {1983-11-01},

journal = {The New England journal of medicine},

volume = {309},

number = {19},

pages = {1193},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{himmelstein_hypernatremic_1983,

title = {Hypernatremic dehydration in nursing home patients: an indicator of neglect.},

author = {D. U. Himmelstein and A. A. Jones and S. Woolhandler},

doi = {10.1111/j.1532-5415.1983.tb05118.x},

issn = {0002-8614},

year  = {1983},

date = {1983-08-01},

journal = {Journal of the American Geriatrics Society},

volume = {31},

number = {8},

pages = {466–471},

abstract = {In order to determine the antecedents of hypernatremic dehydration the authors reviewed the records of 56 patients with this condition at two public hospitals, one of which includes a large chronic care facility. Twenty-nine patients developed hypernatremic dehydration while at nursing homes. All cases came from proprietary nursing homes, although proprietaries account for only 88 per cent of nursing home beds in the community studied (P less than 0.05). There was a cluster of patients from two nursing homes. Sixteen patients admitted from home all showed evidence of inadequate care prior to admission. Eleven patients became hypernatremic while in acute care hospitals. No patient in the public chronic care facility developed hypernatremic dehydration during the period studied. The average serum sodium concentration of patients transferred from nursing homes was significantly higher than that of patients who developed hypernatremic dehydration at home or in acute care hospitals. It is concluded that hypernatremic dehydration in an institutionalized patient may be an indicator of inadequate care, which should prompt further investigation of the living conditions of the patient.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{woolhandler_public_1983,

title = {Public money, private control: a case study of hospital financing in Oakland and Berkeley, California.},

author = {S. Woolhandler and D. U. Himmelstein and R. Silber and M. Harnly and M. Bader and A. A. Jones},

doi = {10.2105/ajph.73.5.584},

issn = {0090-0036 1541-0048},

year  = {1983},

date = {1983-05-01},

journal = {American journal of public health},

volume = {73},

number = {5},

pages = {584–587},

abstract = {Government support of public and private hospitals in Oakland and Berkeley, California was investigated. The private hospitals received government subsidies amounting to at least 60 per cent of their total revenues. The dollar amount of the subsidies to private hospitals was four and one-half times greater than government expenditures on the public hospital. In Oakland and Berkeley, as in many cities, public medical services have been reduced while both government health expenditures and private hospital revenues have increased sharply. The private hospitals, although all nominally non-profit, exhibit revenue maximizing behavior which results in socially unjust and medically irrational resource allocation. Funds might be found for public hospitals and clinics, and resources allocated more justly and rationally, if government expenditures in the private sector were brought under greater public scrutiny and control.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}