- 145 may be unnecessary deaths, more serious illness, and higher costs of health care. Thus, financial coverage (including public and private sources) affects not only access but also the quality and costs of health care. The goal of this OTA assessment is to provide an objective, rigorously critiqued analysis of the often complex, sometimes disputed, network of relationships between health insurance status (either lack of insurance coverage or having inadequate coverage) and negative health outcomes, poor health status, and the timing, location, and nature of health technologies and services delivered. It is the intent of OTA to provide Congress with a clear picture of these important relationships in the context of the U.S. health care system and its financing so that Congress can take them into account as it considers substantial changes in national health policy. Possible Impact on Legislation: -H.R. 8: A bill to provide for an equitable and universal national health plan - H.R. 16: A bill to provide a program of national health insurance, and for other -H.R. 96: A bill to amend title XIX of the Social Security Act to increase the categories of individuals eligible to receive benefits under state plans for medical assistance under such title, to expand the benefits required to be provided under such plans, and for other purposes. - H.R. 290: A bill to amend title XIX of the Social Security Act to reduce infant mortality through improvement of coverage of services to pregnant women and infants under the Medicaid program. - H.R. 535: A bill to provide for the establishment of a National Voluntary Health Insurance Act. - H.R. 650: A bill to amend the Social Security Act and the Internal Revenue Code of 1986 to provide for a Mediplan that assures the provision of health insurance coverage to all residents, and for other purposes. - H.R. 651: A bill to amend the Social Security Act and the Internal Revenue Code - H.R. 860: A bill to amend title XIX of the Social Security Act to require the -H.R. 1645: A bill to amend the provisons of law relating to continuation of health - H.R. 1777: A bill to amend title XVIII of the Social Security Act to provide for coverage of the general population under the Medicare program, and for other purposes. -H.R. 2375: A bill to amend the Social Security Act to provide for a program of - H.R. 2656: A bill to amend title XIX of the Social Security Act to assure -H.R. 3084: A bill to amend the Internal Revenue Code of 1986 to encourage the -H.R. 3229: A bill to establish a United States Health Service to provide high - H.R. 3393: A bill to amend the Internal Revenue Code of 1986 and the Social - 146 -H.R. 3478: A bill to increase working Americans access to health care and affordable health insurance. -H.R. 1230: A bill to provide for universal access to basic group health benefits coverage and to remove barriers and provide incentives in order to make such coverage more affordable. -H.R. 1255: A bill to amend the Social Security Act to make health insurance widely available to individuals, based on income and assets, under a competitive system. - H.R. 1300: A bill entitled the "Universal Health Care Act of 1991". - H.R. 1565: A bill to increase access to health care and affordable health insurance, to contain costs of health care in a manner that improves health care, and for other purposes. - H.R. 2297: A bill to provide grants to states to develop unified state health care plans and to authorize a single Federal payment to a state to provide services under such a plan instead of under the Medicare, Medicaid, and other Federal health care programs. - H.R. 2530: A bill to assist and encourage the development through the states of a system of universal comprehensive health care. -H.R. 2535: A bill to amend the Social Security Act to assure universal access to health insurance for basic health services in the United States through qualified employer health plans and a public health insurance plan, to contain costs and assure quality in the provision of health services, to reform the provision of health insurance to small employers, and for other purposes. - H.R. 3205: A bill to amend the Internal Revenue Code of 1986 and the Social Security Act to provide for health insurance coverage for workers and the public in a manner that contains the costs of health care in the United States. -H.R. 3626: A bill to amend the Social Security Act and the Internal Revenue Code of 1986 to provide for improvements in health insurance coverage through employer health insurance reform, for health care cost containment, for improvements in Medicare prevention benefits, and for other purposes. -H.R. 3689: A bill to amend the Social Security Act to provide for universal access to health benefits through a Federally financed insurance program administered by states, and for other purposes. -S. 700: A bill to amend the Internal Revenue Code of 1986 to impose an excise tax on insurance companies not meeting certain requirements with respect to health insurance provided to small employers. - S. 1211: A bill to amend title XIX of the Social Security Act to permit states the option of providing medical assistance to individuals with a family income not exceeding 300 percent of the income official poverty line with appropriate costsharing, and for other purposes. -S. 314: A bill to establish a uniform minimum package and claim procedures for health benefits, provide tax incentives for health insurance purchases, encourage malpractice reform, improve health care in rural areas, establish state uninsurable pools, and for other purposes. - S. 454: A bill to provide for a comprehensive health care plan for all Americans, and for other purposes. -S. 1177: A bill to amend the Social Security Act to assure universal access to health insurance for basic health services in the United States through qualified employer health plans and a public health insurance plan, to contain costs and assure quality in the provision of health insurance to small employers, and for other purposes. - S. 1227: A bill to amend the Public Health Service Act, the Social Security Act, and the Internal Revenue Code of 1986 to provide affordable health care of all Americans, to reduce health care costs, and for other purposes. - S. 1446: A bill to provide for an equitable and universal national health care - 147 - S. 1872: A bill to provide for improvements in access and affordability of health insurance coverage through small employer health insurance reform, for improvements in the portability of health insurance, and for health care cost containment, and for other purposes. Project Director: Denise Dougherty 228-6590. Estimated publication date: Spring 1993. Requested by: Senate Committee on Labor and Human Resources EVALUATION OF THE OREGON MEDICAID PROPOSAL (R) Expensive medical technologies, substantial and growing numbers of poor people, general health care cost increases, and tight fiscal situations in the Federal government and many states all have contributed to Medicaid difficulties. Many states, including Oregon, have in the past responded by tightening eligibility standards for enrollment in Medicaid, thus serving only the poorest of the poor. The State of Oregon has recently proposed a major departure from Medicaid procedures. It seeks a waiver to excuse it from mandated Federal standards for State participation in the program and to put in place a new but untested system. The proposed system would, Oregon claims, allow the State to include all eligible individuals up to 100 percent of the poverty level, but with a reduction in technologies and services covered, based on a system of rank ordering by medical importance of all medical conditions (diagnoses) and their attendant medical interventions (technologies and services). The costs of Oregon's paying for each medical condition and technology (intervention) would be computed and a cumulative amount, from the top (most medically important), would be compared by the state legislature to the amount of funds available for Medicaid. The legislature will then "draw a line" at the amount to be spent, and services below the line would not be paid for by Medicaid. Oregon believes that this system will allow increased numbers of poor people to receive services and that essential services and disease prevention and health promotion services will be available and emphasized. Those skeptical about the proposal point to its untested nature, to what they term its lack of equity (elderly people and disabled people are exempted), that essentially the reduction in services will apply only to women and children, and that some essential technologies (perhaps including some technologies and services currently mandated by Federal requirements) will most likely fall below the cut-off line. Others are skeptical of the methods used to determine rankings of medical importance. The proposed OTA project would not directly address the concept of "rationing" in health care. Rather, it would evaluate the mechanics of Oregon's proposed system, including a methodologic critique. The major part of the project would be an analysis of evidence (from the health care literature and elsewhere) on the efficacy and costeffectiveness of selected medical services for women and children, paying particular attention to how well Oregon's rankings reflect the medical evidence on those services. It would also analyze the potential implications for the health status of poor women and children due to lack of access to selected technologies and services, especially those low on - 148 Possible Impact on Legislation: -H.R. 96: A bill to amend title XIX of the Social Security Act to increase the categories of individuals eligible to receive benefits under state plans for medical assistance under such title, to expand the benefits required to be provided under such plans, and for other purposes. -H.R. 790: A bill to amend the Internal Revenue Code of 1986 to require taxexempt hospitals to provide sufficient charity care and community benefits, and for other purposes. - H.R. 1392: A bill to amend title XIX of the Social Security Act to improve access to basic health care services for needy children. - H.R. 2114: A bill to provide for certification and require the offering of qualified health plans, to provide Federal assistance to states to establish a program of assistance for low-income persons to purchase comprehensive health insurance and to provide funding for assistance for catastrophic health care expenses of the elderly, and for other purposes. -H.R. 2213: A bill to amend title XIX of the Social Security Act to provide for a - H.R. 2229: A bill to reduce infant mortality in rural, underserved areas by - S. 1211: A bill to amend title XIX of the Social Security Act to permit states the - S. 1574: A bill to ensure proper and full implementation by the Department of Health and Human Services of Medicaid coverage for certain low-income Medicare beneficiaries. - S. 1592: A bill to amend title XIX of the Social Security Act to allow states to provide coverage under Medicaid for the costs of prescription drugs for qualified Medicare beneficiaries, and for other purposes. Project Director: Elaine Power 228-6590. Estimated publication date: Spring 1992. Requested by: House Committee on Energy and Commerce, and its Subcommittee on Health and the Environment HOME INTRAVENOUS AND IMMUNOSUPPRESSIVE DRUG THERAPIES The development of new technologies that permit increasingly sophisticated health care to be provided at home has been historically accompanied by new and perplexing issues for the Medicare program. At present, with the exception of very limited postsurgical coverage of immunosuppressive drugs, Medicare payment for intravenous (IV) drug therapy is limited to hospital-based care. New drug administration devices, new drugs, new treatment protocols, and new systems of home-based care, however, now can make intravenous therapies available to patients in the home. This study will examine the potential impact of coverage of home IV and immunosuppressive drug therapy on the costs of the Medicare program, on the beneficiaries it serves, and on the research and development of new drugs and new forms of drug delivery and treatment. The study will then assess in greater detail the impact of alternative methods of paying for these home-based services, drawing on existing - 149 therapy) and on the experiences of other third-party payers. In developing policy options, the study will pay particular attention to balancing objectives of improving Medicare beneficiaries' health, controlling Medicare and beneficiaries' expenditures, and providing incentives for R&D on innovative technologies and the settings in which they are provided. Possible Impact on Legislation: - S. 193: A bill to provide for the restoration of certain Medicare catastrophic - S. 2889: Public Law: 100-607(11/04/88); A bill to amend the Public Health Project Director: Elaine Power 228-6590. Interim Publications: Outpatient Immunosuppressive Drugs Under Medicare (R), Published September 1991 Home Drug Infusion Therapy Under Medicare (R), Requested by: Senate Committee on Finance GOVERNMENT POLICIES AND PHARMACEUTICAL RESEARCH AND Technological change in medicine depends in part on a base of research and development (R&D) undertaken by pharmaceutical firms. This R&D activity stretches from basic laboratory science to clinical testing of new drugs prior to their market entry. It is generally a lengthy and uncertain process driven by the prospect of future returns sufficient to justify the investment in R&D. Federal policies include both the costs of R&D (e.g., through regulation of new drugs or research subsidies) and returns to investments in R&D (e.g., through policies affecting size of the market or drug prices). How specific policies of U.S. and other governments might alter the delicate balance between costs and returns to pharmaceutical R&D has ramifications for the future health of Americans, for health care costs, and for the future of the U.S. pharmaceutical industry. This project will examine trends in the structure, process, and products of pharmaceutical R&D with the objective of developing and implementing a system for estimating and tracking R&D costs over time. The system for estimating such costs would involve a plan for collection of data on critical elements of the R&D process, to be used in estimates of the costs of discovering and developing successful new pharmaceutical products and returns on R&D are likely to affect R&D costs in the future. The study will also describe the organization of the pharmaceutical R&D enterprise, identifying how costs differ by therapeutic class or biological research area. Finally the study will review how changes in government policies (both domestic and foreign) affect the costs of, and returns from, R&D. The results of these investigations will be used to evaluate the costs of |