A comprehensive evaluation of alternatives for the provision of health care to the medically indigent in Nebraska

Several alternatives for the provision of health care to the medically indigent of Nebraska were analyzed both quantitatively and qualitatively. These alternatives were: expansion of County Medical Assistance Programs, state-purchased health insurance policies, Medicaid expansion, revenue pool to redistribute charity care losses, all-payer rate system, mandated employer-purchased health insurance, and charity care districts. These alternatives were subjected to both cost and sensitivity analysis, then ranked on the basis of both quantitative and qualitative criteria. Qualitative criteria were: maintenance of the 1985 level of health, inclusion of preventive health measures, equity in distribution of unreimbursed medical expenses, and reduced incentives for cost-shifting. Quantitative criteria were cost, and percentage of medically indigent served. Qualitative criteria were integrated using the Delphi Method, and Saaty\u27s Analytical Hierarchy via Expert Choice. Impact analysis for each alternative on Nebraska\u27s health care delivery system was also performed, including the effect on total state disposable income. The alternatives were tested further under four scenarios representing expected future changes in the health care delivery system. These scenarios are: federal matching funds reduction, charity care reductions, state funding reduction, and increase in medical indigents. In this analysis the effects of varying factors, previously held constant at 1985 levels, were assessed for all criteria. The alternatives were then reranked, with state-purchased health insurance scoring highest most consistently. It is recommended that the state adopt a combination of Medicaid expansion and state-purchased health insurance. This combination would best meet all qualitative criteria at a minimum system cost per indigent served. If the recommended comprehensive program cannot be undertaken, a combination of programs is suggested for further research. These include Medicaid expansion, local health department expansion, state-paid insurance continuation, revenue pool, on-site medical teams and patient-imposed care limits. Because it is cost effective, prevention is emphasized by these programs