Most nonelderly americans receive their health insurance coverage through their workplace. Almost all large firms offer a health insurance plan, and even though they face greater barriers to providing coverage, so do the majority of very small firms. These employment-based plans cover two-thirds of nonelderly Americans and pay most of working families' expenses for health care and about one-quarter of national health spending. Despite employers' role in the health insurance market, however, very little attention has been paid to employers' motivations for providing health insurance to workers. Why do employers offer health insurance to workers? Is it because workers want it? Because their unions demand it? Or do employers offer health benefits to workers because their productivity and profitability depend on it?The standard economic theory of the availability of employer-provided health insurance focuses on worker demand (Cutler 1997;Pauly 1997;Summers 1989). According to that theory, employers are willing to arrange health insurance plans for workers because workers are willing to "buy" that health insurance through wages reduced by the amount of the cost of the insurance. The theory states that rather than receiving additional cash compensation and finding and purchasing health insurance on their own, workers prefer to obtain coverage through their employers and so accept a wage offset to cover the cost of that coverage. This theory has a number of problems, though, not the least of which is that the data

Objectives Diabetic kidney disease (DKD) is a frequent complication of diabetes with potentially devastating consequences that may be prevented or delayed. This study aimed to estimate the health and economic benefit of earlier diagnosis and treatment of DKD. Methods Life expectancy and medical spending for people with diabetes were modeled using The Health Economics Medical Innovation Simulation (THEMIS). THEMIS uses data from the Health and Retirement Study to model cohorts of individuals over age 50 to project population-level lifetime health and economic outcomes. DKD status was imputed based on diagnoses and laboratory values in the National Health and Nutrition Examination Survey. We simulated the implementation of a new biomarker identifying people with diabetes at an elevated risk of DKD and DKD patients at risk of rapid progression. Results Compared to baseline, the prevalence of DKD declined 5.1% with a novel prognostic biomarker test, while the prevalence of diabetes with stage 5 chronic kidney disease declined 3.0%. Consequently, people with diabetes gained 0.2 years in life expectancy, while per-capita annual medical spending fell by 0.3%. The estimated cost was $12,796 per life-year gained and $25,842 per quality-adjusted life-year. Conclusions A biomarker test that allows earlier treatment reduces DKD prevalence and slows DKD progression, thereby increasing life expectancy among people with diabetes while raising healthcare spending by less than one percent.

In a new administration and Congress, any health insurance coverage initiative will focus on some, rather than all, Americans. Because lack of affordability is the main reason people lack coverage, most observers acknowledge that government-financed subsidies are needed to expand coverage. But there is considerable disagreement about how these subsidies should be provided. Here we argue that priority in expanding coverage should go to the uninsured population that is least able to afford coverage and most likely to have difficulties getting appropriate and timely care. Despite flaws in existing public programs, which can and should be remedied, strengthening these programs establishes a foundation for truly effective health insurance coverage for all low-income Americans.A ny i nit i at i ve t o e xt end he alt h ins ur a nce coverage to the forty-three million Americans without it is likely to take an incremental rather than a universal or comprehensive approach. An incremental strategy inevitably requires decisions about whom to provide the financial wherewithal to obtain coverage, as well as how to effectively provide it.In this paper we argue that an incremental initiative should give priority to the uninsured who are least able to afford coverage, and that the most effective way to do this is by expanding publicly provided insurance. Today more than thirty-five million lowincome Americans receive their health coverage through Medicaid, and as many as three million additional children get assistance from the State Children's Health Insurance Program (SCHIP). Strength-

A virtual learning collaborative was successful in providing a framework for pediatricians to implement a continuous QI process and achieve practice improvements. This format can be utilized to address multiple health issues.