To provide a baseline and assess the potential of changes brought about under the Affordable Care Act, this study estimates the number of US adults who were underinsured or uninsured in 2010. Beginning in 2014, the Affordable Care Act of 2010 will provide income-related premium assistance and cost-sharing provisions to increase health care access and provide financial protection for people with lower incomes. These provisions will reduce exposure to out-of-pocket expenses for covered benefits. The law will vary cost-sharing standards as well as premium credits by poverty level in order to limit a person's risk of incurring high out-of-pocket expenses and to make care more affordable. The reforms thus seek to expand coverage and to reduce the number of insured people who are "underinsured" based on exposure to medical care costs that are high relative to their incomes.To provide a baseline as of 2010 and to examine the potential of the reforms, we used findings from a recent survey to estimate the number of adults who were underinsured or uninsured in 2010. The analysis updates 2003 and 2007 surveys using the same methodology to identify those who are underinsured. 3 We found a significant increase in the percentage who were underinsured from 2007 to 2010, although the change was less than that observed from 2003 to 2007. This probably reflects the slowdown in health spending as people cut back because of the recession. Including for the first time responses from people reached on their cell phones, the 2010 estimate provides a new baseline and target as the Affordable Care Act reforms unfold. To assess the reforms' potential, the study examined the risk of being underinsured or uninsured by poverty groups who will receive cost-sharing and premium assistance.

The implementation of choice for patients over where and when they are seen by specialists in hospital outpatient clinics has been supported by electronic referral systems in England and the Netherlands. This paper compares the implementation of 'Choose and Book' in England and 'ZorgDomein' in a region of the Netherlands. For England the analysis draws on national data and published studies on 'Choose and Book', national patient surveys, and qualitative data based on general practitioner (GP) focus groups. For the Netherlands the analysis draws on qualitative data collected during observational study as well as survey data among patients, GPs and medical specialists. We find that despite significant differences in the genesis and design of the policy, similar challenges have been faced. The electronic referral systems have forced changes to the process of care at the interface between primary and secondary care and standardisation between practices. Although these changes have the potential to generate improvements and benefits, for example, convenience, certainty and choice for patients and efficiency gains through for example reduced do not attend rates, repeat consultations and duplicative diagnostic tests; they have also generated problems during implementation including GP resistance. Policy ambitions for patient choice may not be realised if the implementation of the booking system is not carefully designed and evaluated.

This paper compares the introduction of policies to promote or strengthen patient choice in four Northern European countries - Denmark, England, the Netherlands and Sweden. The paper examines whether there has been convergence in choice policies across Northern Europe. Following Christopher Pollitt's suggestion, the paper distinguishes between rhetorical (discursive) convergence, decision (design) convergence and implementation (operational) convergence (Pollitt, 2002). This leads to the following research question for the article: Is the introduction of policies to strengthen choice in the four countries characterised by discursive, decision and operational convergence? The paper concludes that there seems to be convergence among these four countries in the overall policy rhetoric about the objectives associated with patient choice, embracing both concepts of empowerment (the intrinsic value) and market competition (the instrumental value). It appears that the institutional context and policy concerns such as waiting times have been important in affecting the timing of the introduction of choice policies and implementation, but less so in the design of choice policies. An analysis of the impact of choice policies is beyond the scope of this paper, but it is concluded that further research should investigate how the institutional context and timing of implementation affect differences in how the choice policy works out in practice.

More educated, affluent patients were no more likely to be offered a choice than other population groups, but there does appear to be a social gradient in who chose to travel beyond the local area for treatment. If these results were replicated across England, there is at least the potential risk that when local hospitals are failing, patient choice could result in inequitable access to high quality care, rather than enhancing equity as the policy's architects had hoped.

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