The year after Kobuleti: what difference does it make?

Following and pursuant to a conference held in Kobuleti, Soviet Georgia in April, 1990, a paper describing proposed principles for legislation establishing a health insurance system for the U.S.S.R. and Union Republics was published. It proposed supplementing the existing publicly financed medical care system with a system of regionally based 'health insurance' funds, as well as formally recognized direct payments to health care providers. While creating the opportunity for insurance funds which were to be regionally based, the system was to be centrally directed. Since the publication of that paper, the reforms it envisions have progressed more slowly than expected. This is due to at least three factors. First, the general state of the Soviet economy, coupled with a strengthening of the movement toward greater autonomy for the Soviet Republics and an accompanying reluctance on the part of the Republics to contribute to the Union budget, has resulted in a greater reduction of that budget (and a greater budget deficit) than anticipated. Second, due in part to perverse financial incentives, the capacity of the Soviet health care system to increase production, even if the financial resources were available, is limited, and has deteriorated during the past year. Third, the patience of health care workers with their working conditions is wearing thin, resulting in less willingness on their part to cooperate with anything less than total and fundamental reform than has been the case in the past. At this point, it appears that any reform of Soviet health care will emphasize autonomy at the levels of the Republics, and a diminution of central power and control. There is a growing feeling that anything short of a significant improvement in the general Soviet economy linked with total reform of health care financing and delivery will fail to reverse the deterioration of the Soviet health care system.