President Clinton's Health Security Act relies on government regulation, not market forces, to control costs. The act creates an entitlement to comprehensive benefits and places the federal budget at risk for total health care costs in order to achieve universal coverage; it creates a system of new state purchasing monopsonies; and it attempts to control costs with price controls on health plan premiums, set and administered by a National Health Board that would be part of the executive branch, not insulated from political considerations. We believe there is a better way.

The authors performed a prenatal care needs assessment for Fresno County, CA, using data from a sample of 11,878 birth certificates for the county for 1989. Birth records, patterns of prenatal care utilization, and low birth weight outcomes in the county were compared with those in a random sample of 11,826 certificates derived from births in the remainder of the State. Bivariate techniques were used in calculating care utilization rates. Multivariate logistic regression analysis was used in associating rates of prenatal care visits and gestational month of initiation of prenatal care with low weight birth outcomes. County women entered prenatal care as early as women in the remainder of the State, but did not return as often for prenatal care visits. Their rate of return for followup visits was 29.9 percent, compared with 24.8 percent for women in all other counties (P 0.001). County women with the lowest rates of visits had 1.4 to 1.9 times the risk of having a low weight birth than other county women with higher rates of visits, and a significantly higher risk than for women of all other counties. An intensive visit schedule for high-risk care was provided 28.9 percent of county women, compared with 33.0 percent of women in all other counties (P 0.001). County women who received a high-risk intensive visit schedule were 2.5 times more likely to have a low weight birth than county women who did not receive the schedule. For all other women in the State, the comparable risk was 2.1 times.

Objective: To examine the cost effects of a single dose (5 ml/kg) of a protein-free synthetic surfactant (Exosurf) as therapy for neonatal respiratory distress syndrome, for both rescue and prophylactic therapy.

Research Design: Nonblinded, randomized clinical trials of both rescue and prophylactic therapy. Regression analyses were used to control for the independent effects of sex, multiple birth, delivery method, birth weight, and surfactant therapy.

Setting: The prophylactic trial was conducted at a university medical center only; the rescue trial also included a tertiary community hospital.

Patients: Prophylaxis was administered immediately after birth to 36 infants (38 control subjects) with birth weights between 700 and 1350 gm. Rescue therapy was administered at 4 to 24 hours of age to 53 infants (51 control subjects) with established respiratory distress syndrome and birth weights > or = 650 gm (no upper limit). Infants in the prophylactic trial were not eligible for the rescue trial.

Results: For the rescue trial, there was a $16,600 reduction in average hospital costs (p = 0.18), which was larger than the cost of the surfactant ($450 to $900), yielding a probable net savings. For the prophylactic trial, hospital costs were larger for treated infants versus control subjects who weighed less than about 1100 gm at birth and lower for treated infants versus control subjects who weighed more than 1100 gm at birth (p 0.05). For the prophylactic sample, the result was an average cost per life saved of $71,500.

Conclusions: Single-dose rescue surfactant therapy is probably a cost-effective therapy because it produced a lower mortality rate for the same (and probably lower) expenditure. Single-dose prophylactic therapy for smaller infants ( or = 1350 gm) appeared to yield a reduction in mortality rate for a small additional cost. The use of multiple-dose therapy in infants who do not respond to initial therapy may alter the effects described above to either increase or decrease the observed cost-effectiveness of surfactant therapy. Regardless, surfactant therapy will remain a cost-effective method of reducing mortality rates, relative to other commonly used health care interventions.

Workers' compensation insurance provides cash benefits and health care for workers who are injured on the job. This DataWatch considers the costs and benefits of combining the health insurance component of workers' compensation with universal health insurance, creating a twenty- four-hour coverage plan. The paper documents a large potential savings from twenty-four-hour coverage: Workers' compensation medical charges are about twice as high as those for comparable off-work injuries. This disparity seems to result from price discrimination and lack of cost controls in workers' compensation. Twenty-four-hour coverage, however, may be difficult to implement.