Health Care Politics and Policy, Assessment Example

The convergence of the consumer-driven healthcare movement with the sharp turn to the political Right taken by the Republican Party in the mid-1990s produced quite a lot of discussion about how to refashion Medicare, the federal government’s single largest health program, into a tool for senior citizens—behaving as utility-maximizing consumers—to use more efficiently.

Part of the impetus behind this effort surely had to do with a desire to cut federal spending, pure and simple. However, another important philosophical consideration was also at work. Many conservatives in Congress wanted Medicare’s beneficiaries to become more directly responsible for the way Medicare’s funds would be used by making those dollars feel much more like part of a limited individual resource. While ultimately unsuccessful, the Republican call to transform Medicare was part of a larger ideological agenda that has gained considerable political traction and that is likely to condition future debates over healthcare reform. Treating citizens like consumers, despite its controversial nature in various respects, has become main-stream. The 1995 challenge to Medicare’s long-standing entitlement structure stands in fairly sharp contrast to its history.

From its creation in 1965 through the early 1990s, political consensus governed the Medicare program. Healthcare analyst Jonathan Oberlander writes that this long-lasting consensus hinged on three points: first, both political parties broadly agreed on policy directions; second, political struggles over Medicare rarely triggered protracted public debates; and third, because both parties agreed on the program’s fundamental principles, they went on to agree substantially on the larger vision, that Medicare should be a universal and federally funded entitlement. This is, at its core, a liberal consensus. However, when attacked in the mid-1990s, this consensus came unraveled not as a result of public opinion movement, but rather because of changes in the outlooks of political elites.20 The period of open political conflict over Medicare passed, but the urge to treat patients more like shoppers has continued.

Congress and the president have once again taken up the task of crafting legislation that strives toward universal healthcare coverage. While mandatory spending is required, discretionary spending is at the discretion of Congress. Of course, such spending is all subject to interpretation. In this political season, the fact that most Americans support the idea of universal coverage may either turn out to be one of the most important principles that motivate policy makers, or it may turn out to be largely irrelevant. An enduring paradox in the debate over health politics is that while most Americans support universal care, we have not reached that goal because of our deep conflicts about how to achieve it, and our political institutions offer numerous venues for that conflict to thwart the smooth transmission of majority public opinion into policy.

Traditionally these factors have been placed into two categories: attitudinal or cultural explanations in the first and institutional explanations in the second. Each bears a bit of revisiting. Unfortunately, no Americans have the “legal right” to health care as it is only given to those who can either afford it or meet a certain criteria to receive it through federal or state funds. In a typical health insurance plan, a premium represents the amount of funds to be paid for a certain health insurance policy. A deductible represents any amount that can be subtracted from the premium based on specific criteria. Cost sharing in health care represents a certain amount that is paid by the patient which is not covered by their health care provider.

During the first decade of the twenty-first century, the American people were whipsawed back and forth between two vastly different methodologies for addressing the nations escalating health care crisis. Both Democrats and Republicans recognized the same grim trends: rapidly rising health care costs, growing numbers of uninsured people, and wide-spread evidence of waste and poor performance in health care sectors. And the two par-ties agreed that the impact of these trends—reduced investment in education and other public priorities diminished competitiveness in global business sectors, and the risk of financial hardship or ruin for millions of families—made it imperative that Washington, D.C., take action. However, the divergent political ideologies and policy priorities of the two parties made it exceedingly difficult for them to find, or even seek out, common ground. The most spectacular evidence of this chasm came in 2009-2010, when President Barack Obama and Democratic majorities in Congress enacted the Patient Protection and Affordable Care Act without a single Republican vote.

Congress will have the final say on the Board’s powers, but I envision it performing several crucial functions. First, it would set the rules for the expanded FEHBP, placing conditions on the private insurers wishing to participate. It might, for example, develop guidelines on premiums and marketing practices. It would implement policies to prevent insurers from shunning high-cost enrollees. In overseeing the pool, the Board would aim to promote competition, curb administrative costs, and protect consumers. The Federal Health Board also would work with Medicare to develop a public insurance option for the pool, designing it to compete with the private insurance plans on the FEHBP menu. The Board’s guidance would aim to maintain choice in insurance, reduce the administrative costs, promote good insurer practices, and protect consumers. Second, the Federal Health Board would promote “high-value” medical care by recommending coverage of those drugs and procedures backed by solid evidence. It would exert influence by ranking services and therapies by their health and cost impacts. In addition to conducting its own research, the Board would suggest research priorities for the National Institutes of Health and other agencies, and analyze all other federal health data, including the electronic health records from the Veterans Administration and Medicare. It would make its decisions in public meetings, with mandatory reports to Congress. In some areas, the Board’s work would be easy.

The separation of powers doctrine is a political policy originating where the constitutional government is made up of three different branches of sub-government entities. Each of these individual branches would carry defined rights to regulate as well as review the powers of the other two branches. One of these branches is the legislative branch. Their role is to create and enact federal laws, including those related to health care policy.

There are many demand shifters in the health care system. Promoting prevention, for example, is relatively simple and painless—even Congress could do it. It is not so clean-cut to determine which back pain or mental illness treatment is the most clinically valuable and cost effective. We won’t be able to make a significant dent in health-care spending without getting into the nitty-gritty of which treatments are the most clinically valuable and cost effective. That means taking a harder look at the real costs and benefits of new drugs and procedures. In Great Britain, NICE, described in part three, uses cost-effectiveness information in deciding whether to cover a new drug or procedure. I’m not suggesting that we should adopt a hard-and-fast rule on cost-effectiveness in public policy. Nevertheless, it is clear that as a nation we have to begin to look at medical care in a different way. The challenge, as David Mechanic of Rutgers University points out, is creating an entity with the credibility and the clout to make those tough decisions. Mechanic agrees that a board modeled on the Federal Reserve might be the answer.

Step-by-step reforms have certainly brought about some useful changes over the past few decades, but this approach has also allowed the costs of Medicare, Medicaid, and private insurance to rise to levels previously unimagined and which are unarguably burdensome on the nation’s economy. Plans for sweeping changes to healthcare delivery and financing often represent some very sophisticated thinking by smart and well-intentioned people, but those plans often call for leaps of faith that involve political vulnerabilities fostered by the attitudinal and institutional constraints discussed here. Appeals to moral suasion are only so powerful. President Obama often invoked the language of the absolute imperative of major reform, telling audiences that “the status quo is untenable,” and “everybody understands we can’t keep doing what we are doing. It is bankrupting families. .. . It is bankrupting businesses…. And it’s bankrupting our government at the state and federal levels.

So we know things are going to change.” Many liberals are concerned, acknowledge-edge that the status quo is no longer viable. Dan Danner—lobbyist for the National Federation of Independent Businesses, primarily a small business group with strong GOP ties in the summer of 2009 referred to how much the landscape has changed since the 1990s. “The difference is that 15 years ago, our members felt that the status quo was better than what was being pro-posed. … This time the status quo isn’t acceptable.” The trouble is, saying this does not make it so. Incremental change at the margins seems the most likely outcome in the near term. But even multiple episodes of minor reform do not necessarily build coherently and constructively one upon the other, thus prudent steps do not necessarily sum to a fundamental redress for the host of problems that have taken roughly a century to develop. Incremental-ism does not appear to likely produce a comprehensive healthcare system, but it seems to be the most realistic alternative Americans have.

Works Cited

Fenton, Joshua J., et al. “The cost of satisfaction: a national study of patient satisfaction, health care utilization, expenditures, and mortality.” Archives of internal medicine 172.5 (2012): 405-411.

Unützer, Jürgen, et al. “Transforming mental health care at the interface with general medicine: report for the presidents commission.” Psychiatric Services(2014).