Health Care Policy in the U.S.—Issues and Prospects (PLS 202, Dluhy)

I. More so that any other policy area in the U.S., this area is controlled by interest groups and subject to the pragmatic/incremental model of decision making.

II. Interest groups have been well established since 1950 when President Truman first offered a version of national health insurance to the Congress. He saw what was happening all over Europe as many western Democracies adopted the social welfare state. Since that time only Medicare and Medicaid have been adopted (1964-65) by President Johnson. Interest group coalitions from the private sector, hospitals, the AMA, and others have consistently opposed further expansion of the public role in health care. Clinton tried in 1993 and 1994 but failed as well. Everyone was relying on HMOs to solve the problems, especially cost problems.

III. Majorities in public opinion polls since the early 1990s have supported a version of national health insurance but elites and interest groups have blocked passage. Why are elites out of step with public?

IV. Target groups who have consistently slipped through the cracks, approximately one in eight plus individuals and families who pay a disproportionate amount of their income on health are at risk. For example, the health burden should not exceed 4% or $1600 a year for a median income family of four ($40,000). With family policies averaging $350-$500 a month, many pay $4200 to $6000 a year or 3 times as much as they should.

· Small businesses

· Immigrants, non-citizens

· Rural, shortage of Doctors and good medical care, mal-distribution of MDs

· Elderly, especially those over 85 who do not have supplemental insurance for Medicare yet have high prescription costs, home health care costs, and eventually nursing home care which is not covered by Medicare. Nursing home care is now averaging about $30,000 a year. Prescription drugs and nursing home care are the biggest gaps.

· Working/middle class families who earn too much to be covered by Medicaid and who either do without or pay a disproportionate amount of income on health care. Children in these families are at risk as well.

V. The question of right vs. privilege (Canada, western Europe) deserving vs. non-deserving.

VI. Issues and things that need to be fixed (Since Kaiser-Permamente demonstrated patients were healthier in HMOs and it was a lot cheaper to provide care, HMOs have grew rapidly. You need a minimum of 5000 in an insurance pool to spread costs around)

· Inflation cost index, affordability—since 1950s health index has always exceeded the CPI

· HMO’s how large? Spread costs. The bigger the better but then problems of continuity of care and quality of care. Super-market care.

· Pre-existing conditions

· Coverage and co-payments

· Para-professionals substituting for MDs

· Mental health usually left out especially long term treatment beyond six sessions

· Out-referrals by HMOs are extremely hard to get (Bill of Rights)

· Long term care in home hard to get and usually not covered by HMOs

· Health care rationing is here, ethical considerations will increase. The last year of life usually accounts for 50% of all the costs of health care during a person’s lifetime. I.e., we do extraordinary things in the last year which almost always fail.

· Prescription drugs and nursing home care

VII. Future of health care, are there alternatives to HMO’s?

· Medical IRAs?

· Cost controls, similar to Canada, highly regulated cost controls

· Sliding scale or subsidized private health insurance, you pay 4% of gross income and government makes up the difference

· Uninsurable pools of insurance subsidized by government