The United States’ approach to health care policy is an anomaly among industrialized nations. Disagreement about what the federal government’s role in health care ought to be, combined with the structure of lawmaking institutions, have yielded generations of improvised policies and programs that intend to mollify individual issues created by the health care system rather than comprehensively addressing its flaws.
Following World War II, while most industrialized nations were creating national systems for health care in order to promote equality between classes, the US opted to exclude the provision health care from the federal government’s list of responsibilities. Unlike in those industrialized nations, there was no ideological consensus in the US that health care was a right. Therefore, national health care was seen as being outside the purview of the state. In part due to the distinctive, deep-seated suspicion of large government, its role was relegated to tackle piecemeal health care issues as they gained traction though an incremental, “disjointed” (Lindblom; Tuohy, p. 71) process.Order now
The federal government has been essentially limited to use health care policy as a tool only when problems within the existing health care system, such as access, affordability for the consumer, overall cost and efficiency, are framed as discrete, palatable issues at opportune times. Any attempt to create a rational, comprehensive plan, such as a national health plan, has been repeatedly suffocated by warring ideologies and the intricacies of US policy-making system. The following three examples epitomize the way in which federal health care policies are inadvertently borne in response to symptoms of a lacking heath care system. In the 1940s, the federal government began to subsidize hospital construction and improvements with the Hill-Burton Act. In the 1960s, the federal government commenced funding health care coverage for specific, deserving populations with Medicare and Mecaid. Beginning in the 1970s, the federal government became involved in regulatory program aimed to control spending – including the Professional Standards Review Organization. In each of these cases, the federal government had a role because of the specific framing of the finite problem.
In the 1940s, the federal government’s involvement with health care policy was initially focused on subsidizing the ‘supply side’ of the health care system. This tactic aimed to expand the US health care system, while appeasing those who believed its operation should be left to the free-market. Federal support began with non-partisan, low-hanging fruit, which included the passage of the Hill-Burton Act. It was a bill that “appealed to everyone and alienated no one” (Rohrer, p. 141), created in response to geographic variations in hospital services – especially a lack of hospitals in rural America. The bill aimed to expand the physical infrastructure of the US health care system by building (and later, improving) hospitals throughout the country. Some, like the doctor representing the Committee of Physicians for the Improvement of Medicine, knew that targeting one small piece of a flawed health care system was not going to a long-term solution. He warned that subsidizing hospitals could “lull the nation into thinking that its health problems were solved” (Rohrer, p. 141; Starr), but that only a national health insurance plan would make accessibility universal. It was clear that the Hill-Burton Act, despite its good intentions, was not the product of a rational, overarching plan to address issues of health care access. Rather, it was a shortsighted attempt to construct and upgrade hospitals that mistakenly oriented the entire health care system to overuse hospitals. In Senator Edward Kennedy’s words, the Hill-Burton Act “allowed a wasteful, inefficient health care system to perpetuate itself” (p. 144). He called for a restructuring of the health care system to shift the policy community towards planning how the system should operate, rather than implementing reactive bandages.
Nearly twenty years later, the federal government’s involvement with health care policy was centered on increasing access to health care by financing the provision of care for ‘deserving groups’ (without, of course, detracting from the private sector). Passing the legislation that enacted Medicaid and Medicare – the government sponsored programs that provide health insurance to two sympathetic groups: the elderly and the deserving poor – was a decidedly more partisan issue than building hospitals had been. Though the passage of Medicaid and Medicare was much harder fought than the Hill-Burton Act, it still had the advantage of a long-softening up period and a receptive political climate. President Lyndon Johnson “understood the power of invoking the martyred president” (Blumenthal and Morone, p.177) and embraced the positions set forth on President Kennedy’s legislative agenda. Though Medicare and Medicaid were widely viewed as programs whose time had come, they were ultimately the improvised creation of legislators looking for a political win.
It is clear that President Johnson had a vision about rights and welfare, but he was also acutely aware of the political constraints to implementing a large scale, pre-conceived plan. He accepted that whatever Congress produced would have to be sufficient; advising Representative Mills to do “what you’ve got to do to make acceptable” (p.180). The deal-making, compromise, and manipulation that went into making it “acceptable” speak volumes about how little consensus there was about the role of government in healthcare.
Medicare and Medicaid had been optimistically viewed as “part of an incremental strategy of policy development” (Tuohy, p. 71) – the antecedent to a national health plan. The failure to pass a national health plan in 1974 and again in 1979 countered the belief that incremental policy actions could progressively lead to a more inclusive program. Though Medicare and Medicaid were more aligned with a long-term vision, both the way the bill was passed and the fact that it did more to strengthen the existing system (rather than restructuring it) indicate that it was more a contingency than a rational plan. Despite this, Medicare and Medicaid did ultimately accomplish a lot; these programs provided health coverage for millions of Americans. Nevertheless, there haven’t been the major gains in coverage or expansion to other populations that was originally predicted in line with the incremental tactic.
Health care costs in the fee-for service health care system were rising and now, with the government shouldering a larger portion of the bill during an economic down turn, there was another specific problem for the federal government to tackle through policy. While strategies to reorganize the health care system through Health Maintenance Organizations were held up in the policy making process, regulatory tactics plowed ahead. The desperation to solve the ‘cost crisis’ led to the hasty adoption of regulatory programs. One such program was the mandate for Professional Standards Review Organizations (PSROs) to generate standards for practice and utilization across the country, “ostensibly with an eye to unnecessarily costly treatment patterns” (Morone, p. 269) and minimize inappropriate Medicare and Medicaid reimbursements. Though well intended, there were doubts about how effective PSROs would be. The legislation, in response to industry pressure, “forbade anybody but physicians to participate in PSRO decisions” (p. 269). Despite the fact that they had complete ownership over its direction, clinicians were still extremely resentful of the federal government’s intrusion into their profession. Expansion into hospitals was arduous and, at times, hostile, especially when PSROs challenged hospital operations or defied their strictly hierarchical structure. The PSROs had little impact on influencing clinician behavior and in effect, “enshrined usual and customary practices as norms” (Brown, p. 23). An evaluation in the late 1970s confirmed how ineffectual PSROs had been, finding that they had “probably cost about as much as it had saved” (Brown, p. 27). Before dismantling them completely, Congress replaced PSROs with a similar, but theoretically more powerful Peer Review Organization (PROs).
The creation of PSROs was another product of contingencies; a program viewed as acceptable because it was non-threatening, but theoretically could have contained costs had in not been administered by the same group it was trying to influence. That PSROs turned out to be “better suited to the industry’s expansion than to its retrenchment” (Morone, p. 269) is evidence of the fact that is was created for its mere tolerability. This – and most other regulatory programs at this time – never had the rational, big-picture forethought attached to them to ensure their success
One of the major lessons learned from these examples of the federal government’s forays into health care policy is that when incrementalism is the strategy – whether by choice or because of the political climate – it becomes even harder to implement a thoughtful, well-organized program. Coherence and continuity are extremely difficult to plan for without being able to predict what the political climate or national mood will be like, what will have changed and what will be the same. At this point, it seems the federal government is incapable of addressing the flaws of the US healthcare system with an overarching, rational, and thoughtful plan. Implementing such a plan would first require ideological consensus, which seems more and more unlikely in this increasing partisan world. This individualistic, market-driven system has become so engrained into the American conceptualization of the health care system that it is nearly impossible to meaningfully restructure the health care system. Even with a majority (not consensus) there is so much uncertainty in the lawmaking process and congressional “institution itself – its intricate rules, processes, folkways, and coalitions.” (Blumenthal and Morone, p. 165). This intersection of ideology and lawmaking almost precludes the passage of a national health plan, without a major cultural shift towards prioritizing health as a human right.