Healthcare
Politics and
Policy in
America
Health policy in the United States has been shaped by the political, socioeconomic, and ideological environment, with important roles played by public and private actors, as well as institutional and individual entities, in designing the contemporary American healthcare system.
Now in a fully updated fifth edition, this book gives expanded attention to pressing issues for
our policymakers, including the aging American population, physician shortages, gene therapy,
specialty drugs, and the opioid crisis. A new chapter has been added on the Trump administration’s failed attempts at repealing and replacing the Affordable Care Act and subsequent
attempts at undermining it via executive orders.
Authors Kant Patel and Mark Rushefsky address the key problems of healthcare cost,
access, and quality through analyses of Medicare, Medicaid, the Veterans Health Administration, and other programs, and the ethical and cost implications of advances in healthcare technology. Each chapter concludes with discussion questions and a comprehensive reference list.
This textbook will be required reading for courses on health and healthcare policy, as well as
all those interested in the ways in which American healthcare has evolved over time.
Kant Patel is Emeritus Professor of Political Science at Missouri State University, USA.
Mark Rushefsky is Emeritus Professor of Political Science at Missouri State University, USA.
Healthcare
Politics and
Policy in
America
Fifth Edition
Kant Patel and
Mark Rushefsky
To the memory of Marc Cooper.—Kant Patel
To my grandchildren, Echo, Damian, and Gabriel. You bring us joy and we
hope that you can help make a better future for us all.—Mark Rushefsky
Fifth edition published 2020
by Routledge
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them in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988.
All rights reserved. No part of this book may be reprinted or reproduced or utilized in any form or by any
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only for identification and explanation without intent to infringe.
Library of Congress Cataloging-in-Publication Data
A catalog record for this title has been requested
First edition published by M.E. Sharpe 2005
Fifth edition published by Routledge 2019
ISBN: 978-0-8153-7633-0 (hbk)
ISBN: 978-0-367-02774-2 (pbk)
ISBN: 978-0-429-39787-5 (ebk)
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Visit the eResources: www.routledge.com/9780367027742
CONTENTS
List of tables and figures
Preface
Foreword
List of Acronyms
Acknowledgments
xiii
xv
xvii
xxiii
xxv
I
Healthcare Politics and Policy
1.
Healthcare Politics ............................................................................................................................................ 3
Health Policymaking in the United States ........................................................................................................ 3
The Health Policy Environment........................................................................................................................ 5
The Constitutional Environment ....................................................................................................................5
The Institutional Environment .......................................................................................................................8
The Political Environment ...........................................................................................................................12
The Changing Political Environment ...........................................................................................................16
The Economic Environment .........................................................................................................................21
The Technological Environment...................................................................................................................22
Key Health Policy Actors ............................................................................................................................... 22
Healthcare Providers...................................................................................................................................22
Third-Party Payers .....................................................................................................................................25
Employers ...................................................................................................................................................28
Consumers...................................................................................................................................................28
Interest Groups............................................................................................................................................30
Conclusion...................................................................................................................................................... 33
Study Questions.............................................................................................................................................. 33
References....................................................................................................................................................... 34
2.
Healthcare Policy in the United States ............................................................................................................ 41
The US Healthcare System in a Comparative Context ................................................................................... 42
Healthcare in Colonial Times ......................................................................................................................... 43
Healthcare in the Nineteenth Century ............................................................................................................ 43
The Transformation of US Medicine: 1900–1935 ........................................................................................... 44
The Role of the Federal Government in Healthcare ....................................................................................... 45
Limited Federal Role: 1900s–1930s .............................................................................................................45
Expanded Federal Role: 1930s–1960s ..........................................................................................................46
Efforts at Healthcare Cost Containment: 1970s–1980s ................................................................................49
Controlling Costs by Planning .....................................................................................................................50
The Political Transformation of the US Healthcare System: 1981–2018 ......................................................... 51
The Reagan Administration: 1981–1989 ......................................................................................................52
The George H. W. Bush Administration: 1989–1993....................................................................................53
The Clinton Administration: 1993–2001 ......................................................................................................54
The George W. Bush Administration: 2001–2009.........................................................................................56
The Barack Obama Administration: 2009–2017 ..........................................................................................60
The Trump Administration: 2017–...............................................................................................................61
The Evolution of Public Health in the United States ...................................................................................... 63
v
vi
CONTENTS
The Seventeenth Century .............................................................................................................................63
The Eighteenth Century...............................................................................................................................63
The Nineteenth Century...............................................................................................................................64
The Twentieth Century ................................................................................................................................65
The Twenty-First Century ...........................................................................................................................66
Organization and Functions of Public Health...............................................................................................67
Public Health Spending and Financing.........................................................................................................70
Public Health Accomplishments and Challenges ..........................................................................................70
Conclusion...................................................................................................................................................... 71
Study Questions.............................................................................................................................................. 73
References....................................................................................................................................................... 73
II
Government Health Programs
3.
The Affordable Care Act: Stumbling Toward Universal Health Insurance? ...................................................... 81
The Road to the Affordable Care Act (2006–2008) ......................................................................................... 81
Kingdon’s Multiple Streams Model..............................................................................................................81
The Political Stream ...................................................................................................................................87
The Legislative Process: An Ordeal by Fire (2008–2010) ................................................................................ 87
The Opening Moves.....................................................................................................................................87
The Legislative Process: Ideal versus Real ...................................................................................................88
Political Parties at War...............................................................................................................................89
Moving Through Congress...........................................................................................................................90
The Affordable Care Act Clears the Obstacles .............................................................................................95
The Patient Protection and Affordable Care Act ............................................................................................ 96
Goals and Purposes .....................................................................................................................................96
Major Provisions .........................................................................................................................................96
Challenging the Affordable Care Act............................................................................................................ 101
The Affordable Care Act on Trial .............................................................................................................. 101
Electoral Challenges.................................................................................................................................. 105
Public Opinion........................................................................................................................................... 105
Implementing the Affordable Care Act......................................................................................................... 106
Federalism and the Affordable Care Act....................................................................................................... 108
Health Insurance Exchanges...................................................................................................................... 108
Medicaid Expansion and the States ........................................................................................................... 109
Legislative Challenges................................................................................................................................... 111
Administrative Challenges ............................................................................................................................ 113
Evaluating the Affordable Care Act.............................................................................................................. 115
Insurance Coverage ................................................................................................................................... 115
Affordable Care......................................................................................................................................... 117
Criticisms of the Affordable Care Act ........................................................................................................ 118
Conclusion.................................................................................................................................................... 120
Study Questions............................................................................................................................................ 124
References..................................................................................................................................................... 124
4.
Medicaid and the Children’s Health Insurance Program: Healthcare for the Poor and the Disabled ................130
Important Facts about the Current Medicaid Program ................................................................................ 131
Program Objective and Structure.................................................................................................................. 132
Medicaid Eligibility and Coverage, Services and Benefits ............................................................................. 132
Eligibility and Coverage ............................................................................................................................ 132
Benefits and Services ................................................................................................................................. 135
Medicaid Financing...................................................................................................................................... 135
Federal Financing ...................................................................................................................................... 135
State Financing ......................................................................................................................................... 135
The Children’s Health Insurance Program (CHIP) ....................................................................................... 137
CONTENTS
vii
The Origins and Evolution of the CHIP..................................................................................................... 137
The Struggle over the Renewal of the CHIP .............................................................................................. 138
CHIP Eligibility, Benefits, Financing, and Cost-Sharing............................................................................ 139
The Affordable Care Act of 2010 and Medicaid Expansion.......................................................................... 140
The Implementation of Medicaid Expansion under the ACA ...................................................................... 141
What Factors Explain States’ Decisions to Expand or Not to Expand? ...................................................... 142
Justifications for Expansion and Consequences .......................................................................................... 145
Justifications for Non-Expansion and Consequences .................................................................................. 146
Changes in Medicaid Enrollees, Enrollment, and Expenditures.................................................................... 147
Characteristics of Program Enrollees ........................................................................................................ 147
Medicaid Enrollment and Expenditures ..................................................................................................... 147
Medicaid Waivers ......................................................................................................................................... 148
What are Medicaid Waivers?..................................................................................................................... 148
Types of Medicaid Waivers ....................................................................................................................... 148
Medicaid Waivers and State Medicaid Reforms, 1980s–2010s ................................................................... 149
The Current State of Medicaid Waivers and Reforms ................................................................................ 150
Broad Overview of Approved and Pending Waivers.................................................................................... 150
Trends in Medicaid Reforms and Experiments: Private-Sector Approaches ............................................... 151
Long-Term Care: Transition from Institutional to Community-Based/Home Care ...................................... 155
Medicaid Pay-For-Performance .................................................................................................................... 157
Conclusion.................................................................................................................................................... 158
Study Questions............................................................................................................................................ 159
References..................................................................................................................................................... 159
5.
Medicare: Healthcare for the Elderly .............................................................................................................165
The Origins of Medicare ............................................................................................................................... 165
Program Objectives and Structure ................................................................................................................ 166
Objectives.................................................................................................................................................. 166
Structure ................................................................................................................................................... 167
Financing Medicare...................................................................................................................................... 168
Supplementing Medicare .............................................................................................................................. 169
Medicaid Buy-In ....................................................................................................................................... 169
Medigap.................................................................................................................................................... 170
Employment Retiree Benefits..................................................................................................................... 170
Transforming Medicare ................................................................................................................................ 170
The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 ....................................... 171
Medicare Advantage.................................................................................................................................. 175
Lessons from the Medicare Modernization Act .......................................................................................... 176
Controlling Costs.......................................................................................................................................... 177
Prospective Payment System ..................................................................................................................... 179
Controlling Physician Costs....................................................................................................................... 180
Reorganizing Payment Mechanisms and Service Delivery .......................................................................... 182
The Problem of Long-Term Care.................................................................................................................. 182
Long-Term Care Insurance........................................................................................................................ 184
Policy Options: Transforming Medicare ....................................................................................................... 185
Incremental Policy Alternatives ................................................................................................................. 185
Comprehensive Policy Alternatives ............................................................................................................ 187
Medicare and the Affordable Care Act ......................................................................................................... 189
Conclusion: The Politics and Policy of Medicare .......................................................................................... 190
Study Questions............................................................................................................................................ 191
References..................................................................................................................................................... 191
6.
Healthcare for American Indians, Alaska Natives, and Veterans ....................................................................196
American Indians and Alaska Natives.......................................................................................................... 196
Population Characteristics and Trends....................................................................................................... 197
viii
CONTENTS
Historical Background.................................................................................................................................. 198
The Legal and Constitutional Status of American Indians and Alaska Natives ........................................... 198
American Indians ...................................................................................................................................... 198
Alaska Natives .......................................................................................................................................... 199
The Evolution of Health Policy .................................................................................................................... 199
The Nineteenth Century............................................................................................................................. 199
The Twentieth Century .............................................................................................................................. 200
The Twenty-First Century ......................................................................................................................... 202
The Indian Health Service: Organization and Structure ............................................................................... 203
Organization and Delivery of Health Services............................................................................................ 204
Urban Indian Health Programs ................................................................................................................. 204
The Indian Health Service and Funding ..................................................................................................... 205
Health Status and Trends.............................................................................................................................. 206
Accomplishments of the IHS ........................................................................................................................ 210
Challenges Confronting the IHS and Healthcare Policy for AIs/ANs........................................................... 210
Increasing Funding for the IHS ................................................................................................................. 211
Increasing Access to Healthcare Services................................................................................................... 211
Providing Culturally Competent Care........................................................................................................ 212
Conclusion................................................................................................................................................. 213
Healthcare for Veterans ................................................................................................................................ 214
Population Characteristics and Trends....................................................................................................... 214
Historical Background: The Development of Veterans’ Benefits .................................................................. 214
Veterans’ Health Policy Development........................................................................................................... 216
The Veterans Health Administration ............................................................................................................ 219
Mission ..................................................................................................................................................... 219
Organization and Structure ....................................................................................................................... 219
Transitioning from Tricare to VA Healthcare ............................................................................................... 220
The VA Healthcare System ........................................................................................................................... 220
Eligibility and Enrollment.......................................................................................................................... 220
Benefits and Services ................................................................................................................................. 221
Health Benefits for Family Members of Veterans....................................................................................... 222
The Health Status of Veterans ...................................................................................................................... 222
Funding and Expenditures of the VA and VHA ........................................................................................... 225
Veterans’ Use of Benefits and Services .......................................................................................................... 226
A History of Scandals at the Veterans Administration ................................................................................. 228
Challenges Confronting the VA Healthcare System ...................................................................................... 230
Conclusion.................................................................................................................................................... 231
Study Questions............................................................................................................................................ 232
References..................................................................................................................................................... 232
III
Problems of the Healthcare System
7.
Falling Through the Safety Net: The Disadvantaged ...................................................................................... 243
Equality and Equity...................................................................................................................................... 243
Important Considerations............................................................................................................................. 245
Social Determinants of Health................................................................................................................... 246
Geography is Destiny................................................................................................................................. 247
Addressing Social Determinants ................................................................................................................ 248
The Uninsured and Underinsured ................................................................................................................ 249
Consequences of Uninsurance and Underinsurance ..................................................................................... 253
Insurance and the Idea of Community ......................................................................................................... 256
A Closer Look: The Poor, Minorities, and Women....................................................................................... 257
Minorities and Low-Income Groups........................................................................................................... 258
Women...................................................................................................................................................... 262
Immigrants and Healthcare .......................................................................................................................... 270
CONTENTS
ix
Lawful Noncitizen Immigrants and Healthcare .......................................................................................... 271
Undocumented Immigrants and Healthcare ............................................................................................... 272
Conclusion: The Problems of the Disadvantaged Remain ............................................................................ 274
Study Questions............................................................................................................................................ 275
References..................................................................................................................................................... 275
8.
The Problem of Rising Healthcare Costs and Spending.................................................................................. 283
Rising Healthcare Costs/Expenditures.......................................................................................................... 283
Expenditures by Type of Health Service .................................................................................................... 286
Growth in Public-Sector Expenditures and Decline in Out-of-Pocket Expenditures .................................... 288
Concentration of Expenditures .................................................................................................................. 290
Healthcare Expenditures in the United States Compared to Other Countries ............................................. 294
Who is Affected by High and Increasing Healthcare Costs? ......................................................................... 294
Households................................................................................................................................................ 294
Businesses ................................................................................................................................................. 297
Government ............................................................................................................................................... 297
Americans’ Views about Healthcare Costs/Expenditures.............................................................................. 299
Factors Responsible for Rising Healthcare Costs/Expenditures.................................................................... 299
The Role and Growth of Medical Technology ............................................................................................ 300
Medical Errors and Costs .......................................................................................................................... 304
Costs of Waste, Fraud, and Abuse in the US Healthcare System................................................................ 308
Lifestyle Choices and Costs/Expenditures.................................................................................................. 310
Administration .......................................................................................................................................... 311
The Overpriced American Healthcare System............................................................................................ 312
Prescription Drugs and Costs/Expenditures ............................................................................................... 314
Cost Drivers.................................................................................................................................................. 322
Healthcare Cost-Containment: Bending the Cost Curve .............................................................................. 323
Theoretical Framework: Government Regulation and Market Competition ................................................ 323
The Regulatory Strategy ........................................................................................................................... 323
The Market Strategy................................................................................................................................. 324
Past Efforts at Controlling Healthcare Costs ................................................................................................ 327
Healthcare Planning and Cost-Containment .............................................................................................. 327
Professional Standards Review .................................................................................................................. 327
Price Regulation........................................................................................................................................ 328
The Special Case of Maryland................................................................................................................... 329
Controlling Drug Prices............................................................................................................................. 329
Health Maintenance Organizations, Healthcare Rationing, Managed Care, and Cost-Containment ........... 331
Health Maintenance Organizations ........................................................................................................... 331
Healthcare Rationing ................................................................................................................................ 332
Managed Competition ............................................................................................................................... 333
Managed Care........................................................................................................................................... 334
Wellness Programs ........................................................................................................................................ 336
Cost-Sharing................................................................................................................................................. 336
Cost-Containment in the Twenty-First Century ........................................................................................... 337
Fraud, Waste, and Cost Control ................................................................................................................ 338
The Affordable Care Act and Cost Control ................................................................................................ 341
The Federal Budget and Healthcare Costs ................................................................................................. 341
A Strategy for Controlling Costs .................................................................................................................. 342
Conclusion.................................................................................................................................................... 343
Study Questions............................................................................................................................................ 343
References..................................................................................................................................................... 344
x
CONTENTS
IV
Contemporary Challenges in American Healthcare
9.
The Role of Biomedical Technology: The Beginning and the End of Life ........................................................ 361
Medical Technologies: Law, Politics, Religion, and Ethics ............................................................................ 361
The Beginning of Life ................................................................................................................................... 363
What are Assisted Reproductive Technologies? .......................................................................................... 363
Types of ARTs .......................................................................................................................................... 363
The Role of Consent and Contracts in ARTs.............................................................................................. 364
New Developments in ARTs ...................................................................................................................... 365
Infertility and ARTs .................................................................................................................................. 367
Government Regulation of ARTs and Surrogacy........................................................................................ 367
Courts and the Right to Conceive and Bear Children.................................................................................. 368
Preventing Unintended Pregnancies, Births, and Abortions ......................................................................... 372
Contraceptive Use, Unintended Pregnancies, and Abortions....................................................................... 372
Abortions in the United States ................................................................................................................... 373
Federal and State Regulation of Abortions................................................................................................. 374
Emergency Contraception ............................................................................................................................ 375
Background ............................................................................................................................................... 375
Use of Emergency Contraception............................................................................................................... 377
State Governments and Emergency Contraception ..................................................................................... 377
Emergency Contraception and the Courts .................................................................................................. 378
The Politics of Emergency Contraception .................................................................................................. 378
RU-486 and Medication Abortion................................................................................................................ 378
State Governments and Medication Abortion............................................................................................. 379
Medication Abortion and the Courts.......................................................................................................... 379
The Politics of RU-486.............................................................................................................................. 380
Courts and Abortion: The Right to Prevent Unwanted Pregnancies and Births........................................... 380
ARTs, Religion, and Politics...................................................................................................................... 382
ARTs, Ethics, and Law.............................................................................................................................. 383
The End of Life: The Right to Die and Physician-Assisted Suicide .............................................................. 384
The Right-to-Die Movement...................................................................................................................... 384
The Right to Die and Physician-Assisted Suicide in Other Countries.......................................................... 385
The Right to Die in the United States........................................................................................................... 386
Courts and the Right to Refuse Life-Sustaining Treatments ....................................................................... 386
Courts and Physician-Assisted Suicide....................................................................................................... 390
States and Physician-Assisted Suicide........................................................................................................ 391
Physician-Assisted Suicide Statistics ......................................................................................................... 392
Public Opinion and the Right to Die .......................................................................................................... 395
Living Wills and Durable Power of Attorney ............................................................................................. 396
Physician-Assisted Suicide: Religion, Morality, and Ethics........................................................................ 397
Conclusion.................................................................................................................................................... 398
Study Questions............................................................................................................................................ 398
References..................................................................................................................................................... 399
10.
Challenges Facing the American Healthcare System.......................................................................................407
The Opioid Crisis.......................................................................................................................................... 407
What Are Opioids? .................................................................................................................................... 408
The Nature and Scope of the Opioid Epidemic ........................................................................................... 409
The Demographics and Geography of the Opioid Epidemic ........................................................................ 410
The Economic and Social Costs of the Opioid Epidemic............................................................................. 412
What is Responsible for the Opioid Epidemic? The Blame Game................................................................ 413
Government’s Response to the Opioid Crisis .............................................................................................. 416
Specialty Drugs/Pharmaceuticals.................................................................................................................. 420
What are Specialty Drugs? ........................................................................................................................ 421
CONTENTS
xi
The Management of Specialty Drugs......................................................................................................... 421
The Role of the FDA in Specialty Drugs.................................................................................................... 422
The Cost of Specialty Drugs and Price Increases ....................................................................................... 423
The Benefits and Effectiveness of Specialty Drugs...................................................................................... 426
Policy Dilemma: Balancing the Costs and Benefits of Specialty Drugs....................................................... 427
Gene Therapy: The Future of Medicine? ...................................................................................................... 427
The Evolution of Gene Therapy ................................................................................................................. 427
What are Gene Editing and Gene Therapy?................................................................................................ 430
The Pros and Cons of Gene Therapy.......................................................................................................... 431
The Cost of Gene Therapy ......................................................................................................................... 432
Controversy over Germline Human Gene Editing ....................................................................................... 433
Germline Human Gene Editing and Ethical Concerns................................................................................. 435
The Regulation of Gene Editing and Gene Therapy .................................................................................... 436
The Role of the Healthcare Workforce ......................................................................................................... 437
The Profile of the Healthcare Workforce ................................................................................................... 437
The Healthcare Workforce and Challenges Facing the American Healthcare System................................. 439
Conclusion.................................................................................................................................................... 443
Study Questions............................................................................................................................................ 443
References..................................................................................................................................................... 444
V
The Continuing Struggle for Healthcare Reform in the United States
11.
Healthcare Politics and Policy in America: Moving Toward Reform? .............................................................453
Healthcare System Goals and Values............................................................................................................ 453
Goals......................................................................................................................................................... 453
Values ....................................................................................................................................................... 455
Fixing the Affordable Care Act..................................................................................................................... 455
Liberal/Democratic Reform Proposals ......................................................................................................... 457
Medicaid-Based Plans ............................................................................................................................... 457
Medicare-Based Plans ............................................................................................................................... 458
Conservative/Republican Proposals .............................................................................................................. 462
Conclusion: Healthcare Reform Choices ...................................................................................................... 469
Study Questions............................................................................................................................................ 471
References..................................................................................................................................................... 471
Appendix A. Important Health Policy-Related Websites and Resources ................................................................473
Appendix B. Chronology of Significant Events and Legislation in US Healthcare .................................................479
Appendix C. Important Concepts...........................................................................................................................489
Appendix D. Important Research Reports..............................................................................................................493
Appendix E. Healthcare-Related Documentaries and Films...................................................................................496
About the Authors..................................................................................................................................................506
Index.......................................................................................................................................................................507
TABLES AND FIGURES
TABLES
1.1
3.1
3.2
4.1
4.2
4.3
5.1
5.2
5.3
5.4
5.5
6.1
6.2
6.3
6.4
6.5
7.1
7.2
8.1
8.2
8.3
8.4
8.5
8.6
8.7
8.8
9.1
9.2
Occurrences of Unified and Divided Governments in the United States, 1900–2020...................................... 17
Ideological Change in Congress, Selected Years............................................................................................. 90
Affordable Care Act (ACA) Timeline ............................................................................................................ 95
Medicaid Benefits .........................................................................................................................................134
State Action on Medicaid Expansion under the ACA, December 2018 ........................................................143
Expenditures for Medicaid and CHIP Programs, Selected Calendar Years...................................................144
Medicare Part A: Hospital Insurance-Covered Services, 2019 ......................................................................167
Medicare Part B: Medical Insurance-Covered Services, 2019........................................................................168
Sources of Prescription Drug Coverage for the Elderly, 2015........................................................................172
Medicare Expenditures, Selected Years, 1970–2016 (in $ billions).................................................................178
Medicare Beneficiaries, Selected Years, 1970–2017 (in millions)....................................................................178
Indian Health Service Funding History and Budget Request, 2014–2019 (in $ millions) ..............................206
Comparison of Selective Health Status Indicators for American Indians/Alaska
Natives and the General Population, 2014–2015...........................................................................................207
Leading Causes of Death for American Indians and Alaska Natives, 1980 and 2015 ...................................208
The VA’s Budget, FY 2015–2019 (in $ billions) .............................................................................................226
Veterans Administration Utilization Profile, 2016.........................................................................................227
Social Determinants of Health......................................................................................................................246
Sources of Health Insurance Coverage, 1999–2016 .......................................................................................250
Selected National Healthcare Expenditures by Sources of Funds and Types of Services,
1960–2016 (in $ billions) ...............................................................................................................................284
Selected National Healthcare Expenditures by Sources of Funds and Types of Services,
2007–2016 (in $ billions) ...............................................................................................................................287
National Healthcare Expenditures and the Economy, 1960–2016 .................................................................289
National Healthcare Expenditures, 2001–2016 .............................................................................................291
Federal Spending on Healthcare (in $ billions) .............................................................................................298
Estimates of the Cost of Waste, Fraud, and Abuse in Healthcare in the United States, 2009........................309
National Retail Prescription Drug Expenditures by Sources of Funds, 1965–2016 (in $ billions) .................317
National Retail Prescription Drug Expenditures by Sources of Funds, 2000–2016 (in $ billions) .................319
Physician-Assisted Suicide Laws in American States, October 2018..............................................................392
Physician-Assisted Suicide Statistics in Oregon and Washington, 2009–2017 ...............................................394
FIGURES
3.1
3.2
8.1
Healthcare Reform Implementation Timeline................................................................................................. 97
Uninsured Rate Among the Nonelderly Population, 1972–2018 ....................................................................116
Bending the Cost Curve .................................................................................................................................324
xiii
PREFACE
We are gratified by the reception Healthcare Politics and Policy in America has received since publication of the
first edition. It has been well reviewed, it has sold well, and it has been adopted by many colleges and universities.
We thank all those who have adopted it for their courses. The first edition was the first joint research project
between Patel and Rushefsky. Since that time, we have published several books on healthcare with M.E. Sharpe:
Politics, Power, and Policy Making: The Case of Health Care Reform in the 1990s; Health Care Policy in an Age
of New Technologies; The Politics of Public Health in the United States; and Health Care in America: Separate
and Unequal. We are grateful that Routledge has picked up this project as part of its purchase of M.E. Sharpe.
We appreciate the support and enthusiasm with which Routledge has allowed us to continue our work. The staff,
from editor Laura Stearns to the copy-editors, have been wonderful to work with.
Patel began working on the first edition of the book while on a sabbatical in the spring of 1991. Rushefsky
joined the project in 1994. It continues to be an interesting experience for both of us. We do not have the
same kind of work habits. One of us (we won’t tell you which one) is very meticulous and organized; the other
is considerably more scattered and sloppy. This has sometimes led to noisy discussions and scampering to find
things. This is the kind of book Felix and Oscar, the Odd Couple, might have written! One adjustment we did
make was that the neat, meticulous one kept all the papers and files because the other misplaced his. That we
remain close friends who share common interests in professional basketball (and computer games) helped the
relationship. Patel, who is from Houston, roots for the Houston Rockets. Rushefsky, from New York, is
a lifelong, avid, irrational Knicks fan. Patel retired from Missouri State University in 2011, and Rushefsky
retired in 2014.
Both of us have had a long involvement in healthcare, dating back to the 1970s. Rushefsky first became
interested in healthcare when his wife, Cynthia, began teaching childbirth classes in rural Rocky Mount, Virginia. She trained some of the nurses and the wife of the administrator of the local rural hospital (about ten
miles along winding mountain roads from where they lived), and that hospital maintained its maternity ward
rather than closing it. That was fortunate for the Rushefskys when their second child, Leah, was born shortly
after midnight on Halloween. They just made it those ten miles to the hospital. Had that hospital not maintained its birthing facilities, they would have had to go another 25 miles to Roanoke. Given the speed with
which Leah was born (so fast that she beat the doctor to the delivery room!), Rushefsky half-jokingly says she
would have been born in Boones Mill (about halfway between Rocky Mount and Roanoke), which had no
hospital. Updating from the first edition of this book, Leah is now married and has given Rushefsky and his
wife three grandchildren, Echo, Damian, and Gabriel, to whom he has dedicated this book. Echo and Damian
were born prematurely, so the Rushefsky clan has had some close encounters with the American healthcare
system.
Patel’s interest in healthcare was developed more conventionally, as an academic. He has a lifelong belief
that access to good healthcare is a right. The two of us agree that the healthcare system has problems; before
publication of the first edition of this book, there was no text that addressed those problems from a political
perspective.
This fifth edition has been considerably updated and reconceptualized. The first two chapters of the book remain
basically the same (with updates), providing background material. We have moved the discussion of the Affordable
Care Act to Chapter 3. That chapter looks at the implementation of the legislation as well as the many challenges it
faces. Chapters 4 and 5 examine Medicaid and Medicare, providing an update and pointing out how they have been
affected by the Affordable Care Act. Chapter 6 focuses on veterans and Native Americans and Alaska Natives, as well
as the Indian Health Service and the Department of Veterans Affairs. Chapter 7 discusses the safety net and focuses
on access issues. Chapter 8 combines two chapters from the previous edition, looking at cost issues. Chapter 9 has
been reconfigured, focusing on the legal, political, and ethical issues raised by biotechnology related to the beginning
of life (reproductive rights) and the end of life (the right to die). Chapter 10 examines four challenges facing the US
healthcare system: the opioid crisis, specialty drugs, gene therapy, and the healthcare workforce. Chapter 11, new to
this edition, examines reform proposals: to the Affordable Care Act and from conservative and liberal perspectives.
xv
xvi
PREFACE
Patel and Rushefsky, as noted above, have different lifestyles. Patel spends the colder months in southwestern
Florida, lounging on the beach, venturing to various festivals, reading, etc. Rushefsky still teaches a bit, spends
time with his family, and is an aspiring (if not altogether successful) musician (guitar and keyboard). Despite
these differences and our retirement, we have, at this time anyway, agreed that we should do a sixth edition, if
our health permits, after the 2020 elections.
FOREWORD
For some two decades or so, Kant Patel and Mark Rushefsky have been conducting studies of America’s health
delivery systems. The numerous articles and books resulting from the studies of these two political scientists have
enriched the literature. It is thus heartening to be able to welcome this, their new study, and also to know that
they intend to prepare another, after the outcomes of the 2020 elections are clear.
As one would expect from political scientists in view of the overwhelming pressure today throughout the discipline to be scrupulously objective, Patel and Rushefsky go to extraordinary lengths to be even-handed. They examine the alternate value structures that motivate various approaches to healthcare—approaches that generate
different conclusions from consideration of the same facts. They are careful not to take sides in the political controversies that—one is tempted to think uniquely—swirl around questions of healthcare in the United States.
They work diligently to present the facts, and the varied arguments involved. They deserve praise for daring to
delve into public policy, a field that many political scientists avoid in their quest for unquestionable objectivity.
This does not mean that a thorough reading of this comprehensive work will produce a sense in the informed
reader that the media are correct when they stress that “all sides do it,” or that all sides take positions that are to
be equally respected. In the current situation in the United States, a completely objective presentation of the facts
frequently can appear partisan, especially when considerations of public policy are involved. Patel and Rushefsky
generally succeed in the difficult task they set for themselves.
The current outlook for healthcare somewhat past the half-way moment of the Trump presidential term—as
for social policies across the spectrum—is murky, at best. In a foreword, perhaps it is excusable to demonstrate
less concern for even-handedness in an unbalanced situation than for speaking truth to power. Hence, this observation: One may hope that the forthcoming elections will produce more enlightened policies after 2020. At
a minimum, such policies would introduce more rationality into the system, policies that could increase both the
amount and the quality of social services in general, and of healthcare in particular.
Today’s political world is certainly chaotic, but that only makes sound planning all the more important. In the
best of possible worlds, healthcare costs would no longer burden citizens (or other residents), no one would go
without needed care, the quality of care rendered would be uniformly excellent, and society as a whole would
benefit.
Patel and Rushefsky present a sound portrait of the complexity of this country’s entire healthcare delivery
system, and of the ills that plague it. Such a system could hardly have evolved from careful planning, and indeed
it did not. It emerged in hit-or-miss fashion.
Thomas Paine was perhaps the first to suggest public provision for citizens. As the eighteenth century was
coming to a close, he had written highly relevant statements, The Rights of Man, and Agrarian Justice. The
visionary nature of his social thought is astonishing. These works not only contained suggestions that foreshadowed, or at the least hinted at, the development of Social Security and similar programs, but even reflected
ideas so advanced that they are hardly considered even today. For example, he recommended that, to serve as
a nest egg of sorts and to assist in alleviating poverty, the government bestow a payment upon everyone reaching
the age of 21. It is highly significant that he recommended the grant be paid both to men and women.
Such visionary thought, however, is hardly characteristic of Americans. To be fair, throughout the nineteenth
and very early twentieth centuries, the state of medical science remained primitive. If there had been public provision for healthcare, it might have done as much harm as good.
Nevertheless, as the twentieth century progressed, so did the quality of medical science in America. Also, suggestions for social insurance began to be heard, and they often included healthcare. With the passage of years,
they became more frequent. Bismarck’s Germany in 1883 had implemented the world’s first modern social welfare
system, and in 1915, the American Medical Association signaled some interest in compulsory government health
insurance, forming its own Social Insurance Committee. Three of the committee members, all physicians—Alexander Lambert, I. M. Rubinow, and S. S. Goldwater—were also members of a similar committee that the American Association for Labor Legislation, a progressive group, had formed earlier.
xvii
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FOREWORD
The very idea that the AMA ever had given thought to any kind of government health program will likely be
astonishing to those who know the history of the bitter resistance that the AMA later directed at any such suggestion. The open-minded attitude was brief, and the receptive attitude from the AMA vanished quickly, and
completely. By 1918, many insurance companies, pharmaceutical houses, and the AMA itself had begun to work
vigorously against any suggestion of government assistance in paying for healthcare, let alone any consideration
of providing health services directly (Skidmore 1970, 2).
It was the AMA, in fact, that succeeded in denying the country its first significant chance to move in the direction of government support for healthcare. Social Security became law with passage of the Social Security Act in
1935, as the jewel in the crown of Franklin D. Roosevelt’s New Deal. FDR had hoped to include health coverage
in the program, but the AMA let it be known that if the proposed program provided health benefits, the organization would mobilize its formidable lobbying powers against the bill. If there were no provision for healthcare,
the AMA would sit out the fight, and take no position on Social Security. In view of the enormous political influence organized medicine possessed, it is likely that Social Security would never have been adopted if the AMA
chose to oppose it. FDR concluded, prudently, that it would be better to have a program of social insurance with
no healthcare provisions than to have no program at all. Thus, he supported the Social Security bill without any
such benefit (Witte 1962).
Ironically, there was a development beginning in the early twentieth century that could potentially have evolved
into a comprehensive system of healthcare outside of government. The discussion here of necessity is brief and
incomplete, but it is sufficient to reveal both an opportunity lost, and the dynamics that make a successful program unlikely in the American setting without government involvement.
It began in Texas, shortly after the beginning of the twentieth century. Dallas teachers and Baylor University
hospital worked out a plan to provide hospitalization to teachers for a small annual fee. Early in the 1930s, the
plan expanded, in order both to benefit the community and to shore up the troubled finances of the hospital, by
helping keep its beds filled.
Other states seized upon the idea, and they too expanded it. Quickly it grew to include multiple hospitals in
a given location. With the cooperation of the American Hospital Association, plans spread across the country,
and became Blue Cross. They incorporated several features that became nearly universal: they were voluntary
and non-profit; they became available to anyone, regardless of health or risk; they were “community rated,” charging a flat fee that was uniform throughout the service area; they operated as charitable associations, and they
sought to provide service to the greatest number, at minimum cost consistent with the amounts needed to maintain the hospitals.
As could have been anticipated, physicians were more resistant to prepaid plans than were hospitals, but before
long they began to form their own plans as well. Prepaid medical plans began in California. Like Blue Cross,
they soon spread across the country. These became Blue Shield. For some time, Blue Cross/Blue Shield thrived as
prepaid, non-profit, community-rated plans.
Blue Cross/Blue Shield emerged to employ the insurance principle to protect against rising healthcare costs,
and to stabilize the finances of healthcare providers during the Great Depression. In the American economy,
however, such a worthwhile arrangement could not prevail unless protected by regulation.
Insurance companies in the private market exist to make profits. Their executives recognized the potential for
huge gains to be made by offering policies to the most healthy segments of the population. By covering only
those that presented the least risk, they could offer the same benefits as Blue Cross, but at much lower rates.
With profit-making companies cherry-picking their most profitable customers, the Blues were left with the highest-risk, thus highest-cost, parts of the population. Thus, to survive, the Blues ultimately were forced to abandon
their most praiseworthy feature, community rating; they had to shift to the risk-rating practices of the profitmaking insurance companies (Skidmore 2008).
The failure of the Blue Cross non-profit, community-rated experiment was a tragedy for healthcare in the
United States. Along with other developments, it led to erecting the bulk of American healthcare upon a solid
foundation of profits, thus ensuring that American healthcare would be enormously expensive—as it turned out,
soon it was by far the most expensive in the world.
There were other dynamics at work as well that encouraged the growth of profit-making health insurance as
the foundation for healthcare. For many reasons, employer-provided health insurance as a fringe benefit grew.
Large groups can negotiate lower rates. Tax policies permitted employers to provide health insurance as
a business expense—thus as a tax write-off—without subjecting employees to tax on the benefits. This connection
meant that many Americans found it their only affordable source of coverage; it meant, also, that many were left
without access to benefits. That worsened with tax policies redistributing wealth upward under Reagan and most
FOREWORD
xix
of his Republican successors, with the decline of labor unions (the policies of the Reagan administration and
subsequent Republican presidencies were influential here, also), and with the advent of business philosophies that
saw maximum profits, astronomical executive salaries, and generous distributions to shareholders as the prime
obligations of business ethics with little or no thought to civic obligation or workers’ welfare.
The striking differences in this regard reflected between the two generations of prominent Romneys in politics
are telling. Mitt Romney, the son, certainly is among the more moderate Republicans of his era. Nevertheless, he
became notorious for having suggested, during his 2012 presidential campaign (aggravated, of course, by his
having been surreptitiously caught on video making the criticism), that 47 percent of the people were “takers,” in
contrast, apparently, to good Republican producers. As Romney himself conceded to Chris Wallace of Fox News
(reported by Chris Cillizza of The Washington Post), the comment was damaging, and made him look out of
touch (Cillizza 2013).
Contrast this with George Romney, the father, another Republican governor (Michigan, for George; Massachusetts, for Mitt—where he pioneered a program of widespread health insurance), who was another would-be
Republican candidate for the presidency (Mitt received the nomination; George did not). Before becoming governor, George was the highly successful CEO of American Motors, a major automobile company that manufactured an automobile, the Rambler, that for several years was extremely popular. As a corporate CEO George
Romney did what today might seem unthinkable, either in politics or in economics: he rejected extra salary.
David Leonhardt looked back at earlier times in an interesting piece, “When the Rich Said No to Getting
Richer,” in The New York Times, in 2017. George Romney, he said, after turning down several large bonuses,
told his board that he did so “because he believed that no executive should make more than $225,000 a year
(which translates into almost $2 million today).” Romney’s restraint came from his Mormon heritage, but also
from a “culture of financial restraint that was once commonplace in this country.” He did not try to make every
dollar possible, nor did many other corporate peers. The CEO of a large American company, then, said Leonhardt, “made only 20 times as much as the average worker, rather than the current 271-to-1 ratio. Today, some
CEOs make $2 million in a single month” (Leonhardt 2017).
In politics, consider whether it likely would have been possible for later politicians to be elected if they had
echoed John F. Kennedy’s stirring inaugural address of 1961. “Ask not what your country can do for you, ask
what you can do for your country,” he admonished. Following the “Reagan Revolution,” one would have been
far more likely to hear stark appeals to selfishness, as, “vote for me—I’ll let you keep more of your hard-earned
money. You can spend it better than government can!” Leonhardt pointed out the obvious: the tax structure had
much to do with this. Now, it encourages concentration of wealth upward; then, it discouraged such upward
skewing. Billionaires, non-existent then, are seen in the corporate world with increasing frequency because of
a tax structure that explicitly encourages their creation. This phenomenon has as much to do with access to
healthcare, and ultimately also with the quality of the care that is received, as it does with cultivation of the class
of the ultra-wealthy.
Consider, also, in this regard, a great medical pioneer and humanitarian, Jonas Salk, the originator of the
polio vaccine, a killed-virus vaccine that cannot itself cause polio. Today, polio is almost extinct. Virtually the
only cases in the world are those caused—in extremely rare cases—by the live-virus Sabin vaccine, itself, which is
no longer used in the US for that reason. Those of us of a certain age can all remember knowing someone who
died from, or who was severely disabled from, polio (the disabled included a former president of the United
States, Franklin D. Roosevelt). Perhaps equally horrible was the spectacle of the “iron lung.” It was a coffin-like
device in which those sufferers who had their breathing ability destroyed by the disease had to stay, literally in
order to keep alive. Only the victim’s head was outside the structure, which alternated pressure and release inside
to provide an artificial respiration to permit the patient to breathe.
In the 1950s, those who today would be billionaires were “only” multi-millionaires. Considering the enormous
scourge of polio, Salk could almost assuredly have been, literally, a billionaire in 1950s dollars, if he had patented
his vaccine. “He did not even consider doing it, though, because he believed the vaccine should belong to the
people” (Skidmore 2016, 9). By “the people,” he meant not those cloistered and frightened behind a wall, but the
people of the world. As the Salk Institute put it in a brief biographical statement, “hailed as a miracle worker,
Salk never patented the vaccine or earned any money from his discovery, preferring it be distributed as widely as
possible” (Salk Institute N.D.)
Blue Cross continues to exist, but it competes with profit-making companies in the insurance market and
behaves accordingly. Many plans have openly shed their non-profit status; others ostensibly remain non-profit,
but in most respects now function in a manner little different from their competitors who are openly profitoriented.
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FOREWORD
When Franklin D. Roosevelt gave his State of the Union message in 1944, he called boldly for an “Economic
Bill of Rights.” He argued that many things should be added to the list of items considered as rights of citizenship. Among others, these included a well-paying job; decent housing; a good education; and comprehensive
healthcare. He reiterated these in his next, and final, annual message, in 1945. Shortly thereafter, the great New
Deal president died.
With no apparent recognition of the irony involved, Ronald Reagan a generation later called for his own “Economic Bill of Rights.” Rather than implementing the rights of the people, Reagan’s version would have made
protecting the people even more difficult than it already was; he sought, instead, to secure the rights of the most
privileged. His proposal attempted to counter what conservatives deemed to be “excesses of government budget
policy.” It would have required “a balanced federal budget every year,” line-item veto authority on appropriations
bills, a “super-majority vote for passing tax increases,” and the like (see Boskin 1987 for a statement lauding
Reagan’s proposals from the point of view of an economic conservative). Reagan (and his supporters) erroneously
equated the national government’s budgetary policy with that of a family. Families, however, cannot create their
own currency, paying their bills with money of their own creation; the government of the United States can, and
in fact does so regularly. Moreover, by definition, super-majority requirements are explicitly undemocratic in that
they empower a minority to thwart the will of the majority—in Reagan’s case, this would have been a privileged
minority formally endowed with permanent power to overrule the “will of the people.”
FDR’s successor as president, Harry Truman, was thwarted in his effort to implement FDR’s second Bill of
Rights, by a Republican takeover of both houses of Congress following the elections of 1946. Now, nearly threequarters of a century later, FDR’s bold plan has remained almost entirely beyond reach. Truman tried valiantly
to secure universal healthcare, but in the face of enormous advertising campaigns and strong political propaganda
on the part of the American Medical Association and other parts of the health community, he was unable to
succeed.
Although he was prevented from expanding the New Deal, Truman fought back vigorously. He did succeed in
holding the line against Republican efforts to roll back, or eliminate, New Deal programs. The Economic Bill of
Rights, though, including its call for universal healthcare, got nowhere.
The far more conservative Eisenhower administration that followed Truman’s made no effort to move toward
healthcare for all. Significantly, however, Eisenhower did adopt what he called “Modern Republicanism,” which
meant an acceptance of basic New Deal programs. They had, Ike believed, become part of the “American Way
of Life,” and thus he halted efforts to curtail or eliminate them. He also, in 1956, signed into law a huge new
benefit through Social Security: Disability benefits.
In contrast to Eisenhower, John F. Kennedy made healthcare his number-one domestic priority. By that time,
the Democrats had more or less given up on universal healthcare as unrealistic at the moment, so the Kennedy
Administration concentrated on healthcare for the most needy group, the aged. He worked diligently to secure
what ultimately became “Medicare,” embarking upon a furious battle with the American Medical Association
and conservative forces in general, but by the time of his tragic assassination had made little headway.
Then came Lyndon Johnson, an acknowledged legislative genius, who succeeded. Medicare and Medicaid
became law. They, along with environmental protections, fostering the arts, establishing public broadcasting,
adopting the Freedom of Information Act, and many others, became part of LBJ’s Great Society, along with its
crown jewels: the Civil Rights Act of 1964 and the Voting Rights Act of 1965 (the latter, now, sadly, emasculated
by the Supreme Court). Medicare’s opponents had worked furiously to keep it from being enacted, but as then
was customary among both Democrats and Republicans, once it was adopted, they worked for the good of the
country to accept it, and improve it as time passed. No serious officeholder would have worked to make the program fail.
Subsequently, Richard Nixon proposed a plan to make health insurance more affordable for workers, but it
failed. President Clinton, decades later, proposed a broad plan, somewhat similar to what later became the
Affordable Care Act. Initially, large numbers of Republicans joined with Democrats to support the Clinton plan,
but there also was formidable opposition from such activists as Newt Gingrich. Bill Kristol (1993), who had been
chief of staff to the former vice president, Dan Quayle, sent a memorandum, in 1993, to all congressional Republicans—all Republican senators and all Republican representatives—urging them not to support such a bill so
long as Clinton was in office. If it were to come, a Republican president should receive the credit. This memo was
perhaps the coup de grace. All Republicans withdrew their support, and the bill died without even coming up for
a vote.
The opponents had feared that Medicare would be “a foot in the door for socialized medicine.” The supporters
had hoped that it could be expanded until ultimately it became healthcare for all. Both were wrong.
FOREWORD
xxi
The only truly substantial expansion of Medicare itself—despite the fears of opponents and the hopes of supporters—came under the administration of George W. Bush. Over the objections of many Republican conservatives—and most Democrats, who objected to the proposal’s lack of a funding mechanism—Bush and his party
succeeded in securing approval in both houses of Congress for Medicare Part D, the prescription-drug benefit.
The inauguration of Part D was clumsy, awkward, and difficult but ultimately it began to function smoothly, and
now provides a much-needed benefit for the people. It also provided, by design, an enormous boon for the
pharmaceutical industry, which actually had supervised the Republican writing of the original bill, and it included
an irrational “doughnut hole” in benefit coverage. The law is therefore flawed, but its flaws could easily be corrected, if the political climate permits it. At the moment, the flaws are worth enduring because of the good Part
D accomplishes. In fact, the Affordable Care Act is gradually closing that infamous doughnut hole.
In 1997, President Clinton signed into law a joint federal-state program, SCHIP, to provide health services for
children. President George W. Bush twice vetoed expansions of the plan on the grounds that the expanded plan
would cover those who had sufficient resources to pay for healthcare. Expanding the plan, he thought, would
point in the direction of healthcare for all.
President Obama, though, came to office in 2009 eager to make his mark on healthcare. During his first month
in office, he signed expansions of SCHIP, and worked to move the country in the direction of universal health
coverage. The next year, with strong efforts on the part of many Democrats—especially the enormously effective
work by the leading Democrat in the House, Nancy Pelosi—Obama signed into law his signature accomplishment, the Affordable Care Act. Republicans soon sought to demonize it by referring constantly to it as the
dreaded “Obamacare.” After some resistance, President Obama actually accepted the term. Since then, despite
virtually universal resistance from Republicans, persistent failed efforts to repeal it, and numerous attempts to
sabotage the law and keep it from performing well, it has become increasingly popular.
Thus, even from this brief, incomplete summary, it is obvious that many ironies exist with regard to the evolutionary process that brought the complex, and often irrational, system that dominates healthcare delivery today
in the United States. For instance, those on the American right, including much of the business community, tend
to be ideologically opposed to government programs, with many exceptions for the exercise of police power over
less-favored groups, or military programs. In most other countries, though, business has tended to be strong supporters of universal healthcare. They recognize that it is generally to their advantage to have the costs of healthcare spread widely throughout the economy, rather than falling especially upon the business community.
In America, by contrast, there has been such strong resistance on the right that complete opposition to universal healthcare, once supported by many in both parties, became a prominent feature of the Republican Party.
Congressional Republicans all campaigned on a platform of “repealing Obamacare.” Such resistance led to
opposition even to the expansion of Medicaid, as provided by the Affordable Care Act, despite it being clearly to
the advantage of states. Expansion would reduce the numbers of their people who lack health benefits, it would
cause considerably more money to flow into the state, and the costs to the state would be minimal, because the
federal government pays for nearly all the added expense. The opposition was both ideological, and personal:
There was resistance to any expansion of government benefits, and also opposition to any program that President
Obama had supported. The benefits of expansion were such, though, that many Republican governors and legislatures found ways to accomplish it, leaving only the most rigidly ideological states in the opposition.
This is the situation as it stands after the Obama presidency, and past the mid-point of Donald Trump’s term
in office. This is the chaotic reality with regard to America’s healthcare delivery systems that Patel and Rushefsky
scrutinize carefully. They admirably identify the patterns, presenting them in a manner that makes them accessible. They put their findings in readable form for the benefit of us all. Their work benefits citizens who seek to
understand the complexity, scholars who attempt to make sense of what seems nonsensical, and especially—perhaps most important of all—for reformers who seek to bring improvements.
Reform ultimately may become Medicare for all, Medicaid for all, some other form of single-payer system, or
another approach that helps to rationalize what exists by making care of high quality available to all who need it
without huge financial demands. However it comes, and whatever form it takes, a prerequisite to improvement
will be understanding of all the voluminous issues, not all of which will be immediately apparent. Patel and Rushefsky, with their keen appreciation of the nuances of the system have made signal contributions to the process.
This book continues their important work, and promises to be the precursor of yet another study following the
results of the forthcoming elections of 2020. It is an especially valuable contribution to the literature of healthcare
in America.
Boskin, Michael J. 1987. “Reagan’s Economic Bill of Rights,” Los Angeles Times, July 14.
Cillizza, Chris. 2013. “Why Mitt Romney’s ‘47 Percent’ Comment Was so Bad.” Washington Post, March 4.
xxii
FOREWORD
Kristol, William. 1993. “Memorandum to Republican Leaders, Subject: Defeating President Clinton’s Health Care Proposal.”
Online at www.scribd.com/doc/12926608/William-Kristols-1993-Memo-DefeatingpPresident-Clintons-Health-Care-Proposal.
Leonhardt, David. 2017. “When the Rich Said No to Getting Richer.” The New York Times, September 17.
Salk Institute. n.d. “History of Salk: About Jonas Salk.” Online at www.salk.edu/about/history-of-salk/jonas-salk/.
Skidmore, Max J. 1970. Medicare and the American Rhetoric of Reconciliation. Tuscaloosa, AL: University of Alabama Press.
Skidmore, Max J. 2008. Securing America’s Future: A Bold Plan to Secure, and Expand, Social Security. Lanham, MD: Rowman
and Littlefield.
Skidmore, Max J. 2016. Presidents, Pandemics, and Politics. New York: Palgrave Macmillan.
Witte, Edwin. 1962. The Development of the Social Security Act. Madison, WI: University of Wisconsin Press.
Max Skidmore
University of Missouri Curators’ Distinguished Professor of Political Science and
Thomas Jefferson Fellow
University of Missouri at Kansas City
ACRONYMS
AAFP
AEI
ASRM
BLS
CHIPRA
DEA
ECPs
EPA
GMO
GWOT
HCBS
LTSS
MAGI
MAs
MLTSS
MRT
MST
NCCPA
NPS
OSHA
PAs
PAS
PBMs
PDMD
UIHP
UIOs
USDA
VSL
American Academy of Family Physicians
American Enterprise Institute
American Society for Reproductive Medicine
Bureau of Labor Statistics
Children’s Health Insurance Program Reauthorization Act
Drug Enforcement Agency
emergency contraceptive pills
Environmental Protection Agency
genetically modified organisms
Global War on Terror
home- and community-based services
long-term care services and support
modified adjusted gross income
medical assistants
Medicaid long-term services and supports
mitochondrial replacement therapy
military sexual trauma
National Commission on Certification of Physician Assistants
National Pharmaceutical Services
Occupational Safety and Health Administration
physician assistants
physician-assisted suicide
pharmacy benefit managers
Prescription Drug Monitoring Program
Urban Indian Health Program
urban Indian organizations
United States Department of Agriculture
value of statistical life
xxiii
ACKNOWLEDGMENTS
As is typical of any book, this text is not the product of its authors only. Patel would like to thank the Faculty
Leave Committee at (Southwest) Missouri State University for the spring 1991 sabbatical that made the initial
research for this project possible. We express our gratitude to Max Skidmore for his gracious offer to write the
Foreword. We would also like to thank Laura Stearns, editor at Routledge, for her insightful judgment in continuing to support this project, and Katie Horsfall, along with the staff at Routledge. Of course, any remaining
errors are the co-authors’.
Kant Patel
Mark Rushefsky
xxv
Section I
HEALTHCARE POLITICS AND
POLICY
1
HEALTHCARE POLITICS
Healthcare is one of the more difficult areas of policymaking. Healthcare policymakers and providers must deal
with a host of issues, ranging from jurisdictional authority, financing, organization, and administration of health
policy and delivery to issues of vested interests, ideological and partisan conflicts, value conflicts, equity, and justice, access to healthcare and quality of care, and questions of life and death (Gauld 2001). Policymakers must
address a host of difficult questions: what are the goals of the healthcare system? What do we hope to accomplish
with a particular healthcare policy? Should patient participation be voluntary or mandatory? Should there be
intermediaries (organizations that accept funds from sponsors to coordinate benefits and provider activities)
between healthcare sponsors and healthcare providers? If there are intermediaries, how many should there be,
and should they be for-profit or not-for-profit? How many sponsors should there be, and should they be governmental or private organizations? How should healthcare be funded, organized, and administered (Dudley and Luft
1999)? In addition, policymaking itself can be influenced by decision-making structures, that is, by the ways in
which policymaking institutions like the executive, legislative, and judicial branches of government are organized
and the rules by which they operate. It is very difficult to question and dramatically change decision-making structures and processes in healthcare, as in many other policy areas, because those with the greatest means and
resources but not necessarily the best scientific evidence often are able to control the definition of “problem” and
what the “truth” is. Thus, we must recognize the power of money/resources in influencing decision-making and policymaking processes in the field of healthcare (Tuulonen 2005).
Policymaking in healthcare is often more art than science since policymaking involves struggles over ideas and
values (Stone 2011). This is illustrated by how numbers—statistics—are used by various actors in health policymaking. Statistics are an important tool for policymakers. They often serve as a warning signal indicating the existence or worsening of a problem, and they may be used to measure and evaluate policy outcomes. However,
numbers can also be strategically used to further particular political agendas. It is often not the magnitude of numbers but rather the interpretation of the numbers that influences policymaking (Schlesinger 2004), while a great deal
of the debate about healthcare policy is framed in terms of scientific, evidence-based medicine as if policy decisions
are always driven by only facts and not societal values. This assumes that one can separate facts and values, that
evidence is free of context and can be objectively weighed, and that health policymaking is essentially an exercise in
scientific decision-making (Russell et al. 2008). In the real world, however, policymaking involves struggles over
ideas and values. Debates over health policy are played out through the rhetorical use of language and the strategic
portrayal of social situations. Policymaking revolves around the naming and framing of a problem (problem definition), the specification of problem boundaries, and the definition and negotiation of the ideas and values that guide
the ways citizens create a shared meaning that motivates them to act (Russell et al. 2008).
It is also important to remember that health policymakers’ decisions are also influenced by the underlying
“politics.” Thus, to understand health policy it is important to understand the underlying politics surrounding
various health policy issues. Awareness of political factors such as partisanship, voters’ views, public opinion, political ideology, values and belief systems, the power of entrenched interest groups, and the nature of media coverage, along with constitutional requirements and institutional arrangements, is essential to understanding health
policymaking (Blendon and SteelFisher 2009; Theodoulou and Kofinis 2004; Weissert and Weissert 1996).
HEALTH POLICYMAKING IN THE UNITED STATES
Healthcare is the largest single industry in the United States (Skeen 2003). In 2016, the United States spent over
$3.3 trillion on healthcare, which amounted to 17.9 percent of the gross domestic product (GDP) (Hartman et al.
2018). If spending on healthcare alone guaranteed physical well-being, Americans would be the healthiest people
3
4
HEALTHCARE POLITICS AND POLICY
in the world. Unfortunately, spending alone does not ensure a high level of care, as witnessed by the fact that the
American healthcare system does not fare well compared to other countries on several indicators such as infant
mortality rates and average lifespan (see next chapter). It is not too surprising that the American healthcare
system is often described as inefficient and ineffective (Freddi 2009) or as scandalous and wasteful (Dentzer 1990;
Taylor 1990).
Health policymaking in the United States involves a complex web of decisions made by various institutions
and political actors across a broad spectrum of public and private sectors. These institutions and actors include
federal, state, and local governments in the public sector. In the private sector they include healthcare providers
such as hospitals and nursing homes; healthcare professionals such as physicians; and healthcare purchasers such
as insurance companies, industries, and consumers. In addition, a wide variety of interest groups and healthrelated professional associations influence and shape healthcare politics and policymaking.
These institutions and actors are involved throughout the policy cycle. This cycle includes getting problems to
the government and agenda-setting; policy formulation and legitimation; budgeting, implementation and evaluation
of policy, and decisions about policy continuation; and modifications and/or termination (Jones 1978; Rushefsky
2007). These institutions and actors interact at every stage of the policy cycle. No one institution or actor dominates
any one stage of policy development. Each contributes to the process by providing input that often is designed to
promote the individual institutions or the actor’s own interests (Brown, Lawrence D. 1978).
Some of the problems in healthcare policymaking are rooted in this diversity of institutions and actors. Any decision
designed to affect the healthcare system generates immediate and heated responses. Any attempt to regulate the healthcare system also produces pressures from opponents of regulation who favor market-oriented approaches to the delivery
of healthcare. Government regulations have often been thwarted by those being regulated as well as by actors in the
system who oppose a strong government role in the field of healthcare (Brown, J.H.A. 1978).
The development of a comprehensive and consistent healthcare policy is made difficult, if not impossible, by
the shotgun approach followed by many policymakers, such as the president and Congre...
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