UCLA Challenges facing the Veteran Healthcare System Essay

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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 52 Vanderbilt Avenue, New York, NY 10017 and by Routledge 2 Park Square, Milton Park, Abingdon, Oxon, OX14 4RN Routledge is an imprint of the Taylor & Francis Group, an informa business © 2020 Taylor & Francis The right of Kant Patel and Mark Rushefsky to be identified as authors of this work has been asserted by 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 electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. Trademark notice: Product or corporate names may be trademarks or registered trademarks, and are used 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) Typeset in Times New Roman by Swales & Willis, Exeter, Devon, UK 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 xviii 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. xx 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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Evolution of Healthcare Policies in America Outline
1. This paper examines how the US health policy for veterans has evolved since its
introduction
- The initiation of the US health policy for veterans: the key players
- Benefits implemented for the returning veterans
- Laws and Departments enacted to oversee the healthy policy
- Factors that influenced the enactment of the healthcare policy for veterans
- The revisions that have been made to the policy
- Services offered under the US health policy for veterans


Running head: HEALTHCARE POLICIES FOR VETERANS IN AMERICA.

Health policies for Veterans in America
Name
Institutional Affiliation

1

HEALTHCARE POLICIES FOR VETERANS IN AMERICA.

2

Healthcare Policies for Veterans in America
Introduction
Health care refers to medical professionals' efforts to restore our physical and mental wellbeing (Marketing Business News, 2021). The term also includes providing services to maintain
emotional well-being, which serves as a necessary good for a particular category of Americans
known as the Veterans (Patel, & Rushefsky, 2020). Given their patriotic services well document,
healthcare policies have been put in place to aid the recovery process of the nation’s war veterans,
and this essay serves to explain how they have evolved since their introduction.
Evolution of Healthcare Policies in America
In 1811, the Federal government authorized the first domiciliary and medical facility for
veterans. The first Naval Home in Philadelphia in 1812 was the first national effort to provide for
the medical care of disabled veterans (Patel and Rushefsky, 2020). This was followed by the
Soldiers Home in 1853 and St. Elizabeth’s Hospital in Washington, DC. Prior to the end of the
Civil War, in March 1865, President Lincoln authorized the first-ever National Soldiers' and
Sailors' Asylum to provide medical and convalescent care for discharged members of the Union
Army and Navy volunteer forces. The first National Home opened in Augusta, Maine, in 1966, is
now the VA's oldest military hospital. Two agencies in the Department of the Treasury, the Bureau
of War Risk Insurance and the Public Health Service were tasked with operating hospitals
specifically for returning World War I veterans. They leased hundreds of private hospitals and
hotels to treat returning injured war veterans and started building new hospitals (Department of
Veteran Affairs, 2021).
In 1924, veterans’ benefits were liberalized to cover disabilities that were not servicerelated and in 1928 admission to Veterans Bureau hospitals and National Homes was extended to

HEALTHCARE POLICIES FOR VETERANS IN AMERICA.

3

women, national guards, and militia veterans. In January 1946, Congress passed, and President
Truman signed into law, Public Law 293, formally creating the Veterans Health Administration
(VHA) within the Veterans Administration (now the Department of Veterans Affairs) and
establishing the Department of Medicine and Surgery within the VA (Patel and Rushefsky, 2020).
Veterans Affairs hospitals immediately sought affiliation with university medical schools in order
to improve the quality and number of physicians. This helped establish a very successful
partnership between the two allowing the veterans’ healthcare system to grow rapidly during the
1940s and 1950s. Over the years, this collaboratio...


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