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History and Health Policy in the United States

History and Health Policy in the United States: Putting the Past Back In

Rosemary A. Stevens
Charles E. Rosenberg
Lawton R. Burns
Copyright Date: 2006
Published by: Rutgers University Press
Pages: 376
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  • Book Info
    History and Health Policy in the United States
    Book Description:

    In our rapidly advancing scientific and technological world, many take great pride and comfort in believing that we are on the threshold of new ways of thinking, living, and understanding ourselves. But despite dramatic discoveries that appear in every way to herald the future, legacies still carry great weight. Even in swiftly developing fields such as health and medicine, most systems and policies embody a sequence of earlier ideas and preexisting patterns.In History and Health Policy in the United States, seventeen leading scholars of history, the history of medicine, bioethics, law, health policy, sociology, and organizational theory make the case for the usefulness of history in evaluating and formulating health policy today. In looking at issues as varied as the consumer economy, risk, and the plight of the uninsured, the contributors uncover the often unstated assumptions that shape the way we think about technology, the role of government, and contemporary medicine. They show how historical perspectives can help policymakers avoid the pitfalls of partisan, outdated, or merely fashionable approaches, as well as how knowledge of previous systems can offer alternatives when policy directions seem unclear.Together, the essays argue that it is only by knowing where we have been that we can begin to understand health services today or speculate on policies for tomorrow.

    eISBN: 978-0-8135-3987-4
    Subjects: Health Sciences, Political Science

Table of Contents

  1. Front Matter
    (pp. i-iv)
  2. Table of Contents
    (pp. v-vi)
  3. Foreword
    (pp. vii-viii)
    David Mechanic

    Henry Ford may have told us that history is bunk, but the fact remains that much of what goes on in our social and political lives is an outgrowth of happenings in the past, the social institutions and arrangements we have developed over time, and the existing physical and social infrastructure on which we build. Scientific discovery, technical innovations, and social revolutions may bring large changes, but most of our policies and processes evolve from preexisting patterns. Some get comfort from thinking we are avant garde and that we are on the threshold of new ways of thinking and doing,...

  4. Acknowledgments
    (pp. ix-xii)
  5. Introduction
    (pp. 1-10)
    Rosemary A. Stevens

    History matters. Shared perceptions of history can move audiences, offer powerful explanatory narratives for the present, suggest intriguing analogies with past events, and help build consensus around policy and management goals. When visible at all, however, policy history is often tailored to specific aims, interests, and agendas. Policy-making is strewn with dubious historical analogies and powerful myths.¹

    One reason for studying the history of health policy is to avoid the pitfalls of thinking too narrowly about the present; in other words, to let one’s imagination rove beyond the seductions of convenient but outdated partisan history. Among the pitfalls: assuming that...

  6. Part I Actors and Interpretations

    • Chapter 1 Anticipated Consequences: Historians, History, and Health Policy
      (pp. 13-31)
      Charles E. Rosenberg

      Policy is a familiar term. But like many indispensable words, it is not easily defined. In one sense it is descriptive: policy refers to current practice in the public sector. It also has a variety of other meanings: policy may imply an “ought” of planning and strategic coherence—or a real world “is” of conflict, negotiation, and compromise.¹

      As the history of United States health policy makes clear, moreover, the real world is not a very orderly place. Policies on the ground seem less a coherent package of ideas and logically related practices than a layered conglomerate of stalemated battles,...

    • Chapter 2 The More Things Stay the Same the More They Change: The Odd Interplay between Government and Ideology in the Recent Political History of the U.S. Health-Care System
      (pp. 32-48)
      Lawrence D. Brown

      Disentangling continuity from change in U.S. health-care policy is no task for those who crave instant intellectual gratification. The system is, of course, (in)famously stable: ever inclined to equate specialization and technology with quality, loath to impose planning on the independent institutional fragments of the “supply side state” (Jacobs 1995), unwilling to discard an employer-based approach to medical coverage, unable to acknowledge medical coverage as a right and to make such coverage universal and affordable, and quick to reject every real reform as a formula for “too much government.”

      The history of this same system, however, also shows much morphing...

    • Chapter 3 Medical Specialization as American Health Policy: Interweaving Public and Private Roles
      (pp. 49-80)
      Rosemary A. Stevens

      What is health policy? On the face of it, there seems a simple answer. Health policy is what governments do, or try to do, to further health care, typically at the national level. As other essays in this volume resoundingly attest, however, seeing health policy only as what government does or fails to do gives a blinkered, partial—and much too tidy—view of the rich, complex, and constantly shifting landscape of health policy in the United States. I want to suggest some of this complexity, nuance, and paradox by examining specialization in American medicine as a vital, yet often...

  7. Part II Rhetoric, Rights, Responsibilities

    • Chapter 4 Patients or Health-Care Consumers? Why the History of Contested Terms Matters
      (pp. 83-110)
      Nancy Tomes

      Since the 1980s, the use of the termhealth-care consumeras a synonym for patient (along with its doctor analogue,health-care provider) has become commonplace in the United States. For many observers today, especially physicians, this linguistic transformation has come to represent the worst consequences of American medicine’s growing market orientation. As one doctor quoted by the columnist Ellen Goodman quipped, “Every time a patient is referred to as a health-care consumer, another angel dies,” while another cited by William Safire observed, “The managed-care organizations call peopleconsumersso they don’t have to think of them aspatients” (Goodman 1999;...

    • Chapter 5 The Democratization of Privacy: Public-Health Surveillance and Changing Conceptions of Privacy in Twentieth-Century America
      (pp. 111-129)
      Amy L. Fairchild

      The right to privacy has never been regarded as absolute. In the late nineteenth century, health officials adopted the practice of name-based reporting for infectious diseases in order to isolate cases, quarantine the exposed, and monitor the health and behavior of the diseased and their contacts as a means of reducing morbidity and mortality. Public-health surveillance has persistently called into question the appropriate limits of privacy ever since. Despite the inherent tension between surveillance and privacy—that is, between a public and a private good—the nature of the conflict has changed, reflecting radical changes in the conception of privacy...

    • Chapter 6 Building a Toxic Environment: Historical Controversies over the Past and Future of Public Health
      (pp. 130-150)
      Gerald Markowitz and David Rosner

      On September 5, 2003, theNew York Timesbusiness section announced a startling new problem. Silicosis, an occupational lung disease caused by the inhalation of silica sand and considered in the 1940s and 1950s a “disease of the past,” was now rivaling asbestosis as the single most important source of toxic tort litigation in the United States. TheTimesnoted that the disease had been a well-documented threat for at least seventy years and the courts were confronting an interesting legal issue (Glater 2003). Liability suits were clearly going to sky-rocket, but since workers’ compensation protected employers from liability suits...

  8. Part III Priorities and Politics

    • Chapter 7 Situating Health Risks: An Opportunity for Disease-Prevention Policy
      (pp. 153-175)
      Robert A. Aronowitz

      The health care issues that capture significant public and professional attention are not necessarily the most important. As potential points of policy intervention, some intellectual assumptions, clinical practices, and structural relationships are so tightly woven into social, economic, and scientific life that they are in some sense invisible. Take, for example, one of the most contentious American health-policy controversies in recent years—Medicare coverage for prescription medications. Participants in this controversy have focused almost exclusively on financial and administrative issues such as cost, the scope of benefits, and the role of private insurers. Seemingly—and strangely—absent from political and...

    • Chapter 8 The Jewel in the Federal Crown? History, Politics, and the National Institutes of Health
      (pp. 176-201)
      Robert Cook-Deegan and Michael McGeary

      The National Institutes of Health (NIH), the United States’ (and the world’s) largest single funder of biomedical research, have grown enormously since World War II. Over this period, health research grew faster than other kinds of research, and the growth was greater in the United States than in other countries, in both absolute and relative terms. What are the reasons for this exceptional—and consistent—growth over six decades?

      The policy story is one of bipartisan support for the National Institutes of Health through many election cycles, persisting through changes of Republican and Democratic control of Congress and the presidency....

    • Chapter 9 A Marriage of Convenience: The Persistent and Changing Relationship between Long-Term Care and Medicaid
      (pp. 202-226)
      Colleen M. Grogan

      It is impossible to discuss the nation’s need for affordable long-term care services without concurrently discussing America’s Medicaid program. Since it was established in 1965, Medicaid has often, in passing, been called our health-care program for “the poor.” In truth, the program has always been at once more and less than that. Medicaid is less than that meager description because it has always systematically excluded certain categories of poor people.¹ However, Medicaid is also much more than a program for “the poor” because it provides long-term care services to elderly who resided, and whose families reside, firmly in the middle...

  9. Part IV Policy Management and Results

    • Chapter 10 Rhetoric, Realities, and the Plight of the Mentally Ill in America
      (pp. 229-249)
      David Mechanic and Gerald N. Grob

      Deinstitutionalization of persons with mental illnesses is now a fact of life. Many have criticized its consequences and insisted that the policy has been disastrous (Isaac and Armat 1990). Few, however, have demanded that we return to institutional solutions for care of persons with mental illnesses. Public mental hospitals in the United States have largely been emptied, with only approximately 54,000 patients in long-term state mental hospitals at the beginning of the twenty-first century. In today’s context, however, the meaning ofdeinstitutionalizationhas changed; it now refers to barriers to long-term inpatient residence. Patterns of care have changed radically as...

    • Chapter 11 Emergency Rooms: The Reluctant Safety Net
      (pp. 250-272)
      Beatrix Hoffman

      In the face of its unwillingness to guarantee health care to all, the United States has increasingly depended on the emergency room as a de facto safety net for people with nowhere else to go. Since the public knows that ERs are a place where “they can’t turn you away,” hospital emergency departments have become crowded, not only with true emergencies, but with people seeking routine medical attention. Hospital advocates insist that they are in the midst of an emergency-care “crisis”: overworked doctors and nurses toiling in overcrowded ERs with little or no hope of being reimbursed for much of...

    • Chapter 12 Policy Implications of Hospital System Failures: The Allegheny Bankruptcy
      (pp. 273-308)
      Lawton R. Burns and Alexandra P. Burns

      During the late 1990s and early 2000s, the economy of the United States was rocked by a series of corporate accounting scandals and bankruptcies. Before there were Enron, Arthur Andersen, WorldCom, Tyco, and Global Crossing, however, there was Allegheny. Formally known as the Allegheny Health, Education, and Research Foundation, or more informally as AHERF, Allegheny filed for bankruptcy in U.S. Bankruptcy Court in Pittsburgh in July 1998. Filing papers cited $1.3 billion in debt owed to 65,000 creditors, making this the nation’s largest nonprofit healthcare bankruptcy.

      Allegheny’s growth, decline, and bankruptcy caused tremendous upheaval in both Pittsburgh (where AHERF’s corporate...

    • Chapter 13 The Rise and Decline of the HMO: A Chapter in U.S. Health-Policy History
      (pp. 309-340)
      Bradford H. Gray

      Health maintenance organizations or HMOs were the object of many of the most bitter criticisms of American health care at the end of the twentieth century. Media accounts drew on experiences of doctors and patients to depict HMOs as impersonal, bureaucratic entities that were primarily interested in controlling costs (or generating profits) rather than enabling doctors and hospitals to meet the needs of patients.¹ A national Harris poll in 1998 found that a solid majority (fifty-eight percent) of the American people believed that the quality of medical care that people receive would be harmed rather than improved by “the trend...

  10. Contributors
    (pp. 341-344)
  11. Index
    (pp. 345-364)