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Policy Challenges in Modern Health Care

Policy Challenges in Modern Health Care

David Mechanic
Lynn B. Rogut
David C. Colby
James R. Knickman
Copyright Date: 2005
Published by: Rutgers University Press
Pages: 294
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  • Book Info
    Policy Challenges in Modern Health Care
    Book Description:

    Health care delivery in the United States is an enormously complex enterprise, and its $1.6 trillion annual expenditures involve a host of competing interests. While arguably the nation offers among the most technologically advanced medical care in the world, the American system consistently under performs relative to its resources. Gaps in financing and service delivery pose major barriers to improving health, reducing disparities, achieving universal insurance coverage, enhancing quality, controlling costs, and meeting the needs of patients and families. Bringing together twenty-five of the nation's leading experts in health care policy and public health, this book provides a much-needed perspective on how our health care system evolved, why we face the challenges that we do, and why reform is so difficult to achieve. The essays tackle tough issues including: socioeconomic disadvantage, tobacco, obesity, gun violence, insurance gaps, the rationing of services, the power of special interests, medical errors, and the nursing shortage.

    eISBN: 978-0-8135-4109-9
    Subjects: Political Science

Table of Contents

  1. Front Matter
    (pp. i-iv)
  2. Table of Contents
    (pp. v-vi)
  3. Preface
    (pp. vii-x)
    Alvin R. Tarlov
    (pp. xi-xiv)
  5. Introduction
    (pp. 1-10)
    David Mechanic, Lynn B. Rogut, David C. Colby and James R. Knickman

    There is widespread consensus that the American health care system underperforms relative to the resources it has available, and that gaps in financing and service delivery pose major barriers to improving health, achieving universal insurance coverage, enhancing quality, controlling costs, and reducing disparities. In addition, while the health care system generously allocates resources to medical services, it devotes far fewer resources to prevention activities and promoting healthier living or lifestyles.

    Many of the issues facing the American health system today flow from the enterprise itself, such as advances in technology and science, uncertainty about treatment effectiveness, the explosion of information...

  6. Part I The Context of Health and Health Care Policy

    • Chapter 1 Morality, Politics, and Health Policy
      (pp. 13-25)
      James A. Morone

      American health care policy is different from health policy in other industrial nations. The United States has no national health insurance, of course. However, that difference simply reflects a deeper contrast in the ways we Americans think about politics and health care. European health policy analysts regularly invoke a “solidarity culture”—a staunch belief in sharing resources and concern for what might be called “the people’s health” (Morone 2000). European political cultures and institutions often reflect this collective ideal.

      What most observers first notice about the American process is the unabashed pursuit of self-interest. In our dynamic (some would say...

    • Chapter 2 Cross Pressures: The Contemporary Politics of Health Reform
      (pp. 26-36)
      Theda Skocpol and Patricia Seliger Keenan

      The past decade has witnessed some amazing twists and turns in U.S. health care politics. Starting in 1993, President Bill Clinton attempted to push through a comprehensive reform that would have guaranteed health insurance to all Americans, extending coverage to low-wage workers who predominated in the ranks of the uninsured. Yet within a year, public opinion turned as interest groups and partisan forces mobilized against the reform proposals, leading Clinton to abandon them (Broder and Johnson 1996; Skocpol 1997). After the 1994 midterm elections, Republicans took control of Congress and redefined health care reform to mean containing costs and restructuring...

    • Chapter 3 The Employer-Based Health Insurance System: Mistake or Cornerstone?
      (pp. 37-52)
      Sherry A. Glied

      For decades, health policy analysts have voiced their disdain for employer-based health insurance. In 1961, Herman and Anne Somers referred to the system as the “‘shotgun’ marriage of medical care and industrial relations” (Somers and Somers 1961, 227). Critics routinely belittle job-based coverage as an unfortunate historical accident, the by-product of short-lived wartime wage and price controls that moved compensation toward such benefits (Hyman and Hall 2001). Analysts today see the dismantling of this illogical, inefficient institution as an essential step toward the development of universal, equitable health insurance in the United States (Fuchs 1994).

      Yet employer-based coverage is a...

    • Chapter 4 Entrepreneurial Challenges to Integrated Health Care
      (pp. 53-68)
      James C. Robinson

      The U.S. health care system is an ongoing experiment in the effort to achieve social goals through market mechanisms—to pursue the public good through private interests. The era of managed care encouraged competition among insurers, capitation contracting between health plans and providers, and the organizational integration of physicians and hospitals to contain costs and foster access to primary care. The ensuing consumer and provider backlash and the failure of many diversified organizations to deliver improvements in quality and efficiency have today substituted a different set of social goals. These include the unwinding of many consolidated organizations, unconstrained access to...

  7. Part II Promoting Population Health and Reducing Disparities

    • Chapter 5 Fundamental Sources of Health Inequalities
      (pp. 71-84)
      Bruce G. Link and Jo C. Phelan

      The primacy of social conditions as determinants of health has been observed for centuries. The idea was forcefully articulated by nineteenth-century proponents of “social medicine,” who noted strong relationships between health and the dire housing circumstances, poor sanitation, inadequate nutrition, and horrendous work conditions that poor people encountered at that time. This social patterning of ill health led to Virchow’s famous declaration that “medicine is a social science” and “politics nothing but medicine on a grand scale” (1848). The idea is also prominent in the work of McKeown, who focused attention on dramatic secular trends toward improved population health (1976)....

    • Chapter 6 A Public Health Approach to Firearms Policy
      (pp. 85-98)
      David Hemenway

      An American who dies before the age of forty is more likely to succumb to an injury rather than a disease. The leading cause of injury death in the United States is motor vehicles. The second leading cause of injury death is firearms. In 2001 some 29,500 Americans were killed with firearms in non-war-related events, and about three times that number were wounded seriously enough to be hospitalized. Gun shot injuries are one of the leading causes of both traumatic brain injury and spinal cord injury.

      The United States has more firearms in civilian hands than any other high-income nation....

    • Chapter 7 Tobacco Policy in the United States: Lessons for the Obesity Epidemic
      (pp. 99-114)
      Kenneth E. Warner

      On June 16, 2004, cigarette smoking killed some twelve hundred Americans. That shocking death toll warranted no headlines. Neither did the same outcome—some twelve hundred more deaths—the following day, nor the day after. Indeed, it is the rare headline that informs the public that smoking accounts for nearly one of every five deaths in the United States, one in three during middle age. Smoking is simply too commonplace, too mundane. Yet it is far and away the nation’s—and increasingly the world’s—leading killer. In this chapter I examine the burden smoking has imposed on society and what...

    • Chapter 8 Patterns and Causes of Disparities in Health
      (pp. 115-134)
      David R. Williams

      The health of the U.S. population has improved markedly over time. Average life expectancy at birth increased by 30 years in the last century, from 47 in 1900 to 77 in 2000 (National Center for Health Statistics 2003). Yet different social groups in the United States continue to experience dramatically varying levels of health. For example, the life expectancy of Asian American women in Bergen County, New Jersey, is 97.7 years, while that of American Indian men in a cluster of counties in South Dakota is 56.6 years (Murray et al. 1998). This 41-year difference in life expectancy indicates that...

    • Chapter 9 Addressing Racial Inequality in Health Care
      (pp. 135-148)
      Sara Rosenbaum and Joel Teitelbaum

      Focusing on the role of race in health policy is not easy. Any such analysis raises a host of complex issues that lie at the policy intersection of health care and civil rights. More fundamentally perhaps, such an exploration cannot proceed without confronting two matters that many might prefer to avoid. The first is the historical dominance of racially biased attitudes, beliefs, and customs in medicine no less than in other areas of life, such as education, employment, housing, transportation, public accommodations, and even marriage and family formation. The second, which follows on from the first, is the need for...

  8. Part III Improving Quality of Care

    • Chapter 10 Still Demanding Medical Excellence
      (pp. 151-161)
      Michael L. Millenson

      Years before the Institute of Medicine began issuing health system quality alerts with nearly the same frequency as Microsoft warnings of rifts in software security, I painstakingly gathered much the same evidence the IOM used to such highly publicized effect.

      I was a veteran journalist transformed by the magic wand of a Robert Wood Johnson Foundation Investigator Award into a health policy researcher. As I read and reread the articles, studies, and reports piled on every surface in my small academic office, I was appalled: years of research on important ways to make medical care safer and more effective had...

    • Chapter 11 Preventing Medical Errors
      (pp. 162-176)

      Most people first became aware of the problem of medical errors in late 1999, when the National Academy of Sciences’ Institute of Medicine (IOM) releasedTo Err Is Human, which announced that up to ninety-eight thousand people die each year from medical errors (IOM 2000). Although the shocking mortality figures came from studies published up to eight years previously (Leape et al. 1991; Brennan et al. 1991; Thomas et al. 2000), they were new to most readers and came now from an impeccable source. Congress promptly scheduled hearings, and shortly thereafter the president called on all federal health agencies to...

    • Chapter 12 Improving Quality through Nursing
      (pp. 177-188)
      Linda H. Aiken

      Both the public and physicians rank nurse understaffing of hospitals as one of the most serious threats to patient safety (Blendon et al. 2002). Two-thirds of hospital bedside nurses concur that there are not enough nurses in their hospitals to provide high-quality care, and close to half score in the high-burnout range on standardized tests. Almost one in four intends to leave his or her job in the hospital within a year (Aiken et al. 2001). Federal estimates suggest that the shortfall of nurses could approach 275,000 by 2010 and 800,000 by 2020 (U.S. DHHS 2002). Until very recently, policymakers...

    • Chapter 13 Improving Medicare for Beneficiaries with Disabilities
      (pp. 189-205)
      Lisa I. Iezzoni

      A few lines caught my eye near the end of a lengthyNew York Timesarticle on June 11, 2003. The article recounted the growing likelihood that Congress would add prescription drug benefits to Medicare and itemized the trade-offs required to trim projected expenses (Pear 2003a, A21). After describing various components of proposed Senate legislation, the article concluded, “To help offset the costs, Medicare would freeze payments for home medical equipment, like wheelchairs and oxygen, for seven years.”

      Of course, the legislation signed by George W. Bush in December 2003 bore little resemblance to this June proposal. In particular, Congress...

    • Chapter 14 Specialization, Specialty Organizations, and the Quality of Health Care
      (pp. 206-220)
      Rosemary A. Stevens

      Specialization is a defining word for American medicine in our time. If it were still possible for a generalist to understand medicine as a body of knowledge and skills, we would not now have mighty health care corporations, millions of workers in hundreds of health care occupations, sprawling academic medical centers with their associated networks, or even managed care. However, while technological innovation and improvements in the quality of health care available to earlier generations testify to the manifold benefits of medical specialization, its downside has also long been evident.

      For more than a century specialization has been portrayed as...

  9. Part IV Frameworks for Fairness in Health Care

    • Chapter 15 Integrating People with Mental Illness into Health Insurance and Social Services
      (pp. 223-237)
      Richard G. Frank and Thomas G. Mcguire

      Mental disorders are prevalent, impair functioning, and impose a large economic burden on American society and the global community. Careers are cut short, investments in education and training are erased, and families are torn apart. Affected individuals are routinely victimized, and jails and prisons are increasingly filled with people whose conduct is a direct result of their mental illnesses (Harwood et al. 1999).

      Medical science has advanced the understanding of mental illnesses and led to improved treatments.Mental Health: A Report of the Surgeon General—which summarized much of what is known about mental illness and its treatment—emphasized that...

    • Chapter 16 Accountability for Reasonable Limits to Care: Can We Meet the Challenges?
      (pp. 238-248)
      Norman Daniels

      All health systems, whether public or private or rich or poor, limit access to medical care. Occasionally, this limit setting takes the form of a public melodrama focused on the “heartless” denial by an “evil” insurer or bureaucrat of a “last-chance” treatment for a dying patient. Such drama leaves little room for the limit setter to claim moral authority. For example, when Medicaid denied coverage for a bone marrow transplant to young Coby Howard in Oregon, the script of the public drama barely mentioned the fact that he was not in remission from his leukemia and therefore was not even...

  10. Contributors
    (pp. 249-254)
  11. Name Index
    (pp. 255-262)
  12. Subject Index
    (pp. 263-276)