Policy Analysis Models

1. An Abbreviated History of American Health PoliticsDr. J. HughesBioethics and Public PolicyTrinity College – Summer 2010

2. Policy Analysis Models • Who gets what and why • Inputs: influences on government • Process: the legislative bargaining and maneuvering • Outputs: decisions, actions and implementation

3. Type of Explanations • Government as rational actor • Popular rule through elections/rep elites • Political bargaining/Interest groups • American political culture • Legislative process • Elite rule • Marxist Functionalism • Class Struggle Marxism

4. Dimensions of Power • Coercive: A and B fight, B loses • Remunerative: A buys B’s consent • Normative: A convinces B that A’s way is the only way • Nondebates: A keeps B from ever thinking about what she wants

5. "Democratic Culture" • The Jacksonian compromise between capitalism and democracy • Domestic Medicine • The Medical Counterculture • Thomsonians, homeopaths • What is homeopathy (3min) • Professional Medicine • AMA founded 1847

6. Germ Theory of Disease • 1867 - Joseph Lister publishes On the Antiseptic Principle in the Practice of Surgery, showing that disinfection reduces post-operative infections. • 1879 - Pasteur demonstrates anthrax vaccine • 1882 – Koch demonstrates TB & cholera micro-organisms • 1885 – Pasteur develops rabies vaccine • 1916 - Polio epidemics break out, continue for decades • 1918-1919 - Flu pandemic kills 15 million people worldwide, 600,000 in U.S.

7. Allopathic medicine triumphs • 1910 – Flexner Report • Hospitals become centers for healing • AMA becomes powerful guild Abraham Flexner

8. Alternative: Social medicine • Role of poverty, housing and education • Growth of social insurance in Europe • John Snow and the removal of the Broad Street pump handle (8 min video) John Snow

9. Progressives and the AALL • Theodore Roosevelt 1901 -- 1909 • AALL Bill 1915 • AMA supported AALL Proposal • AFL opposed AALL Proposal • Private insurance industry opposed AALL Proposal • WWI and anti-German fever • Why did the Progressives fail?

10. 1930s – Health Care in Crisis • Blue Cross and Blue Shield get started • FDR's first attempt at NHI -- failure to include in the Social Security Bill of 1935 • Food, Drug and Cosmetic Act • FDA given control over drug safety • Establishes class of drugs available by Prescription • FDR's second attempt at NHI -- Wagner Bill, Nat. Health Act of 1939

11. 1940s – Building Modernity • War, trauma and penicillin • 1946 – Hill/Burton Act • 1946 - British Nat. Health Service • Wagner-Murray-Dingell Bills • 1948 - Truman's Support • Growth of private insurers

12. 1965 – Medicare/Medicaid • Medicare A: Hospital costs, paid for with payroll tax • Medicare B: Supp insurance for docs & outpatient • Medicaid: federal-state program for the poor, all hospital, doc, lab, home health and nursing home care • Expected goal – universal health coverage in 20 years • No fee schedules for docs or hospitals • Expected 1990 cost: $10 billion • Actual 1990 cost: $180 billion • 1969 – Canadians enact Nat. Health Insurance

13. 1970s– Costs spur innovation • Costs begin to rise • Growth of bureaucracy • Growth of medical specialists • 1973 – Nixon passes HMO Act; provided subsidies and exempted from regs • 1972-1979 Ted Kennedy’s campaign for NHI

14. 1980s – Managed Care • DRGs • Growth of Managed care • Growing interest among employers in controlling costs • Capitation of physician payment • Growth in size of physician groups • Growth of for-profit institutions • Selective contracting • Price competition • Mergers and acquisitions: Hospital Corporation of America • Vertical and horizontal integration • HMOs for Medicaid and Medicare

15. Managed Care Types

16. Type of Health Plan • HMOs v. PPOs (1min) • HMO vs POS vs PPO (4min)

17. 1990-1994 – Clinton Effort • Harris Wofford elected on “single-payer” platform • 1994 Clinton Health Plan • Committee of 500 • Managed competition

18. Clinton’s Plan

19. 1996: HIPAA – patient info privacy 1997: CHIPS – subsidized children’s insurance 1997 Part C: Medicare Advantage plans States: Patient Bill of Rights 2006: Part D: Prescription Drug plans 1994-2008

20. Reform Support Was High

21. Majorities Favored Elements

22. Frontline history 60min Compromises: Pharmaceutical prices Public option Individual Mandate Expansion of Medicaid and subsidies Health Insurance Exchanges No pre-existing condition & high-risk pool 2009 – Obama’s Reform

23. But, we are still the most expensive • Total health spending 17% of GDP in the United States in 2009, highest in OECD • Canada and France about 10% • OECD avereage 8.6% • $2,000,000,000,000 a year • $1 trillion increase in health care spending over the last decade

24. As a Percent of Family Income

25. Health Care Costs per Capita

26. Cost per Year per Capita

27. Cost Trends 1980-2004

28. Public/Private Expenditures More than 75% of health spending is through public insurance in other countries, just half in US

29. Putting Off Care Because of Cost

30. Consequences

31. Causes of Health Care Inflation • Technology • Aging of population, longer lifespan • Lack of effective competition or global budgeting

32. Administrative Overhead

33. Admin Staff per Patient

34. Life Expectancy

35. Spending & Life Expectancy

36. Infant Mortality

37. Obesity

38. Mental Illness OECD 2009 - http://dx.doi.org/10.1787/538536332624

39. Uninsured in the US The problem of the uninsured is continuing to grow. The federal government estimates that over 45 million individuals lacked health insurance coverage of any kind during 2008. Source: SHADAC estimates from the Current Population Survey Annual Social and Economic Supplements, 1995-2008. Note: 1995-2003 data are adjusted for Census correction announced in March 2007.

40. Future Trends • Financial Viability of Medicare and Medicaid • Pressures for universal coverage and cost containment • Emerging technologies could: • dramatically reduce or expand costs, • eliminate, create or transform professions, • enable consumer choice and quality measurement

41. IDEOLOGIES AND MARKETS

42. Democracy • Liberty/Autonomy • Solidarity/Beneficence • Equality/Justice

43. Autonomy/Liberty • Negative freedom from coercion • Positive: freedom to • Exit and Voice • Patient autonomy and informed consent • Right to refuse 

44. Beneficence/Solidarity • Positive rights to demand entitlements of citizenship • Should access to basic health care be a right? • Which services should health care providers be obligated to provide regardless of risks or their moral or economic reservations?

45. Justice/Equality • Equal opportunities • Equality before the law • The right to control institutions through equal sufferage

46. Market vs. State • Exit vs. Voice • Efficiency vs. Equality • Flexibility vs. Accountability • Responsibility vs. Solidarity • Freedom from vs. Freedom to

47. Rights • Dems, liberals, women, the young, seculars support healthcare rights

48. Principles for allocation of scarce medical interventions

49. Emanuel et al’s Proposal

50. GOVERNMENT IN HEALTH CARE