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  1. Introduction

  2. Overview • Health care in America is fundamentally political • Like every other issue, health care tends to follow the public policy process • Costs are a paramount issue in American health politics • Managed care is a revolution without revolutionaries

  3. Health Care IsInherently Political • Health care decisions relate to the allocation of scarce resources • The very definition of politics • National health care systems are reflective of a country’s political traditions and norms

  4. Health Care and the Policy Process I • First step in policy process • Getting item on national political agenda • National Health Insurance (NHI) • First appeared on agenda due to the efforts of early (private) reformers • Returned to agenda as part of FDR’s New Deal

  5. Health Care and the Policy Process II • In second step of policy process: • Political solutions to a given problem are formulated • Could be “re-heated” policies hatched previously • Garbage can theory of policy making

  6. Health Care and the Policy Process II • Early proposals to provide “workingman’s insurance” resurrected during New Deal era and after

  7. Health Care and the Policy Process II • Those opposed to comprehensive (public) provision of benefits offered private schemes • More modest federal financing proposals • Hill-Burton, et. al.

  8. Health Care and the Policy Process III • Third step of policy process involves making a political decision • National health insurance never enacted • Medicare and Medicaid passed by Congress • Signed into law 1965

  9. Health Care and the Policy Process IV • In fourth stage of the policy process • Political decision (law) is implemented • Medicaid initially left states with wide latitude

  10. Health Care and the Policy Process IV • Some, such as New York, used program as means to achieve universal coverage by lowering eligibility requirements • Federal government soon clarified law by setting maximum income levels

  11. Health Care and the Policy Process V • Fifth stage of policy process involves the administration of a given program • Relates to the day-to-day functioning of government program

  12. Health Care and the Policy Process VI • This final stage of policy process often not realized • Involves evaluation of a given program

  13. The Cost of Health Care in America • American health care system is by far the most expensive in the world • Accounting for an ever-burgeoning share of gross domestic product (GDP) • Many of the political issues revolving around health relate to the cost of care

  14. The Managed Care “Revolution” • Managed care offered as means of reducing growth in health care costs • Featured in failed Clinton health plan • Eventually adopted independently by private sector • After brief stabilization: • Health care costs continue(d) to rise

  15. Values in Health Care: Fairness and Efficiency • Broad agreement on desirability of both values in principle • But difficult, if not impossible, to achieve consensus on realizing both • “Inherent tension” between the two • Multiple definitions of both • Depending on one’s perspective

  16. Efficiency Defined • Most simply, efficiency can be conceived as a bargain • With the ideal of achieving the highest ratio of outputs to input • Myth: efficiency can be measured • Efficiency can only be properly defined in reference to an individual, party, or constituency

  17. Assumptions of the Ideal Market: The Rational Actor • Individuals are rational when it comes to their behavior in a given market • Persons possess the ability to discern which goods or services will improve their situation • Employing all available information, individuals will choose the best of available options

  18. Realities of the “Health Care Market”The Rational Actor • “Counterfactual problem” in health care makes it difficult to decide if an alternative decision in care would have yielded a better, or even different, outcome • Market offers few cues • Few know about different health plans • Good “report cards” on plans hard to come by

  19. Assumptions of the Ideal Market:Predetermination of Preferences • Preferences are inherent to the very identity of an individual • Produced, as if by magic, through the “Immaculate Conception of the Indifference Curve” • Providers of goods and services cannot significantly alter individual preferences

  20. Realities of the “Health Care Market”Variability of “Consumer” Preference • Patient preferences can be “physician-induced” • Doctors possess far more information than patient • Extent to which this actually occurs is unclear

  21. Assumptions of Ideal Market: Broad Agreement on Resource Distribution • Members of society: • Expected to share some degree of consensus on the way in which goods and services are distributed • Improvements in the fortunes of others do not cause significant distress on the part of others

  22. Realities of the “Health Care Market” • Possible resentment at superior care offered some • Vastly superior care available to the wealthy in American society • Could create envy among those who are not better off

  23. The Individualistic Model of American Politics • Americans “born free without having to become so” • Tocqueville historically relying on themselves • Not a paternalistic monarch or state to attain privileges

  24. The Individualistic Model of American Politics • Early philosophical liberalism written into U.S. Constitution and design of government institutions • Self-interest often seen to trump hard science • Presenting continual challenges to health care professionals

  25. Considerations of the “Community” in American Politics • Political historians have discerned long tradition of appeal to communal traditions and assistance • Broad public health programs launched by cities at the turn of the 20th century • New Deal-era legislation

  26. Divergence within the Puritan Tradition • Early Puritan ethos elaborated into twin moral stream in American political history • Individualistic “neo-Puritans” stressed sins of the individual, or the “other”

  27. Divergence within the Puritan Tradition • Collectively-inclined neo-Puritans chose to focus on the sins of the community • Advocating collective action to solve problems • Including those relating to public health

  28. Morality Politics in Practice:Case of School Health Clinics-1 • Public health officials by 1990s advocated opening health centers directly inside schools • Conflicted with cultural conservatives • Recommended alternative course of emphasizing individual discipline • “Just say no” anti-drug campaign

  29. Morality Politics in Practice:Case of School Health Clinics-2 • Despite opposition, clinics flourished and multiplied across country • Developed home-grown constituency of parents, students, public-health advocates • Achieved compromise with conservatives on certain issues

  30. Morality Politics in Practice:Obesity Debate-1 • Surgeon general first defined obesity as public health crisis in 2001 • Reactions focused on the individual obese • Fast-food industry came to be blamed by new breed of “muckrakers”

  31. Morality Politics in Practice:Obesity Debate-2 • Villainizing of fast-food purveyors led, in turn, to villainization of the obese • Policy options mooted include mandating high insurance premiums for the obese

  32. Morality Politics in Practice:Obesity Debate-2 • In the end: • Biggest impact of definition of obesity as public health crisis may come in the way it informs the public • Changing lifestyle choices

  33. Chapter 3 Summary • American political history often viewed through the lens of individualism, community, or, in the case of this study, morality

  34. Chapter 3 Summary • Original Puritan impulse led to divergent world views • One focusing on the sins of the individual • Or groups thereof • Other focusing on the ills of society • Social gospel

  35. Chapter 3 Summary • Morality politics can be seen at play in the cases of school health clinics and the debate over obesity in America

  36. U.S. Congress: A Unique Institution • Few other legislatures play such a powerful role when it comes to initiating policy • Accords with the “consensus” model of policy making • Interests must bargain with numerous institutional actors in order to achieve positive outcome on any given issue

  37. U.S. Congress: A Unique Institution • Lack of competing national (unifying) institutions • Tradition of bureaucratic government ensures Congress retains powerful role in policymaking

  38. The ChangingFace of Congress • Party unity/discipline has changed over time • Generally lower than in majoritarian systems • House started 20th century as a highly centralized institution • Power gradually decentralizing over time • Up to the 1990s

  39. The Fate of Health Care Reform in Congress-1 • National health care reform legislation first introduced (gingerly) by Robert Wagner in 1939 • President Truman made health care reform a priority • Further reform attempts were made in the 1970s • Most recently, in 1993-’94

  40. The Fate of Health Care Reform in Congress-1 • Not a single piece of health care reform legislation ever made it to the stage of debate on the floor of the House or Senate

  41. The Fate of Health Care Reform in Congress-2 • Despite Democratic majorities in mid-20th century and party leadership commitment to health care reform • Party cohesion in Congress was low throughout the period

  42. The Fate of Health Care Reform in Congress-2 • Conservative southern Democrats managed to scuttle reform efforts through the mid-1960s • Next, the American Medical Association (AMA) became an obstacle to reform

  43. The Fate of Health Care Reform in Congress-2 • Newer groups such as the National Federation of Independent Business (NFIB) led interest group opposition to health care reform legislation over time

  44. Presidential Strategy and Health Care Reform • President Clinton waited too long to unveil reform plan • Too close to the midterm elections • Ordering of process also proved faulty • Administration hoped to prevail in the House before moving on to the Senate but this did not work

  45. Presidential Strategy and Health Care Reform • Lengthy (secretive) process of formulating reform plan gave interest groups time to galvanize members against it • Intensity of opposition generated greater than expected enthusiasm among natural allies

  46. Chapter 4 Summary • Congress is unique among the legislatures of the world • Structural profile of Congress has changed significantly over time

  47. Chapter 4 Summary • Congress has often served as the graveyard of health care reform legislation • Clinton health care reform package died largely as a result of poor legislative strategy

  48. The Limited Presidency • Presidential power is often curbed by the other governing institutions • Including Congress and the judiciary • Popular distrust of centralized authority has further limited presidential power

  49. The Powerful Presidency • Crises tend to increase the powers of the president • Particularly in time of war • Real or figurative • Powerful personalities and skilled political operators have taken full advantage of the powers left to the president

  50. Three Faces of the Presidency: The Individual • Individual presidents possess the power to place items on the national agenda • To “shape the national conversation” • Some presidents have entered office with a passion for health reform • Others have been forced to address the issue