Hostname: page-component-cd9895bd7-8ctnn Total loading time: 0 Render date: 2024-12-26T09:12:46.310Z Has data issue: false hasContentIssue false
  • English
  • Français

Minding Ps and Qs: The Political and Policy Questions Framing Health Care Spending

Published online by Cambridge University Press:  01 January 2021

William M. Sage
Get access Rights & Permissions [Opens in a new window]

Abstract

Tracing the evolution of political conversations about health care spending and their relationship to the formation of policy is a valuable exercise. Health care spending is about science and ethics, markets and government, freedom and community. By the late 1980s the unique upward trajectory of post-Medicare U.S. health care spending had been established, recessions and tax cuts were eroding federal and state budgets, and efforts to harness market forces to serve policy goals were accelerating. From the initial writings on “managed competition,” through the failed Clinton health reform effort in the early 1990s, to the passage of the Affordable Care Act in 2010, the policy narrative of health spending acquired a superficial consistency. On closer examination, however, it becomes apparent that the cost problem has been repeatedly reframed in political discourse even during this relatively brief period. The clearest transition has been from a narrative centered on rationing necessary care to one committed to reducing wasteful care – although the role of accumulated law and regulation in perpetuating waste remains largely unrecognized and the recently articulated commitment to population health seems an imperfect proxy for explicitly developing social solidarity with respect to health and health care in the United States.

Type
Symposium Articles
Information
Journal of Law, Medicine & Ethics , Volume 44 , Issue 4: Health Reform: Assessing the Affordable Care Act and Moving Forward , Winter 2016 , pp. 559 - 568
Copyright
Copyright © American Society of Law, Medicine and Ethics 2016

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Ehrenreich, B., The American Health Empire: Power, Profits, and Politics (New York: Random House, 1970).Google Scholar
Eisenhower's Farewell Address to the Nation, Jan. 17, 1961, available at <http://mcadams.posc.mu.edu/ike.htm> (last visited November 30, 2016). (last visited November 30, 2016).' href=https://scholar.google.com/scholar?q=Eisenhower's+Farewell+Address+to+the+Nation,+Jan.+17,+1961,+available+at++(last+visited+November+30,+2016).>Google Scholar
Martin, A. B., Hartman, M., Benson, J., and Catlin, A., “National Health Spending in 2014: Faster Growth Driven by Coverage Expansion and Prescription Drug Spending,” Health Affairs (Millwood) 35, no. 1 (2016): 150–160.Google Scholar
Chetty, R., Stepner, M., Abraham, S., Lin, S., Scuderi, B., Turner, N., Bergeron, A., and Cutler, D., “The Association between Income and Life Expectancy in the United States, 2001-2014,” JAMA 315, no. 16 (2016): 1750–1766.Google Scholar
Starr, P., The Social Transformation of American Medicine (New York: Basic Books, 1982): at 261 (discussing the Committee on the Costs of Medical Care, which was convened in 1926 by fifteen economists, physicians, and public health specialists); D. Blumenthal and J. A. Morone, The Heart of Power: Health and Politics in the Oval Office (Berkeley: University of California Press 2009).Google Scholar
Enthoven, A. and Kronick, R., “A ConsumerChoice Health Plan for the 1990s: Universal Health Insurance in a System Designed to Promote Quality and Economy,” New England Journal of Medicine 320, no. 1 (1989): 29–35 (First of Two Parts) and New England Journal of Medicine 320, no. 2 (1989): 94-100 (Second of Two Parts).Google Scholar
Jacobs, L. R., “Politics of America's Supply State: Health Reform and Technology,” Health Affairs 14, no. 2 (1995): 143–157.Google Scholar
Graduate Medical Education National Advisory Committee (GMENAC), Report to the Secretary on Physician Manpower (Sept. 1981).Google Scholar
Vladeck, B. C., “The Political Economy of Medicare,” Health Affairs 18, no. 1 (1999): 22–36.CrossRefGoogle Scholar
Studdert, D. M., Mello, M. M., Sage, W. M., Des Roches, C. M., Peugh, J. J., Zapert, K., and Brennan, T. A., “Defensive Medicine among High-Risk Specialist Physicians during a Malpractice Crisis,” JAMA 293, no. 21 (2005): 2609–2617.CrossRefGoogle Scholar
Blumstein, J. F., “The Fraud and Abuse Statute in an Evolving Health Care Marketplace: Life in the Health Care Speakeasy,” American Journal of Law & Medicine 22, nos. 2-3 (1996): 205–231.Google Scholar
Kissick, W., Medicine's Dilemmas: Infinite Needs Versus Finite Resources (New Haven, Yale University Press, 1994).Google Scholar
Califano, J. A., America's Health Care Revolution: Who Lives? Who Dies? Who Pays? (New York: Simon & Schuster, 1986).Google ScholarPubMed
Kassirer, J. P., Editorial, “Managing Care—Should We Adopt a New Ethic?” New England Journal of Medicine 339, no. 6 (1998): 397–398, at 398 (concluding that physicians should not “capitulate to an ethic of the group rather than the individual”).Google Scholar
Blumstein, J. F., “The Oregon Experiment: The Role of Cost-Benefit Analysis in the Allocation of Medicaid Funds,” Social Science &Medicine 45, no. 4 (1997): 545–554.Google Scholar
Oberlander, J. et al., “Rationing Medical Care: Rhetoric and Reality in the Oregon Health Plan,” Canadian Medical Association Journal 164, no. 11 (2001): 1583–1587.Google Scholar
Starr, P. and Zelman, W. A., “A Bridge to Compromise: Competition under a Budget,” Health Affairs 12, no. Supp. 1 (1993): 7–23.CrossRefGoogle Scholar
McCaughey, Cf. E., “No Exit,” New Republic, February 7, 1994, available at <http://www.newrepublic.com/article/health-care/no-exit> (equating rationing under the Clinton reform with private managed care) (last visited September 9, 2016).+(equating+rationing+under+the+Clinton+reform+with+private+managed+care)+(last+visited+September+9,+2016).>Google Scholar
The Dartmouth Atlas of Healthcare, “Understanding of the Efficiency and Effectiveness of the Health Care System (2015),” available at <http://www.dartmouthatlas.org> (last visited September 9, 2016).+(last+visited+September+9,+2016).>Google Scholar
See Elhauge, E., “Why We Should Care about Health Care Fragmentation and How to Fix It,” in Elhauge, E., ed., The Fragmentation of U.S. Health Care: Causes and Solutions (New York: Oxford University Press, 2010): 1–20, at 5.Google Scholar
Berenson, R. A., “Beyond Competition,” Health Affairs 16, no. 2 (1997): 171–180, at 176 (“The alignment between health plans and providers envisioned in managed competition is virtually impossible.”).CrossRefGoogle Scholar
Blendon, R. J. et al., “Understanding the Managed Care Backlash,” Health Affairs 17, no. 4 (1998): 80–94, at 94 (examining the depth and breadth of the public backlash against managed care and the underlying causes).Google Scholar
Hyman, D. A., “What Lessons Should We Learn from Drive-Through Deliveries?” Pediatrics 107, no. 2 (2001): 406–407.CrossRefGoogle Scholar
Sage, W. M., “Legislating Delivery System Reform: A 30,000-Foot View of the 800-Pound Gorilla,” Health Affairs 26, no. 6 (2007): 1553–1556.Google Scholar
Institute for Healthcare Improvement, “IHI Triple Aim Initiative (2015)”, available at <http://www.ihi.org/Engage/Initiatives/TripleAim/pages/default.aspx> (last visited September 9, 2016).+(last+visited+September+9,+2016).>Google Scholar
Institute of Medicine, Crossing the Quality Chasm: A New Health System for the 21st Century (2001): at 83; Institute of Medicine, To Err Is Human: Building a Safer Health System (1997): at 37; Institute of Medicine, Best Care at Lower Cost: The Path to Continuously Learning Health Care in America (2012).Google Scholar
Porter, M. E. and Teisberg, E. O., Redefining Health Care: Creating Value-Based Competition on Results (Boston: Harvard Business Review Press, 2006); M. E. Porter and T. H. Lee, “The Strategy That Will Fix Health Care,” Harvard Business Review 91, no. 10 (2013): 50-70.Google Scholar
U.S. Department of Health and Human Services, Better, Smarter, Healthier: In Historic Announcement, HHS Sets Clear Goals and Timeline for Shifting Medicare Reimbursements from Volume to Value, Press Release, January 26, 2015, available at <http://www.hhs.gov/news/press/2015pres/01/20150126a.html> (last visited September 9, 2016); B. Wynne, “May the Era of Medicare's Doc Fix (1997–2015) Rest in Peace. Now What?” Health Affairs Blog, April 14, 2015, available at <http://healthaffairs.org/blog/2015/04/14/may-the-era-ofmedicares-doc-fix-1997-2015-rest-in-peace-now-what> (last visited September 9, 2016). (last visited September 9, 2016).' href=https://scholar.google.com/scholar?q=U.S.+Department+of+Health+and+Human+Services,+Better,+Smarter,+Healthier:+In+Historic+Announcement,+HHS+Sets+Clear+Goals+and+Timeline+for+Shifting+Medicare+Reimbursements+from+Volume+to+Value,+Press+Release,+January+26,+2015,+available+at++(last+visited+September+9,+2016);+B.+Wynne,+“May+the+Era+of+Medicare's+Doc+Fix+(1997–2015)+Rest+in+Peace.+Now+What?”+Health+Affairs+Blog,+April+14,+2015,+available+at++(last+visited+September+9,+2016).>Google Scholar
Delbanco, S., “The Payment Reform Landscape: Bundled Payment,” Health Affairs Blog, July 2, 2014, available at <http://healthaffairs.org/blog/2014/07/02/the-payment-reform-landscape-bundled-payment> (last visited September 9, 2016); R. E. Mechanic, “Mandatory Medicare Bundled Payment—Is It Ready for Prime Time?” New England Journal of Medicine 373, no. 14 (2015): 1291-1293; S. A. Farmer et al., “Breaking Down Medicare's Bold New Proposal to Transform Hip and Knee Replacements,” Brookings, August 11, 2015, available at <http://www.brookings.edu/blogs/health360/posts/2015/08/joint-replacement-model-care> (last visited September 9, 2016).+(last+visited+September+9,+2016);+R.+E.+Mechanic,+“Mandatory+Medicare+Bundled+Payment—Is+It+Ready+for+Prime+Time?”+New+England+Journal+of+Medicine+373,+no.+14+(2015):+1291-1293;+S.+A.+Farmer+et+al.,+“Breaking+Down+Medicare's+Bold+New+Proposal+to+Transform+Hip+and+Knee+Replacements,”+Brookings,+August+11,+2015,+available+at++(last+visited+September+9,+2016).>Google Scholar
Shortell, S. M. and Casalino, L. P., “Health Care Reform Requires Accountable Care Systems,” JAMA 300, no. 1 (2008): 95–97); H. H. Luft, “Becoming Accountable—Opportunities and Obstacles for ACOs,” New England Journal of Medicine 363, no. 15 (2010): 1389-1391.Google Scholar
Gobeille v. Liberty Mutual Ins. Co., 577 US _ (2016).Google Scholar
Anderson, G. F. et al., “It's the Prices, Stupid: Why the United States Is So Different from Other Countries,” Health Affairs 22, no. 3 (2003): 89–105.Google Scholar
Brill, S., “Bitter Pill: Why Medical Bills Are Killing Us,” Time, March 4, 2013, available at <http://time.com/198/bitter-pill-why-medical-bills-are-killing-us/> (last visited September 12, 2016); E. Rosenthal, “The Odd Math of Medical Tests: One Scan, Two Prices, Both High,” New York Times, December 15, 2014, available at <http://www.nytimes.com/2014/12/16/health/the-odd-math-of-medical-tests-one-echocardiogramtwo-prices-both-high.html> (last visited September 12, 2016); E. Fuse-Brown, “Irrational Hospital Pricing,” Houston Journal of Health Law & Policy 14, no. 1 (2014): 11-58.+(last+visited+September+12,+2016);+E.+Rosenthal,+“The+Odd+Math+of+Medical+Tests:+One+Scan,+Two+Prices,+Both+High,”+New+York+Times,+December+15,+2014,+available+at++(last+visited+September+12,+2016);+E.+Fuse-Brown,+“Irrational+Hospital+Pricing,”+Houston+Journal+of+Health+Law+&+Policy+14,+no.+1+(2014):+11-58.>Google Scholar
Vogt, W. B. and Town, R., Robert Wood Johnson Foundation, How Has Hospital Consolidation Affected the Price and Quality of Hospital Care? (2006): at 11–12.Google Scholar
Lakdawalla, D. N., Goldman, D. P., and Shang, B., “The Health and Cost Consequences of Obesity among the Future Elderly,” Health Affairs published online, September 26, 2005, available at <http://content.healthaffairs.org/content/early/2005/09/26/hlthaff.w5.r30.citation> (last visited September 12, 2016).+(last+visited+September+12,+2016).>Google Scholar
Susan Ridgely, M. et al., “Bundled Payment Fails to Gain a Foothold in California: The Experience of the IHA Bundled Payment Demonstration,” Health Affairs 33, no. 8 (2014): 1345–1352, at 1352.Google Scholar
Berwick, D. M., “Era 3 for Medicine and Health Care,” JAMA 315, no. 13 (2016): 1329–1330.Google Scholar
President Barack Obama, Remarks in the Rose Garden of the White House on the Supreme Court's Decision in King v. Bur-well (June 25, 2015).Google Scholar
Source unknown, but cf. Schein, E., Organizational Culture and Leadership (San Francisco: Jossey-Bass, 1985).Google Scholar
Institute of Medicine, The Future of Nursing: Leading Change, Advancing Health (Oct. 5, 2011), available at <http://www.nap.edu/read/12956/chapter/1> (last visited September 12, 2016); T. Kelley, “Young Docs: The New Blood That Health Care Needs,” Managed Care, February 2016, available at <http://www.managedcaremag.com/archives/2016/2/young-docs-new-blood-health-care-needs> (last visited September 12, 2016).+(last+visited+September+12,+2016);+T.+Kelley,+“Young+Docs:+The+New+Blood+That+Health+Care+Needs,”+Managed+Care,+February+2016,+available+at++(last+visited+September+12,+2016).>Google Scholar
Sage, W. M., “Relating Health Law to Health Policy: A Frictional Account,” in Cohen, I. G., Hoffman, A., and Sage, W. M., eds., Oxford Handbook of U.S. Healthcare Law (New York: Oxford University Press, 2016).Google Scholar
Sage, W. M., “Assembled Products: The Key to More Effective Competition and Antitrust Oversight in Health Care,” Cornell Law Review 101, no. 3 (2016): 609–700.Google Scholar
Sage, W. M., “Why the Affordable Care Act Needs a Better Name: ‘Americare,’” Health Affairs 29, no. 8 (2010): 1496–1497; W. M. Sage, “Solidarity,” in T. H. Murray and M. Crowley, eds., Connecting American Values with American Health Care Reform (Garrison, NY: The Hastings Center, 2009): at 10.Google Scholar
Cooper, R., Poverty and the Myths of Health Care Reform (Baltimore: Johns Hopkins University Press, 2016).Google Scholar
Berwick, D. M., “Era 3 for Medicine and Health Care,” JAMA 315, no. 13 (2016): 1329–1330.CrossRefGoogle Scholar
Mullan, F., “A Founder of Quality Assessment Encounters a Troubled System Firsthand,” Health Affairs 20, no. 1 (2001): 137–141.Google Scholar