The Politics of Health Care Reform: Lessons from the Past, Prospects for the Future - Softcover

Softcover

ISBN 10: 0822314894 ISBN 13: 9780822314899

Publisher: Duke University Press, 1994

Synopsis

This distinguished collection stands out from the recent flurry of books on health reform by its sustained and sophisticated analysis of the political dimension. In The Politics of Health Care Reform, some of America’s best-known political scientists, historians, and legal scholars make sense of our most turbulent policy issue. They dig below the jargon and minutiae to explore the enduring questions of American politics, government reform, and health care.
The Politics of Health Care Reform explains how successful reforms occur in the United States and shows what is unique about health care issues. Theoretically informed, politically astute, historically nuanced, this volume takes an inventory of our health policy infrastructure. Here is an account of the institutions, ideas, and interests that shape health policy in the 1990s: Congress, the federal courts, interest groups, state governments, the public bureaucracy, business (large and small), the insurance industry, the medical profession. The volume offers a fresh look at such critical matters as public opinion, the politics of race and gender, and the lessons we can draw from other nations.
The Politics of Health Care Reform is the definitive collection of political science essays about health care. Expanded from two special issues of the Journal of Health Politics, Policy and Law, the most prominent scholarly journal in the field it helped create, this collection will enliven the present debate over health reform and instruct everyone who is concerned about the future of American health care.

Contributors. Lawrence Brown, Robert Evans, William Glaser, Colleen Grogan, Robert Hackey, Lawrence Jacobs, Nancy Jecker, Taeku Lee, Joan Lehman, David McBride, Ted Marmor, Cathie Jo Martin, James A. Morone, Mark Peterson, David Rochefort, Rand Rosenblatt, David Rothman, Joan Ruttenberg, Mark Schlesinger, Theda Skocpol, Michael Sparer, Deborah Stone, Kenneth Thorpe

About this title

About the Author

James A. Morone is Professor of Political Science at Brown University and Editor of the Journal of Health Politics, Policy and Law.

Gary S. Belkin, a Physician at Massachusetts General, completing a residency in psychiatry, is Associate Editor of the Journal of Health Politics, Policy and Law.

Excerpt. © Reprinted by permission. All rights reserved.

The Politics of Health Care Reform

Lessons from the Past, Prospects for the Future

By James A. Morone, Gary S. Belkin

Duke University Press

Copyright © 1994 Duke University Press
All rights reserved.

ISBN: 978-0-8223-1489-9

Contents

Introduction, 
Part 1: The Fault Lines of American Health Politics, 
A Century of Failure: Class Barriers to Reform, 
The Struggle for the Soul of Health Insurance, 
Is the Time Finally Ripe? Health Insurance Reforms in the 1990s, 
Black America: From Community Health Care to Crisis Medicine, 
From Community Health Care to Crisis Medicine: Have We Learned the Right Lessons?, 
Part 2: Political Institutions, 
Congress in the 1990s: From Iron Triangles to Policy Networks, 
The Bureaucracy Empowered, 
The Courts and the Reconstruction of American Social Legislation, 
Part 3: Business, 
Dogmatic Slumbers: American Business and Health Policy, 
Together Again: Business, Government, and the Quest for Cost Control, 
Can an Employer-Based Health Insurance System Be Just?, 
Revisiting the Employment-Insurance Link, 
The Pragmatic Appeal of Employment-Based Health Care Reform, 
Part 4: The People, 
Is Health Care Different? Popular Support of Federal Health and Social Policies, 
The Politics of American Ambivalence toward Government, 
Part 5: Federalism, 
American States and Canadian Provinces: A Comparative Analysis of Health Care Spending, 
Regulatory Regimes and State Health Policy, 
The Unknown States, 
Part 6: Lessons from Abroad, 
Who Gets What? Levels of Care in Canada, Britain, Germany, and the United States, 
Canada: The Real Issues, 
Lessons from the Frozen North, 
Universal Health Insurance that Really Works: Foreign Lessons for the United States, 
Index, 
Contributors, 

CHAPTER 1

A Century of Failure: Class Barriers to Reform

David J. Rothman

Abstract To understand fully the persistent failure of the United States to enact national health insurance requires an appreciation not only of the role of government and the dynamics of politics but of underlying social realities. One consideration, which dates back to the Great Depression, is the absence of the middle class from a coalition in favor of such a policy. This absence reflects both the constricted vision of the middle class and the spirited campaigns of groups like Blue Cross to make certain that middle-class needs were met in order to reduce pressure for government intervention. Another critical social feature is the special entrepreneurial character of the American medical profession. Physicians saw themselves as small businessmen and, as such, shared and promoted a suspicion of governmental intervention. All the while, Americans justified the absence of a national program in terms of the ethos of voluntarism, which had a sufficient base in reality for the posture to be maintained without great embarrassment. In fact, the rhetoric that surrounded the enactment of Medicare reinforced these views, making it appear that, the elderly aside, all was well with the provision of medical services in the country. Even as national health insurance assumes a new prominence on the political agenda, it remains unclear whether these several considerations will allow for the enactment of sweeping changes.

There are some questions that historians return to so often that they become classics in the field, to be explored and reexplored, considered and reconsidered. No inquiry better qualifies for this designation than the question of why the United States has never enacted a national health insurance program. Why, with the exception of South Africa, does it remain the only industrialized country that has not implemented so fundamental a social welfare policy?

The roster of answers that have been provided is impressive in its insights. Some outstanding contributions to our understanding of the issues come from James Morone, Paul Starr, Theodore Marmor, and Theda Skocpol. Their explanations complement, rather than counter, each other. In like manner, the elements that this essay will explore are intended to supplement, not dislodge, their work. A failure in policy that is so basic is bound to be overdetermined, and therefore, efforts to fathom it will inevitably proceed in a variety of directions.

The Liberal State

Morone's frame for understanding American health policy in general and the failure of national health insurance in particular centers on the definitions of the proper role of the state, the acceptable limits for all governmental actions. His starting point is with the fact that the medical profession successfully "appropriated public authority to take charge of the health care field," taking for itself the task of denning the content, organization, and, perhaps most important, the financing of medical practice (Morone 1990: 253-84). This accomplishment points to more than the power of the American Medical Association's lobbying machine; AMA rhetoric, which has seemed to other observers to be bombastic, comical, or even hysterical, in Morone's terms was effective precisely because it drew on popularly shared assumptions about the proper relationship between governmental authority, professional capacity, and professional autonomy. By the terms of this consensus, the government's duty was to build up professional capacity without infringing on professional autonomy—and as long as the medical profession defined national health insurance as an infringement on its autonomy, such a policy would not be enacted. Government was permitted to build hospitals (witness the implementation of the Hill-Burton Act) and to endow the research establishment (witness the extraordinary growth of the National Institutes of Health), but it was not allowed, at least until very recently, to challenge or subvert professional autonomy.

Paul Starr also focuses on conceptions of state authority to explain health policy. Alert to the markedly different course of national health insurance in European countries, he posits that where a spirit of liberalism and a commitment to the inviolability of private property interests in relation to the state were strongest, movements for social insurance made the least headway. Thus, Bismarck's Germany could accomplish what Theodore Roosevelt's or Franklin Roosevelt's United States could not. Put another way, the fact that socialism never put down strong roots in this country, the absence here of a socialist tradition or threat, obviated the need for more conservative forces to buttress the social order through welfare measures.

Starr is more ready than Morone to credit the raw political power of the AMA, but he also reminds us that the AMA found allies among not only corporations but also labor unions. Union leaders preferred to obtain health care benefits for its members through contract negotiation, not through government largesse—even if that meant, or precisely because that meant, that nonunion members would go without benefits (Starr 1982: part 2).

Paralleling their studies are detailed accounts of the legislative histories of various health insurance proposals, the fate of Progressive, New Deal, and Fair Deal initiatives. The work of Theodore Marmor has clarified the political alliances that came together to enact Medicare and Medicaid (Marmor 1982). So too, the writings of Theda Skocpol place health care legislation more directly in the tradition of American welfare policies (Weir et al. 1988). In all, the existing literature illuminates the effects of both conceptions of governmental authority and the realities of constituent politics to tell us why the United States stands alone in its failure to enact national health insurance.

Co-opting the Middle Class

Despite the sophisticated and perceptive quality of these arguments, still other considerations underlie the failure to enact national health insurance. An analysis of them does not subvert the basic contours of the other interpretations but provides a deeper social context for the story.

The starting point for such an analysis is a frank recognition of the fact that what is under discussion is essentially a moral failure, a demonstration of a level of indifference to the well-being of others that stands as an indictment of the intrinsic character of American society. This observation, however, is not meant to inspire a jeremiad on American imperfections as much as to open an inquiry into the dynamics of the failure—not only how it occurred but how it was rationalized and tolerated. Americans do not think of themselves as callous and cruel, and yet, in their readiness to forgo and withhold this most elemental social service, they have been so. This question arises: How did the middle class, its elected representatives, and its doctors accommodate themselves to such neglect? To be sure, Morone, Starr, and others have made it clear that ideas on the proper scope of government were powerful determinants of behavior, that leaders like FDR made strategic political calculations that traded off health insurance for other programs, and that the AMA smugly equated physician self-interest with national interest. But given the signal importance of health care—and, a minority of commentators aside, the ongoing recognition that it is more than one more commodity to be left to the vagaries of the marketplace—there is a need for an even broader framework for understanding these events. The chess moves of politicians, and even the rules of the game of politics, seem somewhat too removed and abstract. Put most succinctly: How could Americans ignore the health needs of so many fellow countrymen and still live with themselves? How could a society that prides itself on decency tolerate this degree of unfairness?

For answers, it is appropriate to look first to the 1930s. As a result of the Great Depression, American social welfare legislation was transformed, as exemplified by the passage of the Social Security Act. Moreover, by the 1930s, the popular faith in the efficacy of medical interventions was firmly established and the consequences of a denial of medical care, apparent. Already by the 1910s, some would-be reformers defined the goal of health insurance not merely as compensation to the sick for wages lost during illness but as the opportunity to obtain curative medical care. Twenty years later, this credo was accepted by almost all reformers, although the efficacy of medical interventions was, at least by current standards, far from impressive. Also by the 1930s, the hospital, which had earlier been almost indistinguishable from the almshouse, had become a temple of science and its leaders, Men in White, widely celebrated. In keeping with these changes, physician visits and hospital occupancy now correlated directly, not inversely, with income.

Why then was national health insurance omitted from the roster of legislation enacted in the 1930s? If medicine was so valued and government so receptive to novel (at least for Americans) social insurance programs, why was health insurance kept off the roster? Although such considerations as FDR's reluctance to do battle with the AMA or to fragment his southern alliance were important, perhaps even more determinative were the tactics, thoroughly self-conscious, that were helping to remove the middle classes from the coalition of advocates for change. And eliminating the middle classes from the alignment successfully deflated the political pressure for national health insurance.

One of the pivotal groups in designing and implementing this strategy was a newly founded, private health insurance company, Blue Cross. Against the backdrop of the report of the Committee on the Costs of Medical Care, urging greater federal intervention in health care, Blue Cross presented itself as the best alternative to government involvement. Its organizers and supporters, such as Rufus Rorem and Walter Dannreuther, held out the promise that enrolling the middle class in its plan would blunt the thrust for national health insurance. Blue Cross, declared Dannreuther, would "eliminate the demand for compulsory health insurance and stop the reintroduction of vicious sociological bills into the state legislature year after year." Blue Cross advertisements, pamphlets, radio programs, and publications insisted that neither the rich nor the poor confronted difficulties in obtaining medical services, the rich because they could easily afford it, the poor because they had ready access to public hospitals. Only the middle classes faced a problem, and unless their needs were met, they were bound to agitate for a change in governmental policy. ("It is the people in the middle income group who often find it most difficult to secure adequate medical and hospital care," declared Louis Pink, president of New York Blue Cross. "It is sometimes said that the very poor and the rich—if there are any rich left—get the best medical care.") The idea was not to buy the middle classes off by expanding the services of public hospitals and persuading them to take a place on the wards to meet emergency needs. Such a solution, as Blue Cross proponents explained, would not only strain the public hospital system beyond its capacity, but would not work because the middle classes considered the public hospitals to be charity, with all innuendo intended, and they were not about to accept charity. As one Blue Cross official insisted: "The average man, with the average income, has pride. He is not looking for charity; he is not looking for ward care. He wants the best of attention for himself and his family.... Yet out of his savings, he is very seldom prepared to meet unexpected sickness or accident expenses." Thus, to use the public hospital was not only to get second-best care but to be stigmatized as dependent, incapable of standing on one's own two feet. Like the dole, the public hospital violated the American way. Were this the only choice, the middle classes would push for, and obtain, national health insurance.

The alternative that embodied the American way was a private subscription plan, which, for as little as three cents a day (the Blue Cross slogan), protected members from the high cost of hospitalization. "The Blue Cross Plans are a distinctly American institution," declared one of its officials, "a unique combination of individual initiative and social responsibility. They perform a public service without public compulsion." Another executive asserted that Blue Cross exemplified "the American spirit of neighborliness and self-help [which] solves the difficult and important problem of personal and national health." All of which led inexorably to the conclusion: "Private enterprise in voluntarily providing hospital care within the reach of everyone is solving the public health problem in the real democratic way. The continued growth of the Blue Cross Movement might well be considered the best insurance against the need of governmental provision for such protection" (quoted in Rothman 1991).

Blue Cross was notably successful in enrolling middle-class subscribers, serving, as intended, to reduce or eliminate their concern over the payment of hospital bills. To be sure, it took some time to build up a membership, but by 1939 there were thirty-nine Blue Cross plans in operation with more than 6 million subscribers. Indeed, the plans became even more over time, with some 31 million subscribers by 1949 (Starr 1982: 298, 327). In fact, from its inception the impact of Blue Cross was probably greater than even the membership statistics indicate. Its extraordinarily active advertising campaigns made a compelling case that private, as against public, initiatives were more than sufficient to meet the problem, so that even those who did not immediately enroll may have accepted the viability of this alternative. There was no reason to press for political change when the private sector seemed to have resolved the issue. Thus both in rhetoric and in reality, Blue Cross helped to undercut middle-class interest in and concern for national health insurance. The result, fully intended, was that they did not join or lend strength to a coalition for change. Politics could do business as usual, allowing a variety of other considerations to outweigh support for such an innovation.

In fact, the dynamic set off by Blue Cross in the 1930s gained strength in the post-1945 period, not only from its own growth but from the labor movement. Not just private insurance but union benefits served to cushion the middle classes from the impact of health care costs. Over these years, contract provisions negotiated with business corporations provided unionized workers with health care benefits, reducing their felt need for government programs. With that many more middle-class households effectively covered, it would require empathy, not self-interest, to push for national health insurance, and that empathy, for reasons that we will explore further below, was in short supply. As a result, public responsibility for health care became linked to the welfare system, serving only the poor, not the respectable. Coverage was something to be provided for "them," not what "we" needed or were entitled to as citizens.

How this divide between "we" and "they" shaped welfare policy emerges with particular vividness in the history of the almshouse in the 1930s. When the decade began, the institution was still one of the mainstays of public welfare policy, particularly for the elderly and for those considered the "unworthy poor." Although the post-World War II generation associates the almshouse with Dickensian England, it was of major importance in this country even at the start of the Great Depression. Only in the mid-1930s did the almshouse begin to lose its hold on welfare programs, moved aside by such New Deal relief programs as the Works Project Administration (WPA) and the Social Security Act. In fact, WPA regulations prohibited the expenditure of funds to build or enlarge these institutions; the WPA was ready to build roads but not to build or refurbish almshouses. Why this distinction? Why the abandonment, at long last, of the almshouse? Because for the first time, almshouse relief would have had to include the middle classes. With state and city budgets staggering under the burden of relief and private charities altogether unequal to the task, absent a WPA or Social Security Act, many of the once-unemployed would have had to enter the almshouse. The prospect of having respectable middle-class citizens in such a facility was so disturbing as to transform government relief policy.

Imagine this same dynamic at work in health care. Picture the middle classes having no alternative but to crowd into the public hospital, to receive medical services in the twelve-bed wards. It is by no means fanciful to suggest that had this been the case, a different kind of pressure would have been exerted on the government to enact health insurance coverage. Blue Cross, however, self-consciously and successfully short-circuited the process and thereby allowed the play of politics to go on uninterrupted.

(Continues...)

Excerpted from The Politics of Health Care Reform by James A. Morone, Gary S. Belkin. Copyright © 1994 Duke University Press. Excerpted by permission of Duke University Press.
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Edition details

• Publisher: Duke University Press
• Publication date: 1994
• Language: English
• ISBN 10: 0822314894
• ISBN 13: 9780822314899
• Binding: Paperback
• Number of pages: 564
• Editor: Belkin Gary S., Morone James A.