HEALTH CARE

HEALTH CARE. The term "health care system" refers to a country's system of delivering services for the prevention and treatment of disease and for the promotion of physical and mental well-being. Of particular interest to a health care system is how medical care is organized, financed, and delivered. The organization of care refers to such issues as who gives care (for example, primary care physicians, specialist physicians, nurses, and alternative practitioners) and whether they are practicing as individuals, in small groups, in large groups, or in massive corporate organizations. The financing of care involves who pays for medical services (for example, self-pay, private insurance, Medicare, or Medicaid) and how much money is spent on medical care. The delivery of care refers to how and where medical services are provided (for example, in hospitals, doctors' offices, or various types of outpatient clinics; and in rural, urban, or suburban locations).

Health care systems, like medical knowledge and medical practice, are not fixed but are continually evolving. In part, health care systems reflect the changing scientific and technologic nature of medical practice. For instance, the rise of modern surgery in the late nineteenth and early twentieth centuries helped create the modern hospital in the United States and helped lead to the concentration of so many medical and surgical services in hospital settings. However, the rise of "minimally invasive" surgery a century later contributed to the movement of many surgical procedures out of hospitals and into doctors' offices and other outpatient locations. A country's health care system also reflects in part the culture and values of that society. Thus, physicians in the United States, Canada, France, Germany, and Great Britain follow similar medical practices, but the health care systems of these nations vary considerably, reflecting the different cultural values and mores of those societies.

Traditional Medical Practice in America

For the first century of the republic, almost all physicians engaged in "general practice"—the provision of medical and surgical care for all diseases and for all patients, regardless of sex and age. Typically, doctors engaged in "solo practice," whereby they practiced by themselves without partners. Doctors' offices were typically at their homes or farms. Reflecting the rural makeup of the country, most physicians resided in rural settings. House calls were common. Payment was on the "fee-for-service" basis. Doctors would give patients a bill, and patients would pay out of pocket.

Medicine at this time was not an easy way for an individual to earn a living. Many physicians could not be kept busy practicing medicine, and it was common for doctors to have a second business like a farm, general store, or pharmacy. Physician income, on average, was not high, and doctors often received payment in kind—a chicken or box of fruit rather than money. Doctors also experienced vigorous competition for patients from a variety of alternative or lay healers like Thomsonians, homeopaths, and faith healers.

In the last quarter of the nineteenth century and first quarter of the twentieth century, fueled by the revolution in medical science (particularly the rise of bacteriology and modern surgery), the technologic capacity and cultural authority of physicians in the United States began to escalate. Competition for patients from alternative healers diminished, and most Americans thought of consulting a doctor if they needed medical services. The location of care moved to doctors' offices for routine illnesses and to hospitals for surgery, childbirth, and major medical problems. Indeed, the hospital came to be considered the "doctor's workshop." In 1875, there were 661 hospitals in the United States containing in aggregate about 30,000 beds. By 1930, the number of acute care hospitals had increased to around 7,000, and together they contained about one million beds. Since most hospitals were concentrated in cities and large towns, where larger concentrations of patients could be found, doctors were increasingly found in larger metropolises. In the 1920s, the U.S. population was still 50 percent rural, but already 80 percent of physicians resided in cities or large towns.

Before World War II (1939–1945), about 75 to 80 percent of doctors continued to engage in general practice. However, specialty medicine was already becoming prominent. Residency programs in the clinical specialties had been created, and by 1940 formal certifying boards in the major clinical specialties had been established. Decade by decade, fueled by the growing results of scientific research and the resultant transformation of medical practice—antibiotics, hormones, vitamins, antiseizure medications,

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safer childbirth, and many effective new drugs and operations—the cultural authority of doctors continued to grow. By 1940, competition to "regular medicine" from alternative healers had markedly slackened, and the average U.S. physician earned 2½ times the income of the average worker. (Some medical specialists earned much more.) Most physicians continued in solo, fee-for-service practice, and health care was not yet considered a fundamental right. As one manifestation of this phenomenon, a "two-tiered" system of health care officially existed—private rooms in hospitals for paying patients, and large wards for indigent patients where as many as thirty or forty "charity" patients would be housed together in one wide open room. In many hospitals and clinics, particularly in the South, hospital wards were segregated by race.

The Transformation of Health Care, 1945–1985

The four decades following World War II witnessed even more extraordinary advances in the ability of medical care to prevent and relieve suffering. Powerful diagnostic tools were developed, such as automated chemistry analyzers, radioimmunoassays, computerized tomography, and nuclear magnetic resonance imaging. New vaccines, most notably the polio vaccine, were developed. Equally impressive therapeutic procedures came into use, such as newer and more powerful antibiotics, antihypertensive drugs, corticosteroids, immunosuppressants, kidney dialysis machines, mechanical ventilators, hip replacements, open-heart surgery, and a variety of organ transplantations. In 1900, average life expectancy in the United States was forty-seven years, and the major causes of death each year were various infections. By midcentury, chronic diseases such as cancer, stroke, and heart attacks had replaced infections as the major causes of death, and by the end of the century life expectancy in the United States had increased about 30 years from that of 1900. Most Americans now faced the problem of helping their parents or grandparents cope with Alzheimer's disease or cancer rather than that of standing by helplessly watching their children suffocate to death from diphtheria.

These exceptional scientific accomplishments, together with the development of the civil rights movement after World War II, resulted in profound changes in the country's health care delivery system. Before the war, most American physicians were still general practitioners; by 1960, 85 to 90 percent of medical graduates were choosing careers in specialty or subspecialty medicine. Fewer and fewer doctors were engaged in solo practice; instead, physicians increasingly began to practice in groups with other physicians. The egalitarian spirit of post–World War II society resulted in the new view that health care was a fundamental right of all citizens, not merely a privilege. This change in attitude was financed by the rise of "third-party payers" that brought more and more Americans into the health care system. In the 1940s, 1950s, and 1960s, private medical insurance companies like Blue Cross/Blue Shield began providing health care insurance to millions of middle-class citizens. In 1965, the enactment of the landmark Medicare (a federal program for individuals over 65) and Medicaid (joint federal and state programs for the poor) legislation extended health care coverage to millions of additional Americans. Medicare and Medicaid also brought to an end the era of segregation at U.S. hospitals, for institutions with segregated wards were ineligible to receive federal payments. Third-party payers of this era continued to reimburse physicians and hospitals on a fee-for-service basis. For providers of medical care, this meant unprecedented financial prosperity and minimal interference by payers in medical decision-making.

Despite these accomplishments, however, the health care system was under increasing stress. Tens of millions of Americans still did not have access to health care. (When President Bill Clinton assumed office in 1993, the number of uninsured Americans was estimated at 40 million. When he left office in 2001, that number had climbed to around 48 million.) Many patients and health policy experts complained of the fragmentation of services that resulted from increasing specialization; others argued that there was an overemphasis on disease treatment and a relative neglect of disease prevention and health promotion. The increasingly complicated U.S. health care system became inundated with paperwork and "red tape," which was estimated to be two to four times as much as in other Western industrialized nations. And the scientific and technological advances of medicine created a host of unprecedented ethical issues: the meaning of life and death; when and how to turn off an artificial life-support device; how to preserve patient autonomy and to obtain proper informed consent for clinical care or research trials.

To most observers, however, the most critical problem of the health care system was soaring costs. In the fifteen years following the passage of Medicare and Medicaid, expenditures on health care in dollars increased

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nearly sixfold, and health care costs rose from 6 percent to 9 percent of the country's gross domestic product (GDP). Lee Iacocca, while president of Chrysler in the late 1970s, stunned many Americans by pointing out that U.S. automobile companies were spending more per car on health premiums for workers than for the steel that went into the automobiles. Public opinion polls of the early 1980s revealed that 60 percent of the population worried about health care costs, compared with only 10 percent who worried about the quality of care. Millions of Americans became unwillingly tied to their employers, unable to switch to a better job because of the loss of health care benefits if they did so. Employers found their competitiveness in the global market to be compromised, for they were competing with foreign companies that paid far less for employee health insurance than they did. In the era of the soaring federal budget deficits of the Reagan administration, these problems seemed even more insurmountable.

The Managed Care Era, 1985–Present

In the mid-1980s, soaring medical care costs, coupled with the inability of federal regulations and the medical profession on its own to achieve any meaningful cost control, led to the business-imposed approach of "managed care." "Managed care" is a generic term that refers to a large variety of reimbursement plans in which third-party payers attempt to control costs by limiting the utilization of medical services, in contrast to the "hands off" style of traditional fee-for-service payment. Examples of such cost-savings strategies include the requirement that physicians prescribe drugs only on a plan's approved formulary, mandated preauthorizations before hospitalization or surgery, severe restrictions on the length of time a patient may remain in the hospital, and the requirement that patients be allowed to see specialists only if referred by a "gatekeeper." Ironically, the first health maintenance organization, Kaiser Permanente, had been organized in the 1930s to achieve better coordination and continuity of care and to emphasize preventive medical services. Any cost savings that were achieved were considered a secondary benefit. By the 1980s, however, the attempt to control costs had become the dominant force underlying the managed care movement.

Unquestionably, the managed care movement has brought much good. It has forced the medical profession for the first time to think seriously about costs; it has encouraged greater attention to patients as consumers (for example, better parking and more palatable hospital food); and it has stimulated the use of modern information technologies and business practices in the U.S. health care system. In addition, the managed care movement has encouraged physicians to move many treatments and procedures from hospitals to less costly ambulatory settings, when that can be done safely.

However, there have been serious drawbacks to managed care that in the view of many observers have outweighed its accomplishments. Managed care has not kept its promise of controlling health care costs, and in the early years of President George Walker Bush's administration, the country once again faced double-digit health care inflation. In the view of many, the emphasis on cost containment has come at the erosion of the quality of care, and the dollar-dominated medical marketplace has been highly injurious to medical education, medical schools, and teaching hospitals. Managed care has also resulted in a serious loss of trust in doctors and the health care system—creating a widespread fear that doctors might be acting as "double agents," allegedly serving patients but in fact refusing them needed tests and procedures in order to save money for the employing organization or insurance company. As a result, the twenty-first century has opened with a significant public backlash against managed care and a vociferous "patients' rights movement."

Ironically, many of the perceived abuses of managed care have less to do with the principles of managed care than with the presence of the profit motive in investor-owned managed care organizations. Nonprofit managed care organizations, such as Kaiser Permanente, retain about 5 percent of the health premiums they receive for administrative and capital expenses and use the remaining 95 percent to provide health care for enrollees. For-profit managed care companies, in contrast, seek to minimize what they call the "medical loss"—the portion of the health care premium that is actually used for health care. Instead of spending 95 percent of their premiums on health care (a "medical loss" of 95 percent), they spend only 80, 70, or even 60 percent of the premiums on health services, retaining the rest for the financial benefit of executives and investors. Some astute observers of the U.S. health care system consider the for-profit motive in the delivery of medical services—rather than managed care per se—the more serious problem. However, since 90 percent of managed care organizations are investor-owned companies, the for-profit problem is highly significant.

Future Challenges

The U.S. health care system has three primary goals: the provision of high-quality care, ready access to the system, and affordable costs. The practical problem in health care policy is that the pursuit of any two of these goals aggravates the third. Thus, a more accessible system of high-quality care will tend to lead to higher costs, while a low-cost system available to everyone is likely to be achieved at the price of diminishing quality.

Certain causes of health care inflation are desirable and inevitable: an aging population and the development of new drugs and technologies. However, other causes of soaring health care costs are clearly less defensible. These include the high administrative costs of the U.S. health care system, a litigious culture that results in the high price of "defensive medicine," a profligate American practice style in which many doctors often perform unnecessary tests and procedures, the inflationary consequences of having a "third party" pay the bill (thereby removing incentives from both doctors and patients to conserve dollars), and the existence of for-profit managed care organizations and hospital chains that each year divert billions of dollars of health care premiums away from medical care and into private wealth. Clearly, there is much room to operate a more efficient, responsible health care delivery system in the United States at a more affordable price.

Yet the wiser and more efficient use of resources is only one challenge to our country's health care system. In the twenty-first century, the country will still face the problem of limited resources and seemingly limitless demand. At some point hard decisions will have to be made about what services will and will not be paid for. Any efforts at cost containment must continue to be appropriately balanced with efforts to maintain high quality and patient advocacy in medical care. Better access to the system must also be provided. Medical insurance alone will not solve the health problems of a poor urban community where there are no hospitals, doctors, clinics, or pharmacies. Lastly, the American public must be wise and courageous enough to maintain realistic expectations of medicine. This can be done by recognizing the broad determinants of health like good education and meaningful employment opportunities, avoiding the "medicalization" of social ills like crime and drug addiction, and recognizing that individuals must assume responsibility for their own health by choosing a healthy lifestyle. Only when all these issues are satisfactorily taken into account will the United States have a health care delivery system that matches the promise of what medical science and practice have to offer.

BIBLIOGRAPHY

Fox, Daniel M. Health Policies, Health Politics: The British and American Experience, 1911–1965. Princeton, N.J.: Princeton University Press, 1986.

Fuchs, Victor R. The Health Economy. Cambridge, Mass.: Harvard University Press, 1986.

Gray, Bradford H. The Profit Motive and Patient Care: The Changing Accountability of Doctors and Hospitals. Cambridge, Mass.: Harvard University Press, 1991.

Hiatt, Howard H. America's Health in the Balance: Choice or Chance? New York: Harper and Row, 1987.

Ludmerer, Kenneth M. Time to Heal: American Medical Education from the Turn of the Century to the Era of Managed Care. New York: Oxford University Press, 1999.

Lundberg, George D. Severed Trust: Why American Medicine Hasn't Been Fixed. New York: Basic Books, 2000.

Mechanic, David. Painful Choices: Research and Essays on Health Care. New Brunswick, N.J.: Rutgers University Press, 1989.

Rodwin, Marc A. Medicine, Money, and Morals: Physicians' Conflicts of Interest. New York: Oxford University Press, 1993.

Rosen, George. The Structure of American Medical Practice, 1875–1941. Edited by Charles E. Rosenberg. Philadelphia: University of Pennsylvania Press, 1983.

Rosenberg, Charles E. The Care of Strangers: The Rise of America's Hospital System. New York: Basic Books, 1987.

Starr, Paul. The Social Transformation of American Medicine: The Rise of a Sovereign Profession and the Making of a Vast Industry. New York: Basic Books, 1982.

Stevens, Rosemary. In Sickness and in Wealth: America's Hospitals in the Twentieth Century. New York: Basic Books, 1989.

Kenneth M.Ludmerer

See alsoHealth and Human Services, Department of ; Medicare and Medicaid .

Political Issues

Health Care

Throughout much of the 1990s, health care was a political issue. Calls for reform came from across the political spectrum. Although most people agreed that something needed to be done to hold down spiraling costs and to provide better health care coverage for the uninsured, there was no agreement on how reform might be implemented. In 1990 the bipartisan Pepper Commission proposed creating two new programs to address the crisis. One program would have provided basic health insurance to those currently uninsured. Employer mandates would have required employers to either provide health insurance for their employees or to pay into a government fund to provide the insurance. Another program would have underwritten the costs of long-term care. The annual cost of the two programs was estimated at $66.2 billion. Neither program, however, was passed into law. A revised reconciliation budget was passed and signed into law in 1990 (HR 5835), which reduced spending on Medicare by $44.2 billion over five years. Most of the reduction, $34 billion, was achieved by lowering payments to providers. The rest came from out-of-pocket increases for beneficiaries. Senate supporters of rural hospitals were concerned that such institutions were absorbing a disproportionate share of the reduction. In 1991 more than three dozen health care reform bills were introduced in Congress. None of them were acted upon during the year. After extensive lobbying by the Bush administration Congress passed restrictions on the ways states could raise funds to pay for their share of Medicaid. Restrictions were placed on the amount of revenue that could be raised from taxing providers, "voluntary" donations from providers were banned as a source of future funding, and a permanent cap of 12 percent of expenditures was placed on the amount states could pay to hospitals that treated a "disproportionate share" of Medicaid patients.

New Reform Plans

In 1992 health care became a major election issue. In February President George Bush presented a health-care reform plan in the form of a ninety-four-page white paper. The plan sought to build on the existing Medicare system, including low-income vouchers, tax incentives, insurance streamlining, and a reduction in the amount of red tape. It promised to cover the more than thirty-five million Americans without health insurance and to stop the spiraling costs for the Medicare system by limiting malpractice awards, increasing preventive health care, encouraging coordinated care, and encouraging healthy life styles. The legislation died in Congress.

Health Security

On 27 October 1993, with much fan-fare, President Bill Clinton introduced his health care reform bill, called the National Health Security Act, which would have reformed the entire U.S. health care system. A key objective was to provide health insurance for all Americans. The plan was to be financed through a combination of savings in existing programs, new revenues, and a series of cross subsidies. It would have required employers to pay for 80 percent of their employees' health insurance, with the government providing subsidies to low-income workers and some small businesses. There would have been a 75¢ per-pack cigarette tax. All insurance would be purchased through regional health alliances that would be under government control. The plan placed controls on the number and distribution of residency programs and required that half of U.S. medical school graduates be trained in primary care fields. After a storm of criticism and harsh attacks from a variety of interests, the plan failed to make its way through Congress.

DATE-RAPE DRUG

Rohypnol, a treatment for insomnia, was legally available in more than sixty countries, and U.S.-bound travelers could bring a three-month supply into the country for their own personal use. On the street the drug acquired such monikers as roofies, rope, the forget pill, and roach. The drug is a sedative related to Valium but is ten times stronger than the latter. At $1 to $5 per pill, it was cheap and therefore popular with teenagers, who liked to combine it with alcohol. Demand for the pills inspired trafficking in the drug into the United States from Colombia and Mexico. Although it was confiscated by police in more than thirty states, its use appeared heaviest in Florida and Texas.

Local authorities soon had a new problem to face besides teenagers abusing the drug at rave parties. Like alcohol, roofies made some of its users fearless and aggressive. The drug also was capable of causing a blackout, with complete loss of memory. Easily spirited into the drink of an unsuspecting victim, rohypnol soon became known as the "date-rape drug." Reports of such attacks popped up throughout the country. Perpetrators were difficult to prosecute, however, as the women often had no recollection of the events that occurred after being administered the drug. One Florida man, who bragged to friends about drugging and raping dozens of women, was convicted and sentenced to eight years in prison. Bar and party patrons were advised to be aware of the drug, and federal authorities considered placing the sleeping pill on tighter restrictions.

Source:

Jean Seligmann and Patricia King, "'Roofies': The Date-Rape Drug," Newsweek, 127 (26 February 1996): 54.

Competing Legislation

More than twenty competing health care bills were introduced in 1993. Among the more important offerings in the Senate were a moderate Republican bill sponsored by John Hubbard Chafee (R-Rhode Island); a conservative Republican bill sponsored by Donald Lee Nickles (R-Oklahoma) and Connie Mack III (R-Florida); and a bipartisan bill sponsored by John Berlinger Breaux (D-Louisiana) and David Ferdinand Durcnberger (R-Minnesota). On the House side, proposals included a single-payer plan sponsored by James A. McDermott (D-Washington), and bipartisan bills sponsored by James Hayes Shofner Cooper (D-Tennessee) and Frederick Lawrence Grandy (R-Iowa) as well as by Roy Roland (D-Georgia) and Michael Bilirakis (R-Florida). The House Republican bill garnered the most votes, but none of the legislation passed. The omnibus deficit-reduction bill of 1993 enacted increased reimbursement for primary care physicians while cutting reimbursement for specialists, cuts to hospitals for overhead costs, attempts to reduce loopholes in the system, and increased spending for children's health care. The bill cut Medicare by $62.9 billion and Medicaid by $7.1 billion over five years.

Continuing Debate

In 1994 the debate over the various health plans continued, as Senators McDermott (D-Washington) and Paul David Wellstone (D-Minnesota) introduced a single-payer plan modeled after that utilized in Canada. Representative Fortney Hillman "Pete" Stark Jr. (D-California), offered a plan that differed from the one offered by the president by mandating tight budget controls over health care costs. Plans put forward by Nickles, Mack, Robert Joseph "Bob" Dole (R-Kansas), and William Philip "Phil" Gramm (R-Texas) called for substantially less government involvement. On 8 November the Republicans won control of both the House and Senate. Many attributed this change in control as a rejection of the Health Security Act. In 1995 political wrangling continued unabated. The Republicans refused to pass the Clintons' bill, and the President vetoed the Republican Medicare Preservation Act. Republicans blamed Democrats for being indifferent to the impending bankruptcy of Medicare and Democrats blamed Republicans for trying to make deep spending cuts at the expense of senior citizens. A minor managed-care pilot program within Medicaid was passed by Congress and signed into law by the president.

Stagnation

In 1996 most major reform efforts continued to stagnate. The Health Insurance Portability and Accountability Act (HIPAA) was passed into law. In mid 1997 the logjam was finally broken. Congress by a large margin passed a Balanced Budget Act (BBA), with Administration support. It included $112 billion in Medicare cuts over five years, mostly in payments to hospitals, home-health services, and other providers. Several managed-care options were introduced into Medicare with the objective of increasing choices to seniors. The measures were thought to be a short-term fix, delaying the expected depletion of the Medicare Part A trust fund by several years. The package expanded Medicare benefits to include coverage of preventive-health measures such as cancer screening and imposed tough anti-fraud measures. The BBA included the Children's Health Insurance Program (CHIP), which allocated $23 billion to allow states to provide coverage for children whose families earned up to 300 percent of the official poverty level. This coverage could be either through Medicaid or through another program subject to HCFA approval. The balanced budget bill established a seventeen-member national bipartisan commission on the future of Medicare. It was unable, however, to report back to Congress by its 1 March 1999 deadline. The members could not muster the required eleven votes needed even to bring a recommendation.

Medicare

In January 1998 President Clinton proposed expanding Medicare to displaced workers and retirees ages fifty-five to sixty-four on the basis that these groups often found it hard to obtain private health insurance. The proposal was not adopted. The following year he proposed a Medicare drug benefit, but this measure also was not adopted. Revised projections from the Congressional Budget Office showed that Medicare spending had slowed much more than Congress had intended, dropping at a rate of $206 billion rather than $115 billion. Congress passed a bill late in 1999, inserted into the fiscal year 2000 omnibus budget bill, which granted some relief to those institutions hardest hit by the BBA. It became law on 29 November 1999, and provided $16 billion in relief over five years and $27 billion over ten years. For all of the legislative activity, by the end of the decade the U.S. system of private insurance and market-driven health care remained unchanged. Tinkering with funding, however, served to prolong the solvency of the Medicare Trust Fund.

Sources:

Joel D. Howell, Technology m the Hospital: Transforming Patient Care in the Early Twentieth Century (Baltimore: Johns Hopkins University Press, 1995).

Health Care Debate

Major Debate

Health-care reform was one of the first and most divisive major-policy initiatives of the Clinton administration. Health care first became a public policy issue for Americans after World War II, when President Harry S Truman advocated national health insurance. The American Medical Association (AMA), however, vigorously opposed it, and it was not until 1965 that Medicare and Medicaid were finally established, covering retired persons and those on welfare, respectively. The remainder of the population was still responsible for paying for its own health care either through employers or out-of-pocket. The working poor were most at risk under these conditions because they did not qualify for Medicaid and generally did not work for employers that offered medical insurance. From the 1960s to the 1980s, health-care costs continued to rise because of inflationary trends and technological advances. By the 1990s even employers who furnished health-care plans found it difficult to continue to provide the level of protection to which workers had become accustomed without raising copayments and/or lowering benefits. Health maintenance organizations (HMOs) entered into this environment with the promise of lowering insurance costs by focusing on preventive care rather than corrective medicine. Though the premise was sound—save money by preventing expensive health problems—it assumed long-term cost savings that did not necessarily materialize in the short run. Other forms of cost savings had to be found. HMOs pursued efficiency by requiring that nonroutine procedures be authorized by insurance companies before being completed. Family doctors were replaced by medical groups, which lowered over-head but tended to make care impersonal. Despite the reduction in personal attention, costs continued to rise, as did insurance premiums.

Clinton's Task Force

President Clinton perceived that the political environment was ripe for a bold new plan of universal health care for all Americans. He chose the First Lady, Hillary

[This text has been suppressed due to author restrictions]

Rodham Clinton, to take the lead in overhauling the $915 billion health-care system and extending care to thirty-seven million uninsured Americans. Clinton trusted her abilities and she was anxious to make a new role for the First Lady as policy maker. While she had a sharp, analytical mind, it was the mind of a lawyer, not a politician—she made some early and critical mistakes. A blue-ribbon task torce was organized to come up with a health plan, but she chose not to include any representatives from the AMA or the hospital administration field among its 511 members. She also chose to hold meetings in secret. These two decisions left the committee and her open to charges of attempting to undermine the democratic process and covertly promote a socialist agenda. The committee also had problems meeting its deadlines. President Clinton initially imposed a one-hundred-day deadline for the report; however, it was changed when the First Lady's father died. The report finally came out in September 1993 and was introduced into Congress in late October, but it was dead on arrival. The insurance industry and Republican Party had organized a media blitz against the plan, calling it "socialized medicine" and claiming that it would do away with a patient's freedom to choose his or her own doctor.

Health Security Act

The plan was not as bad as its critics charged. It had six major goals: security, comprehensive benefits, cost savings, quality care, individual choice, and paperwork reduction. Security would have been obtained by providing for "portability" of plans. Whenever a person lost or changed jobs, they would be allowed to take their plan to the next job. Comprehensive benefits focused on preventive health and included screenings, physicals, and immunizations, as well as doctor visits, hospital care, emergency services, Laboratory and diagnostic services, prescription drugs, mental-health care, hospice and home-health care, vision and hearing care, and children's dental care. It was projected that the plan would have been funded through employer and employee contributions, Medicare and Medicaid savings, federal taxes, savings through paper-work reduction, and fraud prevention. The plan was ambitious in its coverage and much too optimistic in its cost savings, particularly those it projected through Medicare and Medicaid. Ultimately, the possible bene-fits of the plan did not matter. After being introduced into Congress, it was assigned concurrently to several committees that held hearings over the next year. Parts of the plan eventually found their way into law, albeit in a different form, but most simply died in committee. Even President Clinton gave up supporting it, realizing it was a lost cause.

Reform Derailed

The failure of health-care reform was a classic example of what happens to public policies that have diffuse benefits and concentrated costs. The benefits of health-care reform would have been spread marginally over the whole population and would only be felt if someone were seriously ill. Since the probability of serious illness for any individual is unknown, the average person was not motivated to become politically active in the debate. Groups bearing the costs, for example, the doctors, hospitals, and insurance companies, had well-organized, well-heeled, experienced lobbyists who played on the fears of the weak and old. Even the American Association of Retired Persons (AARP), which had initially supported Clinton's program, switched sides when its members began to fear that they would lose the option to choose their own doctors and other health-care providers. Without a strong support system among the public, lawmakers were unwilling to risk their political careers on the controversial proposal. Though a failure as legislation, the debate over health care continued throughout the decade.

Sources:

"The Health Security Act of 1993," White House Electronic Publications, 20 September 1993, Internet website.

Frank Maranote, "In Sickness or in Health: Hillary Takes Charge," Hillary Clinton Quarterly, Internet website.

Bernard D. Reams Jr., ed., Health Care Reform, 1993-1994: The American Experience: Clinton and Congress—Law, Policy, and Economics: A Legislative History of the Health Security Act (Buffalo, N.Y.: Hein, 1996).

health care n. see primary care, secondary care, tertiary care.