This important collection of essays, originating in a 1989 conference on the disadvantaged in American health care, provides incisive commentary on U.S. health care policy and politics. Examining public responses to health crises and analyzing the political logic of the American community, this volume charts the immobility of U.S. health policy in recent years and points to its disastrous consequences for the 1990s.
Focusing on the particular needs of disadvantaged groups--the elderly, children, people with AIDS, the mentally ill, the chemically dependent, the homeless, the hungry, the medically uninsured--these essays develop strong policy statements. The authors describe the growth in U.S. health care programs, from Kerr-Mills to Medicare, Medicaid, and subsequent revisions, and stress the serious omissions resulting from incremental policy expansion, both in identifying disadvantaged groups and in implementing programs. They report the weakness of the U.S. health care system compared to systems of other technologically developed countries.
Contributors. Deborah A. Stone and Theodore R. Marmor, Judith Feder, Alice Sardell, Bruce C. Vladeck, Michael Lipsky and Marc A. Thibodeau, Daniel M. Fox, William E. McAuliffe, M. Gregg Bloche and Francine Cournos, Lawrence D. Brown, James A. Morrone
Health Policy and the Disadvantaged
By Lawrence D. BrownDuke University Press
Copyright © 1991 Duke University Press
All rights reserved.
ISBN: 978-0-8223-1142-3Contents
Acknowledgment,
Introduction,
References,
Health Care of the Disadvantaged: The Elderly,
The financial burden of out-of-pocket expenses,
The risks of cost containment,
The limits to "self-financing",
Expanding Medicare's protection: Long-term care,
References,
Child Health Policy in the U.S.: The Paradox of Consensus,
Introduction,
Child health policy at the federal level: From the Progressive era to the Reagan "revolution",
Child health on the policy agenda in the 1980s: The expansion of Medicaid eligibility,
The limitations of the Medicaid expansions,
Child health on the governmental agenda: The framing of the issue,
Beyond Medicaid expansion: Proposals for financing and restructuring health care delivery,
Child health legislation for fiscal years 1990 and 1991,
Child health policy and health care politics: Speculation on the future,
Conclusion,
References,
Health Care and the Homeless: A Political Parable for Our Time,
The homeless population,
Homelessness and health,
Health services to the homeless,
The politics of homelessness,
The politics of studying homelessness,
References,
Domestic Food Policy in the United States,
Introduction,
Development of food policies,
Ongoing issues,
Directions for the future,
References,
Chronic Disease and Disadvantage: The New Politics of HIV Infection,
The politics of AIDS to 1989,
Perceiving HIV infection as a problem of the disadvantaged,
Policies for HIV infection among the disadvantaged,
The future of policy for HIV and the disadvantaged,
References,
Health Care Policy Issues in the Drug Abuser Treatment Field,
Legalization of drugs of abuse,
Policy issues in the public sector,
Policy issues in the private sector,
Conclusions,
References,
Mental Health Policy for the 1990s: Tinkering in the Interstices,
Introduction,
Identifying the chronic and disabled mentally ill,
The tragic incompleteness of "deinstitutionalization" policy,
A failure of empathy,
Clinical opportunities and political possibilities,
Conclusion,
References,
The Medically Uninsured: Problems, Policies, and Politics,
Who are the uninsured?,
What can be done?,
Is change imminent?,
Conclusions,
References,
The Deconstructed Center: Of Policy Plagues on Political Houses,
Epilogue: Tales of Trouble,
References,
Index,
Contributors,
CHAPTER 1
Health Care of the Disadvantaged: The Elderly
Judith Feder
Abstract. This chapter explores threats to the maintenance and expansion of public commitment to financing health care for the elderly. Threats come from rising costs that increase financial burdens, especially on low-income elderly; efforts to contain costs that may undermine benefits; and financing initiatives that treat the elderly as the sole revenue source for addressing problems in that age group. A review of these threats provides lessons not only for sustaining and improving health care for the elderly, but also for policy toward equally or more disadvantaged groups.
Relative to other population groups considered in this volume, the elderly are decidedly advantaged. Unlike others, they are the beneficiaries of a universal, publicly financed health insurance system—Medicare—that pays their medical bills, regardless of their incomes, and assures them access to mainstream medical care. Furthermore, as a large and organized constituency that votes, the elderly are politically advantaged. That advantage is nowhere more evident than in the budget battles of the 1980s, which left Medicare and social Security relatively unscathed while other social programs were decimated.
Political commitment to health care for the elderly does not mean the elderly are not deserving of special attention. Without government's commitment, the elderly would be sorely disadvantaged, given their considerable health care needs. And despite government's commitment, many of their needs, most especially in long-term care, go largely untouched.
However, questions about health care policy toward elderly people are somewhat different from questions asked for other disadvantaged groups. For others, the major question is whether and how to establish adequate financing for health care needs; for the elderly, the primary question is whether the current public commitment can be sustained and extended. This paper will explore that question, first by examining threats to government protection of the elderly that emerged in the 1980s, and then by considering how experience with existing programs may inhibit expansion to cover long-term care.
Despite the existence and even expansion of the Medicare program in recent years, Medicare's protection has been eroded by the continuing and growing financial burden of costs the program does not cover, by efforts to control public expenditures, and by innovations in financing—"self-financing"—that treat the elderly population as the only appropriate revenue source for solving problems in their age group.
The politics and policy associated with these developments not only have implications for Medicare's survival and improvement but also offer the following lessons, which go beyond the elderly to policy toward equally or more disadvantaged groups: (1) efforts to assure universal, non-means-tested programs should not ignore the fact that provision of adequate protection must take income into account; (2) cost containment designed to make and keep social programs affordable should be carefully designed and monitored so that preoccupation with costs does not overwhelm commitment to benefits; and (3) segmentation of the population into distinct "problem" groups should not become a segmentation of financing sources that undermines basic principles of insurance and social justice.
The financial burden of out-of-pocket expenses
Medicare was established in 1965 to assure elderly people affordable health insurance protection. Without insurance, medical costs impeded many people's access to care and constituted a sizable financial burden to those who received care. Medicare aimed to remedy these problems through a government insurance program that paid the bulk of hospital and physician bills for almost all the elderly, at rates set to reflect what hospitals cost and what physicians charged.
There is little doubt that with these policies, Medicare contributed to a marked improvement in access to care for the elderly, to the increased sophistication of that care (through support of improved technology), and (though there is more debate on this subject) to longer life expectancy for elderly people. However, Medicare never eliminated the elderly's responsibility to pay for their medical care. Beneficiaries pay a premium to finance a portion of their physician services and pay cost sharing on both physician and hospital care. As health care costs have risen (in part because of Medicare's generous policies toward provider payment), the burden of these payments has risen as well.
Increases in the burden of cost sharing under Medicare date from the beginning of the Medicare program and, for the most part, represent the unintended...
