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An Abbreviated History of American Health Politics Dr. J. Hughes Bioethics and Public Policy Trinity College – Summer 2010. Policy Analysis Models. Who gets what and why Inputs: influences on government Process: the legislative bargaining and maneuvering - PowerPoint PPT Presentation
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An Abbreviated History of American Health Politics
Dr. J. HughesBioethics and Public Policy
Trinity College – Summer 2010
Policy Analysis Models
Who gets what and why
Inputs: influences on government
Process: the legislative bargaining and maneuvering
Outputs: decisions, actions and implementation
Type of Explanations
Government as rational actorPopular rule through
elections/rep elitesPolitical bargaining/
Interest groupsAmerican political cultureLegislative processElite ruleMarxist FunctionalismClass Struggle Marxism
Dimensions of Power
Coercive: A and B fight, B loses
Remunerative: A buys B’s consent
Normative: A convinces B that A’s way is the only way
Nondebates: A keeps B from ever thinking about what she wants
"Democratic Culture"
The Jacksonian compromise between capitalism and democracy
Domestic Medicine The Medical Counterculture
– Thomsonians, homeopaths– What is homeopathy (3min)
Professional Medicine – AMA founded 1847
Germ Theory of Disease
1867 - Joseph Lister publishes On the Antiseptic Principle in the Practice of Surgery, showing that disinfection reduces post-operative infections.
1879 - Pasteur demonstrates anthrax vaccine
1882 – Koch demonstrates TB & cholera micro-organisms
1885 – Pasteur develops rabies vaccine 1916 - Polio epidemics break out,
continue for decades 1918-1919 - Flu pandemic kills 15
million people worldwide, 600,000 in U.S.
Allopathic medicine triumphs
1910 – Flexner ReportHospitals become
centers for healingAMA becomes
powerful guild
Abraham Flexner
Alternative: Social medicine
Role of poverty, housing and education
Growth of social insurance in Europe
John Snow and the removal of the Broad Street pump handle (8 min video)
John Snow
Progressives and the AALL
Theodore Roosevelt 1901 -- 1909 AALL Bill 1915 AMA supported AALL Proposal AFL opposed AALL Proposal Private insurance industry
opposed AALL Proposal WWI and anti-German fever Why did the Progressives fail?
1930s – Health Care in Crisis
Blue Cross and Blue Shield get started
FDR's first attempt at NHI -- failure to include in the Social Security Bill of 1935
Food, Drug and Cosmetic Act– FDA given control over drug safety
– Establishes class of drugs available by Prescription
FDR's second attempt at NHI -- Wagner Bill, Nat. Health Act of 1939
1940s – Building Modernity
War, trauma and penicillin1946 – Hill/Burton Act1946 - British Nat. Health
ServiceWagner-Murray-Dingell Bills 1948 - Truman's SupportGrowth of private insurers
1965 – Medicare/Medicaid
Medicare A: Hospital costs, paid for with payroll tax
Medicare B: Supp insurance for docs & outpatient
Medicaid: federal-state program for the poor, all hospital, doc, lab, home health and nursing home care
Expected goal – universal health coverage in 20 years No fee schedules for docs or hospitals Expected 1990 cost: $10 billion Actual 1990 cost: $180 billion 1969 – Canadians enact Nat. Health Insurance
1970s – Costs spur innovation
Costs begin to riseGrowth of bureaucracyGrowth of medical specialists1973 – Nixon passes HMO Act;
provided subsidies and exempted from regs
1972-1979 Ted Kennedy’s campaign for NHI
1980s – Managed Care
DRGs Growth of Managed care Growing interest among
employers in controlling costs
Capitation of physician payment
Growth in size of physician groups
Growth of for-profit institutions Selective contracting Price competition Mergers and acquisitions: Hospital Corporation of America Vertical and horizontal integration HMOs for Medicaid and Medicare
Managed Care Types
Type of Health Plan
HMOs v. PPOs (1min)HMO vs POS vs PPO (4min)
1990-1994 – Clinton Effort
Harris Wofford elected on “single-payer” platform
1994 Clinton Health Plan– Committee of 500– Managed competition
Clinton’s Plan
ConsumerChoice
ConsumersVouchers Health Alliances
Producing report cards on- benefits and access- pt satisfaction/ disenrollment- clinical outcomes- cost
ReportCards
Plan A Plan B Plan C Plan D
1994-2008
1996: HIPAA – patient info privacy1997: CHIPS – subsidized children’s
insurance1997 Part C: Medicare Advantage plansStates: Patient Bill of Rights2006: Part D: Prescription Drug plans
Reform Support Was High
Majorities Favored Elements
2009 – Obama’s Reform
Frontline history 60min Compromises:
– Pharmaceutical prices
– Public option
Individual MandateExpansion of Medicaid and
subsidiesHealth Insurance ExchangesNo pre-existing condition &
high-risk pool
But, we are still the most expensive
Total health spending 17% of GDP in the United States in 2009, highest in OECD
Canada and France about 10%OECD avereage 8.6%$2,000,000,000,000 a year$1 trillion increase in health care
spending over the last decade
As a Percent of Family Income
Health Care Costs per Capita
1970 1980 1990 2003
United States $352 $1,072 $2,752 $5,711
Switzerland $351 $1,031 $2,029 $3,847
Norway $141 $665 $1,393 $3,769
Iceland $163 $703 $1,593 $3,159
France $205 $697 $1,532 $3,048
Belgium $148 $636 $1,341 $3,044
Canada $299 $783 $1,737 $2,998
Austria $193 $770 $1,328 $2,958
Netherlands NA $755 $1,435 $2,909
Australia $252 $691 $1,306 $2,886
Sweden $312 $944 $1,589 $2,745
Denmark $384 $927 $1,522 $2,743
Ireland $117 $519 $794 $2,455
United Kingdom $163 $480 $987 $2,317
Italy NA NA $1,387 $2,314
Japan $149 $580 $1,116 $2,249
Finland $191 $590 $1,419 $2,104
Cost per Year per Capita
Cost Trends 1980-2004
Public/Private Expenditures
More than 75% of health spending is through public insurance in other countries, just half in US
Putting Off Care Because of Cost
Consequences
Causes of Health Care Inflation
TechnologyAging of population, longer lifespanLack of effective competition or global
budgeting
Administrative Overhead
Admin Staff per Patient
Life Expectancy
Spending & Life Expectancy
Infant Mortality
Obesity
Mental Illness
OECD 2009 - http://dx.doi.org/10.1787/538536332624
Uninsured in the US
The problem of the uninsured is continuing to grow. The federal government estimates that over 45 million individuals lacked health insurance coverage of any kind during 2008.
Source: SHADAC estimates from the Current Population Survey Annual Social and Economic Supplements, 1995-2008. Note: 1995-2003 data are adjusted for Census correction announced in March 2007.
Future Trends
Financial Viability of Medicare and Medicaid
Pressures for universal coverage and cost containment
Emerging technologies could:– dramatically reduce or expand costs, – eliminate, create or transform professions, – enable consumer choice and quality
measurement
IDEOLOGIES AND MARKETS
Democracy
Liberty/AutonomySolidarity/BeneficenceEquality/Justice
Autonomy/Liberty
Negative freedom from coercionPositive: freedom to Exit and Voice Patient autonomy and informed
consent Right to refuse
Beneficence/Solidarity
Positive rights to demand entitlements of citizenship
Should access to basic health care be a right?
Which services should health care providers be obligated to provide regardless of risks or their moral or economic reservations?
Justice/Equality
Equal opportunitiesEquality before the lawThe right to control institutions
through equal sufferage
Market vs. State
Exit vs. VoiceEfficiency vs. EqualityFlexibility vs. AccountabilityResponsibility vs. SolidarityFreedom from vs. Freedom to
Rights
Dems, liberals, women, the young, seculars support healthcare rights
Principles for allocation of scarce medical interventions
Emanuel et al’s Proposal
GOVERNMENT IN HEALTH CARE
TransNational Agencies
UN: World Health OrganizationForeign AidInternational Family PlanningRefugee Assistance and Famine ReliefWTO and Transnat. Treaties on
Environmental Protection
Executive Branch
Health and Human Services The Secretary of Health and Human Services (OS) Administration for Children and Families (ACF) Administration on Aging (AOA) Agency for Healthcare Research and Quality (AHRQ) Agency for Toxic Substances and Disease Registry (ATSDR) Centers for Disease Control and Prevention (CDC) Food and Drug Administration (FDA) Health Care Financing Administration (HCFA) Health Resources and Services Administration (HRSA) Indian Health Service (IHS) Program Support Center (PSC) Substance Abuse and Mental Health Services Administration (SAMHSA) National Institutes of Health (NIH)
National Institutes of Health
Office of the Director (OD) Nat. Cancer Institute (NCI) Nat. Eye Institute (NEI) Nat. Heart, Lung, and Blood Institute (NHLBI) Nat. Human Genome Research Institute
(NHGRI) Nat. Institute on Aging (NIA) Nat. Institute on Alcohol Abuse and Alcoholism
(NIAAA) Nat. Institute of Allergy and Infectious Diseases
(NIAID) Nat. Institute of Arthritis and Musculoskeletal
and Skin Diseases (NIAMS) Nat. Institute of Child Health and Human
Development (NICHD) Nat. Institute on Deafness and Other
Communication Disorders (NIDCD) Nat. Institute of Dental and Craniofacial
Research (NIDCR) Nat. Institute of Diabetes and Digestive and
Kidney Diseases (NIDDK)
Nat. Institute on Drug Abuse (NIDA) Nat. Institute of Environmental Health Sciences
(NIEHS) Nat. Institute of General Medical Sciences
(NIGMS) Nat. Institute of Mental Health (NIMH) Nat. Institute of Neurological Disorders and
Stroke (NINDS) Nat. Institute of Nursing Research (NINR) Nat. Library of Medicine (NLM) Warren Grant Magnuson Clinical Center (CC) Center for Information Technology (CIT) Nat. Center for Complementary and Alternative
Medicine (NCCAM) Nat. Center for Research Resources (NCRR) John E. Fogarty InterNat. Center (FIC) Center for Scientific Review (CSR)
Congressional Health Policy Committees
Senate Committee on Health and Labor
House Ways and Means Committee
Lobbyists
Other Federal Health Policy
Supreme Court: Rulings on Assisted Suicide, Oregon scheme, etc.
EPACHAMPUS
State and Local
State – State Legislative Committees– State Depts of Health– State Depts of Insurance Regulation– State Depts of Professional Regulation
Municipal and County Depts of HealthMicropolitics
– Hospitals
COMPARATIVE SYSTEMS
American Exceptionalism: Lack of Global Budgeting
Year in which elected representatives enacted universal
health care:
Germany1883
Switzerland 1911
New Zealand 1938
Belgium 1945
United Kingdom 1946
Sweden 1947
Greece 1961
Japan 1961
Canada 1966
Denmark 1973
Australia1974
Italy 1978
Portugal 1979
Spain 1986
South Africa 1996
Causes of American Exceptionalism
Libertaran valuesWeak federal structuresRacial and ethnic diversityLack of a strong socialist
movement
Over-Use of High-tech, Under-Use of Public Health
Over-specialization of physician labor force
Underuse of non-physician providersToo Few Primary Care DocsUnderinvestment in public health and
primary care
Lack of Clear Priorities: Rationing
Priority-Setting in National Systems
British Informal RationingThe Oregon Approach
Lack of Adequate Competition
Third Party Payment Makes No One Accountable
Health Purchasing Decisions are Too Complex
Canadian National Health Insurance (“Medicare”) 1946 - Swift Current, Sask. 1947 - Saskatchewan 1957 - Liberal government of Louis St. Laurent introduces a national
hospital insurance program. 1965 - Royal Commission headed by Emmett Hall calls for a universal
and comprehensive national health insurance program 1966 - Parliament enacts Bill 227, creating a national health insurance
system 1977 - Trudeau Liberals replaces from 50:50 cost-sharing with 5yr block
payments 1978 - Doctors begin “extra-billing” to raise their incomes above the
levels provided through public insurance schemes (1980-84) 1980-84 - CHC calls for Canada’s health care to reflect 5 principles:
public and non-profit; comprehensive; universal; portable; and accessible.
1984 - Canada Health Act
British National Health Service
1942 - Beveridge report 1946 - The NHS Bill1948 – Implementation1980s – Thatcher reform attempts1991 – NHS Trusts2000 – Blair examining reforms
Hospital Use per Capita in OECD, 2004
Hospital Costs per Day in OECD, 1996
Hospital Days
Hospital Days, MI & Childbirth
Doctor Visits per Capita
Physician Incomes in OECD, 1996
• After adjusting for inflation, physician incomes increased most rapidly in the United States between 1965 and 1991
Mean Physician Income 1992-1996
Managedcaremag.com
In 1973, the average income for physicians in private practice was $137,000, which was 4 times greater than the median income.
In 1997, the average income for physicians in private practice was $200,000, which was 10.6 times greater than the median U.S. income of $18,800.
MRIs in the OECD, 2006
INSURANCE AND MANAGED CARE
Basic Ideas of Insurance
Risk poolsMeans testingRisk-rating and Community-ratingGuaranteed Issue, Renewability and
PortabilityPre-Existing ConditionsMandating Coverage
What is Managed Care?
The Industrial Model Changes in Physician PracticeChanges in Physician Payment Exclusion of Expensive ProvidersChanges in Organizations
Changes in Physician Practice
gate-keeping primary-care assignment pre-utilization authorizationutilization reviewdoc, unit, hospital & plan report cardspractice guidelines & critical pathways
Where the Primary Care Docs Will Come From
Nurses, NPs, PAs
Family & General Practitioners
Internists
Retrained Specialists
Quasi-Primary
Primary Specialists
True Specialists
(Oncologists,Cardiologists,Rheumatologists) (Geriatrics, Pediatrics)
Hospital Stays After Childbirth
Dr. Frank (Dartmouth Med School) studied 15,000 infants born in New Hampshire in 1993.
Of those newborns discharged early– 1.61% were re-admitted– additional 2.04% needed emergency care
among those who stayed at least two days, – 1.09% were re-admitted – 1.17% were treated in the emergency room.
The medical costs of all 361 infants who returned to the hospital was $670,000, while savings of discharging the 3600 newborns early was $7.5 million.
Changes in Physician Payment
FFSCapitation“At-risk" capitation Salaried employment
Physician Incentives
Salary
FFSCapitation
At-Risk Capitation
FFS with Ownership of Equipment
Have a Many Patients as Possible, But Do As Little As Possible For Them
Have a Many Patients as Possible, and Do As Much As Possible To Them
Have as Few Patients as Possible, and See Them As Little As Possible
Exclusion of Expensive Providers
PPOs and "economic credentialing"
substitution for physicians: NPs, PAs, etc.
Gatekeeping
Changes in Organizations
integration of all services and payments
shrinking hospitals: more ambulatory care, shorter stays, more home care
The Medical Loss Ratio
Managed Care Models
Staff-Model HMOGroup-Model HMONetwork-Model HMOIndividual Practice Association (IPA)Point of Service (POS)Preferred Provider Organization (PPO)
Alleged Decline of Managed Care
PPOs most popular PPOs contract with panels
of providers who agree to provide medical care and be paid according to a negotiated fee schedule.
Less oversight of services used than for HMOs.
Out-of-network visits more expensive but large numbers of providers often make going outside unnecessary.
HMOs and Preventive Medicine
1. HMOs can't count of being rewarded for long-term investments
2. HMOs (and physicians) don't know how to deliver effective prevention, and to the extent that they have...
3. Effective prevention programs often are as expensive as treating the illness, especially across the life-course
4. Consequently, while there is plenty of evidence that HMOs have reduced tests, procedures and hospitalizations with little negative effect...
5. There is little evidence that HMOs provide more or better preventive medicine
Conclusion: If the only group sure to profit is society as a whole, than the appropriate investor is society.