Health Policymaking in the United
States
1 Health and Health Policy
Health policies affect health→ health affects physical and
mental well-being of the people, orgs, systems→ affects economies
- Definition of health is important because it reflects nation’s values
regarding health, the resources it is willing to utilize
- Health is a function of many variables, or health determinants
Healthy People 2010 determinants= determine health of individuals and
populations
(1) Biology= genetic makeup, family history, problems acquired during life,
diet, smoking, substance use, disabilities, illnesses
(2) Behaviors= individual responses or reactions to internal stimuli and external
conditions…may have reciprocal effect on biology
(3) Social environment= interactions with family, friends, coworkers,
community, housing, presence/absence of violence, personal, religious
beliefs cultural customs, language---their behavior in turn, contribute to
quality of social environment
(4) Physical environment= tangible, plus ozone and radiation which are less
tangible; exposure to toxic substances, irritants, infectious agents---physical
environment can promote health
(5) Policies and interventions= smoking cessation campaigns, mandatory child
restraints/safety belt use, immunization programs, disease prevention
(6) Quality health services= access to quality health care services and information
Health Policies defined:
“Authoritative decisions that pertain to health or influence the pursuit of health,
created through a dynamic public policymaking process at federal, state, and
local levels of government and generally affect or influence groups or classes
of people (physicians, the poor, the elderly, children)…”
U.S. = has few, large health-related policies approached in piecemeal,
incremental approach
Societal traits that affect the basic approach to health in the U.S. :
(Despite all of our differences, these core traits/values we share.)
- High value on individual autonomy, self-determination, and personal privacy
- Widespread (though not universal) commitment to justice for all of its
members
- Deep-seated belief in the potential of technological rescue
- Long-standing obsession with prolonging life with little regard for costs of
doing so
Forms of health policies:
(1) Laws = sometimes called “programs”, preceded by “P.L.”…aimed to achieve
specific objectives
ex. Breast and Cervical Cancer Prevention Act, P.L 106-354
Medicare Program
(2) Rules and Regulations = enacted to guide the implementation of laws; made
in the executive branch of government; proposed and final form are published
in the Federal Register
ex. Proposed changes to Medicare payment system, 2005
quality designations and classifications, re: EPA
(3) Operational decisions = help in the implementation; ex. Operational
protocols and procedures helping those affected by provisions of enacted laws
(4) Judicial decisions = ex. Supreme Court decides not to hear appeal; ruled that
the FDA cannot regulate tobacco
Free market economies= best determine production and consumption of goods and
services; gov intrudes (policy intervention) when private markets fail to
achieve public objectives
An ideal, freely-competitive market is characterized by:
- Buyers and sellers have sufficient information to make informed decisions
- A large number of buyers and sellers participate
- Additional sellers can easily enter the market
- Each seller’s products or services are satisfactory substitutes for those of their
competitors, and
- The quantity of products or services available in the market does not swing the
balance of power toward either buyers or sellers
But since health care “violates” these characteristics……
Patient Protection and Affordable
Health Care Act
(March 2010)
Categories of health policies:
1. Allocative policies – are designed to provide benefits to some distinct group or
class of individuals or organizations at the expense of others to ensure that
public objectives are met… ≈ subsidies that seek to alter demand for or supply
of particular product or services, or to guarantee access to products or services
for certain people
2. Regulatory policies- are designed to influence the actions, behaviors, and
decisions of others, directive…to achieve public objectives
*5 categories of regulatory policies:
- market-entry restrictions
- rate- or price-setting controls on health services providers
- quality controls on provision of health services
- market-preserving controls
- social regulation
Connection between health policy and health:
Policies affect variables called health determinants, which in turn, directly affect
health.
Consider the role of policy in the following determinants:
- Physical environment in which people live and work
- Behavioral choices that people make and the role that biology play in their health
- The social factors that affect people’s health, to include economic circumstances;
socioeconomic position in the society; income distribution within the society;
discrimination based on race/ ethnicity, gender, or sexual orientation; availability
of social networks or social support
- Health services available to people and their access to these services
Health policy in the States
Traditional roles in health policy include:
- Financing or paying for health services for several categories of people (shares
finding of Medicaid with fed gov’t, health care of state employees, teachers)
- Ensuring the public’s health (protection of the environment, safe practices in
workplaces, food service establishments, family planning, communicable
disease control, nutritional counseling)
- Regulating health-related professionals and organizations, including health
insurance organizations and plans (license and regulate various h.c.
professions and h.c.o. through issues like standards of care, accreditation;
HIPAA…)
- Experimenting with comprehensive health reform strategies (states must find
their own solutions- others’ will not apply to individual state’s idiosyncrasies
and unique needs)
2 Impact of Health Policy
Policies are developed as a means to achieve someone’s desires or preferences- no
assumptions about appropriateness or attainability of objectives
Some objectives:
- adding years and quality to life
- Eliminating disparities in health and access to health services
- Improving access to, reducing costs of, and increasing the quality of health
services
- Protecting the nation’s citizens from terrorism
- Removing from the environment, substances and conditions harmful to health
- Improving safety consciousness in highways and potentially dangerous places
- Moderating consumption of food, drink chemicals
- Modifying unsafe sexual behaviors and practices
Health policy and health determinants:
- Physical environment: asbestos, dioxin, excessive noise, ionizing radiation, bio
agents, by-products/wastes of technological growth, ultraviolet radiation from the
sun, radon gas, , lead in paint
- Human behavior and biology: choices about tobacco and alcohol use, diet and
exercise, sexual behavior, violence, genetic predispositions = root factors as
stress, depression, anger, hopelessness which are made worse by economic/social
conditions
= changes in behaviors can chance the pattern of causes of death
- Social factors: chronic unemployment, absence of supportive family structure,
poverty, homelessness, discrimination=
Poor: patchwork of uncoordinated services from public hospitals, local health
departments, clinics; care is episodic with different providers
Affluent: coordinated, continuing, comprehensive health care
- Health services: issues of availability of and access to health services= can be
preventive/acute/chronic/restorative, or palliative
Production of health services depend on resources: money, human resources, and
technology all of which are heavily influenced by health policies which in turn,
impacts directly on individual health
Resources involved in the production and distribution of health services:
• Money- 16% of GDP in 2006; U.S. spends more on health than any other
country but does not deliver the best quality, access, and availability. Higher
prices=more difficult for many people to purchase the service or the insurance to
cover for these services= takes money away from other priorities as education
and homeland security
• Human resources- shortage of nurses at a time of longevity, retiring nurses,
quality of care issues,
• Technology- advances result in better pharmaceuticals, devices, procedures used
in providing health services; better disease understanding at the molecular level
and intervention at the genetic level; funding policies through private and
government R&D; regulatory policies attempts to ensure technology's safety and
efficacy = paradox is ↑ in cost due to ↑ longevity due to use of technology that is
available
Health policy and health-related organizations
Existence and accomplishments of many organizations are affected by health policies (and by
their mission, objectives, leadership) and by external environments (see fig 2.1, p 58)
yields
External Environment Opportunities & Threats
Biological to which the org
Cultural responds with
Demographic Strategies
Ecological
Whose s/w
influence the implementation
Economic future of which
Ethical strategic Organizational requires
Legal choices structure
Political
Psychological
Social
technological
which produce Organizational performance
*consider questions on p 66
Health policy and health-related interest groups:
Consumer-based, practitioner groups, insurance companies, etc. exist because of
their organizational members’ collective interest in policymaking and the
resulting policies in gaining some advantage
Ex. AMA, ACHE, (colleges or academies where membership depends on medical
specialty), ANA ADA, PhRMA, BCBS, and “solidarity groups” like AARP,
AHA, NAACP, NOW …common identity based on shared characteristics are
race, gender, age, connection to a specific disease or condition
3 Context and Process of Health
Policymaking
Structure of decision-making process the same for all policy domains such as health
care, education, defense, taxes, welfare, et cetera
Domains are intertwined because the government must fund, through taxes, services
or programs established by other policies (health and tax policies)--- and $ spent
in one domain have alternative uses in other domains
Political marketplace: parallels economic markets: both involve the
bargaining/negotiation of the exchange of products and services at mutually-
acceptable outcome (what each shall give and take and what cost)
Negotiations in economic exchange situations usually follow: win/win or win/lose
(cooperative or competitive, respectively)
2 general types of issues resolved:
• Tangible resources= what products/services are exchanged for how much money
• Intangibles= felt/appeared to win or lose? competed fairly?
competed effectively? “saved face”?
Negotiations in economic exchange situations:
• Cooperative (win/win) strategy works best when:
- negotiators want to attain fair, reasonable, specific settlement and
both think that this is possible
- sufficient resources are available in the environment (or for the
situation to be redefined) so both can get a win/win outcome
- intangible goals are to establish a cooperative relationship
• Competitive (win/lose) strategy works best when:
- when each wants to get as much as they possibly can; both do not
think win/win is possible
- insufficient resources, or their desire to get as much as possible
makes make win/win impossible
- intangible goal of each negotiator is to beat the other
Operation of political markets:
All public policies are made within the context of political markets
Fundamental differences:
(1) buyers/demanders in economic markets express their preferences by
spending their own money ≈ they reap the benefits of their choices and they
bear the costs of these choices;
(2) costs and benefits of decisions are taken into account over the long run
But: …in political markets, (1) there is no direct linkage between who receives
the benefits and who bears the cost….policy decisions of contemporary
policymakers are influenced by the preferences of current voters, to the
detriment of future generations --- (2) decision-makers (who face periodic
reelection) typically favor policies that provide immediate benefits to their
constituents…as long as the immediate benefits exceed immediate costs
Demanders of health policies:
Those in pursuit of health for themselves or others, or other ends such as economic
advantage
- Individuals do not have the $ or time; negative cost/benefit outcome since no
policy affects single individuals or very small groups
- Organizations have pooled resources, better information available, benefits are
multiplied in scale
- Interest groups= most effective demanders of policies by combining and
concentrating members’ resources (AMA, AARP, PhRMA)
= result arise because in democratic societies, people realize that the opportunities
to achieve particular benefits or outcomes are enhanced through collective
action within the political marketplace, a right granted and protected by the U.S.
Constitution
James Madison (Federalist Papers, 1787) felt interest groups were inherently bad but
that government should not seek to check this activity and instead, set one groups
ambition against the selfish preferences and behaviors of other factions or groups.
Pluralist view of policymaking
As there are so many interest groups, everyone’s interests can be represented by one
or more of them--- to compete and counterbalance, though admittedly, some are
stronger than others
Group theory of politics:
- interest groups provide essential linkages between people and their government
- interest groups compete with others, through counterbalance
- no group is likely to be too dominant--- group with more money might be
counterbalanced by larger numbers in a consumer group
- Competition among interest groups is basically/generally fair
Criticisms:
(1) too many,& have become too influential=drives the government instead of
government working for what is the best for the nation (public interest);
(2) government seems to consider that all interest groups are legit & in trying to
satisfy multiple and conflicting demands, avoids making the difficult right
choices
Elitist view of policymaking
Believe that the real political power in the U.S. is concentrated in the hands of the
very few who control the nation’s key institutions, organizations, and much of
it’s wealth, …and that most interest groups are powerless and ineffectual; the
“big interests” look out for themselves in part by disproportionately influencing,
if not controlling the public policymaking process.
Believe that the “power elite” or “the establishment” acts as a gatekeeper to the
public policymaking process and unless the power elite considers the issue to be
important, the issue does not even get on the policy agenda….resolution mostly
reflect the values, ideologies, and preferences of the governing elite due to their
superior position in society…they shape the formulation and controls the
implementation of policies
Central tenets of the power elite theory
- Real political power resides in a very small number of groups; other groups may
win minor policy victories, but the power elite always prevails on significant
policy issues
- Members of the power elite share a consensus or near-consensus on basic values
that should guide public policymaking: private property rights, preeminence of
markets and private enterprise as the best way to reorganize the economy, limited
government, and the importance of both individual liberty and individualism
- Members of the power elite have a strong preference for incremental changes in
public policy… incrementalism permits time for economic and social systems to
adjust to changes without feeling threatened, with minimal economic dislocation
or disruption and with minimal alternation in the social system’s status quo
- Elites protect their power bases; some limited movement of non-elites into elite
positions is permitted to maintain social stability but only after the non-elites
clearly accept the elites’ consensus values
“tokenism”?
Legislators as suppliers of health policies:
Either members of the U.S. Congress, state legislature, or city councils
- display a mix of public- and self-interest motivations through actions
- will decide depending on whose interest they choose to serve, after calculating
the benefits and costs of their policymaking decisions, and consider who will
reap the benefits and bear these costs
- re-election is an ever-present consideration
- Since policies create winners and losers, best strategy would let the winders win
their victory but not by a huge margin, and therefore cushioning the impact o the
losers.
Example: (scenarios)
Policy to increase health care in rural areas through tax increases might be:
(1) few services at low cost
(2) more services at higher cost
(3) many services at very high cost= solution: meaningful level of service but far
below what could have been provided at a cost below what would have been
required for higher level of service= “winners win more service”; “losers who
have to pay for the extra services will not pay as much” therefore the legislator
maximized his/her net political gain
Executives and bureaucrats as suppliers:
Presidents, governors, mayors, senior public-sector executives offer policies to
legislators in the form of legislative proposals
- May also make policies directly in the form of rules or regulations used to guide
the implementation of laws and in the operational protocols and procedures they
use to operationalize the policies they are responsible for implementing
Difference between executives and legislators:
- Executive branch bears more responsibility for the state of the economy than
legislative branch and is held more explicitly accountable…and since the
economy is tied to budget implications, there are policy repercussions
Career bureaucrats equate well-being of their agencies in terms of size, budgets,
prestige with public interest, though not necessarily true. Career bureaucrats are
very protective of their agencies, evidenced by their relationships with agencies
with legislative oversight (authorization, appropriation, performance review
responsibilities) over them
Judiciary as supplier:
Makes policies whenever the court interprets an ambiguous law, establishes judicial
procedure, or interprets the U.S. Constitution…they influence or direct the
actions, behaviors, and decisions of others
- Responsibilities are more focused narrowly on specific cases or situations and not
as chaotic as in executive and legislative branches
- Role in interpreting the law is at core of its role as policy supplier, to include
power to declare federal and state laws unconstitutional
( interpret, nullify, and apply)
- Federal judges are appointed rather than elected, and the appointments are for
life…therefore are not subject to the same self-interest concerns related to
reelection that other policy-makers face= enhances their ability to act in the
public interest, although judges vary in their personal commitments to this
objective
Power and influence in political markets:
Power- potential to exert influence
Influence- process of successfully persuading others to follow their advice,
suggestion, or order
Legitimate power≈ formal power or authority, derived from relative position in a
social system, organization, or group; exists because it is more advantageous to
assign or ascribe certain powers to individuals, organizations, or groups for tem
to fulfill their duties effectively
Reward power based on ability of one person, organization, etc to reward others
when they comply with preferences regarding decisions and actions, either in pay
increases, promotions, status symbols/perks, office size/location…consumer
groups reward with buying power; in political markets, reward is in the form of
political capital as favors that can be provided, exchanged, or “cashed in”
sometime in the future…coercive power= capacity to withhold rewards or
prevent someone from obtaining desired reward
Expert power derives from possessing expertise valued within the political
marketplace such as problem-solving or performing crucial tasks
Referent power derives from ability to engender admiration, loyalty, and emulation
from others …in policy marketplace, when it pertains to individuals, is called
charismatic power
Ethics in the political marketplace:
Because of human control in the public policymaking process, its operation, as well
as its outcomes and consequences are directly affected by the ethics of those who
participate in the process
Ethics help the way problems are defined, and the way policy solutions are defined
Ethical principles that guide all participants in political markets where policymaking
occurs are: respect for autonomy of other people, justice, beneficence, and non-
maleficence
Ethical principles:
Autonomy- individuals have the right to their own beliefs and values, and to the
decisions and choices that further these beliefs and values; relates to rights of
individuals to independent self-determination regarding how they live their lives
and to their rights regarding the integrity of their bodies and mind…policymaking
influences issues that pertain to privacy and individual choice, including
behavioral or lifestyle choices….no incompatibility between individual’s
autonomy and the government's authority as long as government's authority does
not exceed the limits set by those who are governed…principle depends on
integrity=when participants tell the truth, honor confidences, and keep promises,
the process is more ethically sound than if these things are not done.
Justice- justice is done when a person receives that which he or she deserves;
distributive justice= fairness in the distribution of health-related benefits (those
in need) and burdens (those who endanger) in society--difficult question is “What
is fair?”
3 most popular perspectives on the principle of justice:
- Egalitarian holds that everyone should have access to both the benefits and the
burdens arising from the pursuit of health, and that fairness requires recognition
of different levels of need (ex. Medicare for the elderly, Medicaid for
the poor, removing discrimination to achieve equality)
- Libertarian requires a maximum of social and economic liberty for individuals,
such as policies that favor unfettered markets as the means of distributing the
benefits and burdens associated with pursuit of health
- Utilitarian holds that fairness is best served when public utility is maximized=
greatest good for the greatest number of people (ex. restricting pollution,
ensuring safe workplaces, controlling communicable diseases)
* Principle of justice provides most of the underpinnings for all health
policies=morally defensible=not due to arbitrary or capricious decisions….for
fair and equitable impact…legal system exists in part to ensure that principle of
justice is respected and for appeals
Beneficence- participants in the process act with charity and kindness; that they
overtly seek to do good- but balances benefits and burdens so that nobody
exclusively benefits while burdening others
Non-maleficence- rooted in medical ethics (primum non nocere= first, do no harm);
decisions should minimize harm, and together with ‘beneficence”, seek to ensure
the quality of health services and products
Characteristics of the policymaking process:
- Policymaking is a cyclical process
- Policymaking is influenced by external factors
- Policymaking components are interactive and interdependent
- Policymaking is a highly political process
* Discuss 108, fig 3.2 model of U.S. policymaking process
Characteristics of U.S. policymaking process
• Policymaking is a cyclical process- numerous decisions are reached, but then
revisited as circumstances change and therefore subject to subsequent
modifications
• Policymaking is influenced by external factors- influenced by factors external to
the process itself (open system), one in which the process interacts with and is
affected by, events and circumstances in its external environment (i.e.,
individuals, organizations, interest groups, biological, economic, social, ethical,
legal, technological…)
• Policymaking components are interactive and interdependent- 3 distinct
component parts, yet interactive, interdependent, and interconnected
- Policy formulation= incorporates activities associated with agenda-setting and
development of legislation
- Policy implementation= incorporates activities associated with rulemaking that
help guide implementation and operationalization
- Policy modification= allows for all prior decisions made within the process to be
revisited and perhaps changed
A Model of the Public Policymaking Process in the United States
Preferences of individuals, organizations, and interest groups, along with biological, cultural, demographic,
ecological, economic, ethical, legal, psychological, social, and technological inputs
Bridged by formal enactment of
legislation
Policy Formulation Phase
Agenda Setting Policy Implementation Phase POLICY
Problems Development of Rulemaking Operation
Possible solutions Legislation
Political circumstances
“Window of Opportunity” *
Feedback
* Window of
opportunity opens when Policy Modification Phase
there is favorable Feedback from individuals, organizations, and interest groups
confluence of problems, experiencing the consequences of policies, combined with the
possible solutions, and assessments of the performance and impact of policies by those who
political circumstances
formulate and implement them, influence future policy formulation and
implementation
4 Political Competency
Individuals and organizations have 2 areas of concern regarding policies and
policymaking process:
- How the policies will affect them and the people and things that they care about
or that they are responsible for….prefer to have the information before the
policies impact them
- Need to be able to influence the policymaking process and thereby, the policies
that affect them= policies cause people to gain, or lose, benefits; some
organizations see demand for their services increase or decrease, or see revenues
and expenses rise or fall
Political competency: knowledge, skills, and abilities present to successfully analyze
impact on one’s domain of interest, and influence the public policymaking
process
* Most important factor in political competency is understanding that the public
policymaking process is a decision-making process.
Some organizations or interest groups have specialized administrative departments
or units (usually called public affairs department/governmental affairs department
to analyze and influence public policy environments
- When politically competent staff are able to predict with reasonable accuracy
future policymaking decisions or changes months or better still, years, ahead of
implementation= responses can be more thoughtful, effective, and appropriate.
- Additionally, they can exert their influence on emerging policies by helping
shape the nature and scope of these policies that will affect their organizations or
groups = to do this, one needs a broad, anticipatory focus on the public policy
environment to increase the chances of anticipating changes in advance and
implement proactive preparation
Benefits and limitations to effectively analyze public policy environments:
Analysis permits- classify, organize, identify, assess, speculate, and link complex
information for optimum outcome
But….
- No one can foretell the future through analyses of public policy environments: at
best, only informed opinions and guesses
- People cannot possibly see every aspect and of the policymaking process
- Leaders may be able to discern relevant or emergent policies but fail to or be
unable to correctly interpret the impact on their own group
- Leaders may correctly interpret the impact but the organization is unable to
respond appropriately
How to analyze public policy environments: (must include other external factors as
biological, cultural, demographic, ecological, economic, ethical, legal,
psychological, social, and technological)
5-step analysis method:
- Scanning= to i.d. strategic public policy issues (anything that may lead to policies
and are relevant to your organization, system, group
- Monitoring= the strategic public policy issues identified
- Forecasting= or projecting the future direction of strategic policy issues
- Assessing= the importance of strategic public policy issues for the entity
- Diffusing= the results of the analysis among those in the organization or interest
group who can help formulate and implement its response to these issues
“public policy issues”= strategic policies and emerging problems, possible solutions,
and political circumstances all of which could lead to strategically important
policies
Scanning:
- Need to be identified and addressed by a collective and not by a single individual
- Might use nominal group technique, brainstorming, focus groups, Delphi
technique
- Consider the “suppliers” of public policies when scanning
Monitoring:
- Is more than scanning; more narrower focus than scanning
- Tracking or following issues over time through building a base of
data/information collected and verified through earlier monitoring
- May also use expert opinion, and other methods like scanning
- To help understand the evolution of policies = better forecasting
Forecasting:
- To allow time to formulate and implement successful responses to issues
- May use the other previous techniques, or sophisticated simulations
- Extrapolation=most widely-used forecasting technique= tracking a particular
issue, then using information gathered, predict future changes, because policies
do not simply appear= evolutionary, but works best when conditions are stable=
only general conditions can be predicted, such as number of people served by a
program or funding stream
- Significant policy changes, demographics, technology, etc, can render predictions
meaningless or misleading
- Scenario development of plausible story about the future, like fed’s response to
new medical technology, or funding for medical education or research, regulation
of health plans, etc…best to present multiple scenarios, just don’t be premature in
choosing(!)
Assessing strategic importance of public policy issues:
- Using quantification, modeling, and simulation of potential impacts
- Learning from foreign experience and/or from other experienced outside entities
- Caution: watch for personal biases and prejudices when conducting environmental
assessment…danger in trying to fit preconceived notions rather than considering
realities of the actual situation
Diffusing results of environmental analysis into organizations/groups that will carry
out their responsibilities:
- Must be done effectively or could be undervalued and ignored
To avoid this, leaders can: use their power to dictate diffusion; or use reason to
persuade all affected; or (best way ) educated the participants to emphasize and
convince them of its importance
* After “analysis” comes the other half, which is influencing public policy
environments.
Influencing public policy environments:
Leaders must adhere to ethical principles of respect for autonomy of other people,
justice, beneficence, and non-maleficence to avoid being self-serving or being
perceived as such.
Power, which is the potential to exert influence, derives from 3 general sources:
- Positional power = based on the entity’s (organization, group) place or role in the
larger society, the degree to which they are recognized as legitimate participants
in the political marketplace, recognition given by courts to bring legal action
(earn hearings for their views or preferences) as part of their efforts to exert
influence…but this power is not enough
- Reward or coercive power = based on entity’s capacity to reward compliance or
to punish non-compliance with preferred decisions, actions, or behaviors by
policymakers in the form of $ campaign contributions, votes
- Expert power = based on the entity’s possession of expertise or information that
is valued by others
As important as having power is the ability to FOCUS your efforts and resources for
optimum outcomes.
Phases to influence policymaking: (p 146, fig 4.1)
▪ Influencing policies at policy formulation phase:
At agenda setting by: defining and documenting problems
developing and evaluating solutions
shaping political circumstances through lobbying and the courts
At legislation development by: participating in drafting legislation
testifying at legislative hearings
▪ Influencing policies at the policy implementation phase:
At rulemaking by: providing formal comments on draft rules
serving on and providing input to rulemaking advisory bodies
At policy operation by: interactions with policy implementers
▪ Influencing policies at the policy modification phase:
By documenting the case for modification through operational experience and formal
evaluations
Human element in analyzing and influencing public policy environments
Diverse preferences, objectives, priorities, levels of understanding of issues, and
others , make accurate analysis or successful influence difficult
Ex. Medicare-- various perspectives from:
Program beneficiary- may be unhappy with some aspects (average of 22% of their
income for out-of-pocket expenses), but overall, positive impression as the
principal source of health benefits for the nation’s elderly and people with
disabilities (protects their families from expenses of their relatives’ health care)
and serves as a promise of protection for young Americans as they plan their
retirement
Hospital executive- on average, hospitals get 38% of their revenues from Medicare;
perceive that the program’s reimbursement rates to hospitals are too low to cover
costs and are losing money
Balancing perspectives:
Policymakers- see widening gap between program revenues and program expenditures,
a reason for which, are the baby boomers; those who stand re-election do not like
difficult fiscal choices
Alternative ideas- raise program’s eligibility age (like SS), slowing the rate of growth
in provider payments (risks provider participation and therefore reducing access for
beneficiaries), and increasing Part A taxes or Parts B and D premiums….pressure
from a bi-partisan’s Balanced Budget Act of 1997
- Still no consensus due to different mindsets (4 world-views that are oversimplified
but are really more complex): Policymakers are classified as:
• True romantics- don’t recognize pending imbalance between Medicare’s revenue &
expenses; that resources are limited, & that the limitations should be reflected in
policy
• Pseudo romantics- do recognize the problems, but hope that some new resources
might suddenly be found; have other objectives in mind
• Truly self-serving- know about the problems but have own interests and agenda first
to take care of before choosing to fix the problem
• Procrastinators- postpone the inevitable, though they fully realize the problem and
what must be done, forcing the difficult decision-making on future policymakers and
the consequences to future generations