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Working the margins
PUBLIC POLICY, NUTRITION PRACTICE, AND THE EVOLVING HEALTH CARE MARKET
POLICY ALISON
Nutrition
Vol. 13, Nos. 718, 1997
EDITOR:
B. KING, PHD
Procter & Gamble Pharmaceuticals,
Norwich, New York, USA
Working the Margins GREGG From the Department of Medicine,
With the recent inauguration the 105th Congress and the executive branch of President Clinton’s second term, Washington must begin anew the process of governing and making policy in a politically divisive context. Although ongoing investigations of the President’s campaign-financing activities and the Speaker’s college course have created an environment of acrimony, it now appears that the leadership of both the legislative and executive branch realize that continued diversions from the policy agenda will not curry favor with the citizenry. Public-opinion polls and the cabal of consultants are in agreement: the American public wants its government to spend more time governing and less time pandering, policing, and posing for the press. The current air of “bipartisanship” may prove ethereal with the latest revelation or investigation of our elected officials, but for the time being it is in the best interest of all parties to apply themselves to the task of governing. What does the new era of “bipartisan civility” mean for health policy in the 105th Congress? Depending upon your half-full versus half-empty perspective, the 105th Congress could prove to be quite active in the health sphere or do little in terms of major reform. It is likely that both will be true.
S. MEYER,
MD, MSC
Uniformed Health Services University of the Health Sciences, Bethesda, Maryland
Despite the bipartisan context legislators and the White House are promoting, the chances for major health-care reform on the scale proposed by the President in 1993 are remote. The policy window that facilitated the creation of the President’s promotion developed from a public perception of runaway health-care inflation (which was at 12-19% from 198919921, a relatively weak economy with concerns over job (and thus health insurance) security, and the consolidation of the legislative and executive branch under a single party, which was elected on a platform that included health-care reform. In 1997 we do not have any of these prerequisites for a major revolutionary change in policy. On the other hand, the period between policy windows can often produce significant evolutionary change over time. The policy process of incrementalism’ will now be playing out in the healthcare arena. Instead of a major change in policy, such as the creation of closely regulated health insurance purchasing cooperatives, we will see some reforms regarding policies regulating the marketing activities of managed-care organizations. Instead of a uniform benefits package, we will see prohibitions on sameday discharges for some procedures.
The early health-policy activities of the new government will surely focus on issues that are publicly consumable. Such legislation is characterized by high public visibility, wide acceptance across the political spectrum, and the lack of a powerful consolidated opposing interest group willing to take it on in the public arena. The medical necessity of a postdelivery length of stay of more than 24 h may be debatable on a scientific basis, but in the political world it is a no-lose proposal. Such reforms have wide public support, affect the lives of “ordinary” citizens, give the nation evidence that its federal government is doing something about health care, and provide great Rose Garden signing photo-ops for Congressional leaders and the President. A promotional campaign to oppose such “common sense” legislation from managed-care or health insurers would only serve to further damage public perception of those organizations. Mandated lengths of stay of more than 24 h for mastectomy and a national plan for the distribution of scarce transplant organs are other examples of such “mom and apple pie” health-care legislation we may see from the new Congress. Other health-care legislation from the new Congress is likely to focus on specific
The opinions and assertions contained herein are the private views of the author and are not to be considered Department of the Air Force or the Department of Defense.
Nutrition 13:710-711, 1997 OElsevier Science Inc. 1997 Printed in the USA. All rights reserved.
ELSEVIER
official or reflecting
the views of the
0899-9007/97/$17.00 PII SO899-9007(97)00004-X
WORKING
711
THE MARGINS
identifiable problem areas within the U.S. health-care system. An example of such work on the margins is the Kennedy-Kassebaum act signed into law at the close of the last Congress. That legislation confronted a small facet of the access issue, the lack of portability of health insurance between employers. The lack of portability was a key contributing factor to the public perception of health-care insecurity. Proposals to address other specific issues such as targeted legislation concerning pre-existing illness exemptions and mandated mental health benefits are likely to surface and gain support. Other more ambitious and broad proposals regarding tort reform, rate regulation, and medical savings accounts are likely to receive some consideration in
the Congress but are far less likely to get through committees and onto the floor. The evolutionary piecemeal approach to health-care reform, however, is still subject to the forces of political winds. It is possible that a proposal may “take off ” and gain rapid support, allowing for more latitude in the change of policy direction. For example, a consolidation of public concerns over profits among insurers and managed-care organizations could create the backlash necessary to create policies promoting physicianowned health plans. A recent return of health-care inflation, as noted by a rise in premiums to employers by 4-7% compared with <3% over the previous 2 y, may engender other reforms. Much of that rise is attributed to consolidation REFERENCES
1. Kingdon, JW. Agendas, public policies. 1984
alternatives, and New York: Harper Collins,
2. Winslow R. Health-care costs may be heading up again. Wall Street Journal. ary 1997, Bl
21 Janu-
of the market with less competition among plans and the growth in prescription drug costs.’ Both of these issues may receive attention from the Congress if such trends continue. In sum, the new government will bring more evolution than revolution in health-care policy. As such, this policy evolution is best characterized as “punctuated equilibrium,” where small change may be punctuated by occasional major reform leaps rather than as strict gradualism. Given current trends, the forces facilitating those leaps are most likely to come from the market. The incremental changes may be predictable, but the potential for something more is far less amenable to prophecy by policy wonks and pundits.
POLICY ALISON
Nutrition
Vol. 13, Nos. 718, 1997
EDITOR:
B. KING, PHD
Procter & Gamble Pharmaceuticals,
Norwich, New York, USA
Working the Margins GREGG From the Department of Medicine,
With the recent inauguration the 105th Congress and the executive branch of President Clinton’s second term, Washington must begin anew the process of governing and making policy in a politically divisive context. Although ongoing investigations of the President’s campaign-financing activities and the Speaker’s college course have created an environment of acrimony, it now appears that the leadership of both the legislative and executive branch realize that continued diversions from the policy agenda will not curry favor with the citizenry. Public-opinion polls and the cabal of consultants are in agreement: the American public wants its government to spend more time governing and less time pandering, policing, and posing for the press. The current air of “bipartisanship” may prove ethereal with the latest revelation or investigation of our elected officials, but for the time being it is in the best interest of all parties to apply themselves to the task of governing. What does the new era of “bipartisan civility” mean for health policy in the 105th Congress? Depending upon your half-full versus half-empty perspective, the 105th Congress could prove to be quite active in the health sphere or do little in terms of major reform. It is likely that both will be true.
S. MEYER,
MD, MSC
Uniformed Health Services University of the Health Sciences, Bethesda, Maryland
Despite the bipartisan context legislators and the White House are promoting, the chances for major health-care reform on the scale proposed by the President in 1993 are remote. The policy window that facilitated the creation of the President’s promotion developed from a public perception of runaway health-care inflation (which was at 12-19% from 198919921, a relatively weak economy with concerns over job (and thus health insurance) security, and the consolidation of the legislative and executive branch under a single party, which was elected on a platform that included health-care reform. In 1997 we do not have any of these prerequisites for a major revolutionary change in policy. On the other hand, the period between policy windows can often produce significant evolutionary change over time. The policy process of incrementalism’ will now be playing out in the healthcare arena. Instead of a major change in policy, such as the creation of closely regulated health insurance purchasing cooperatives, we will see some reforms regarding policies regulating the marketing activities of managed-care organizations. Instead of a uniform benefits package, we will see prohibitions on sameday discharges for some procedures.
The early health-policy activities of the new government will surely focus on issues that are publicly consumable. Such legislation is characterized by high public visibility, wide acceptance across the political spectrum, and the lack of a powerful consolidated opposing interest group willing to take it on in the public arena. The medical necessity of a postdelivery length of stay of more than 24 h may be debatable on a scientific basis, but in the political world it is a no-lose proposal. Such reforms have wide public support, affect the lives of “ordinary” citizens, give the nation evidence that its federal government is doing something about health care, and provide great Rose Garden signing photo-ops for Congressional leaders and the President. A promotional campaign to oppose such “common sense” legislation from managed-care or health insurers would only serve to further damage public perception of those organizations. Mandated lengths of stay of more than 24 h for mastectomy and a national plan for the distribution of scarce transplant organs are other examples of such “mom and apple pie” health-care legislation we may see from the new Congress. Other health-care legislation from the new Congress is likely to focus on specific
The opinions and assertions contained herein are the private views of the author and are not to be considered Department of the Air Force or the Department of Defense.
Nutrition 13:710-711, 1997 OElsevier Science Inc. 1997 Printed in the USA. All rights reserved.
ELSEVIER
official or reflecting
the views of the
0899-9007/97/$17.00 PII SO899-9007(97)00004-X
WORKING
711
THE MARGINS
identifiable problem areas within the U.S. health-care system. An example of such work on the margins is the Kennedy-Kassebaum act signed into law at the close of the last Congress. That legislation confronted a small facet of the access issue, the lack of portability of health insurance between employers. The lack of portability was a key contributing factor to the public perception of health-care insecurity. Proposals to address other specific issues such as targeted legislation concerning pre-existing illness exemptions and mandated mental health benefits are likely to surface and gain support. Other more ambitious and broad proposals regarding tort reform, rate regulation, and medical savings accounts are likely to receive some consideration in
the Congress but are far less likely to get through committees and onto the floor. The evolutionary piecemeal approach to health-care reform, however, is still subject to the forces of political winds. It is possible that a proposal may “take off ” and gain rapid support, allowing for more latitude in the change of policy direction. For example, a consolidation of public concerns over profits among insurers and managed-care organizations could create the backlash necessary to create policies promoting physicianowned health plans. A recent return of health-care inflation, as noted by a rise in premiums to employers by 4-7% compared with <3% over the previous 2 y, may engender other reforms. Much of that rise is attributed to consolidation REFERENCES
1. Kingdon, JW. Agendas, public policies. 1984
alternatives, and New York: Harper Collins,
2. Winslow R. Health-care costs may be heading up again. Wall Street Journal. ary 1997, Bl
21 Janu-
of the market with less competition among plans and the growth in prescription drug costs.’ Both of these issues may receive attention from the Congress if such trends continue. In sum, the new government will bring more evolution than revolution in health-care policy. As such, this policy evolution is best characterized as “punctuated equilibrium,” where small change may be punctuated by occasional major reform leaps rather than as strict gradualism. Given current trends, the forces facilitating those leaps are most likely to come from the market. The incremental changes may be predictable, but the potential for something more is far less amenable to prophecy by policy wonks and pundits.