At the Intersection of Health, Health Care and Policy

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Cite this article as: J K Iglehart America's health care system Health Affairs 11, no.4 (1992):5-6 doi: 10.1377/hlthaff.11.4.5

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Health Affairs is published monthly by Project HOPE at 7500 Old Georgetown Road, Suite 600, Bethesda, MD 20814-6133. Copyright © by Project HOPE - The People-to-People Health Foundation. As provided by United States copyright law (Title 17, U.S. Code), no part of may be reproduced, displayed, or transmitted in any form or by any means, electronic or mechanical, including photocopying or by information storage or retrieval systems, without prior written permission from the Publisher. All rights reserved.

From the Editor Downloaded from by Health Affairs on June 22, 2016 by HW Team

America’s health care system reflects the unfettered pluralism of a wealthy society that favors private-sector approaches and limited governmental participation. The result is a market-driven, expensive enterprise without a central rudder, which fosters and finances medical innovation, insures most of the populace, but falls woefully short of universality. To sell systemic reform, President-elect Bill Clinton must persuade Americans to swallow two unpopular but inevitable realities if, as opinion polls suggest, they truly favor universality: an expansion of government’s authority to regulate the system and a redistribution of income to subsidize expanded coverage. Clinton must also neutralize the concentrated efforts of private health interests to thwart reform. This is a formidable challenge for a president elected with 43 percent of the vote and a laundry list of competing priorities, but he will head a government dominated by one party for the first time in almost a generation. Over the last twelve years of Republican rule, Washington narrowed the definition of the appropriate federal health role to overseeing public programs, leaving the private sector largely to its own devices. But this vision was no match for a system built to spend. Federally financed personal health services consumed an ever-greater portion of general revenue, and tax-financed subsidies for private health insurance favored people with means. The government favored a brand of rough justice by, in essence, shifting federal patient care costs onto privately insured patients. Having reached (again) a time when policymakers are seemingly determined to reform our health care system, we thought it appropriate to examine some of the tnajor features of today’s system, given that its shape will heavily influence any future reforms These features include the complicated and unplanned nature of its structure, its evolving regulatory framework, the expanding roles played by the courts and the media, and the relationship between political action and health policy making. This thematic issue rests on an assumption that every modern society-even those driven by energetic forms of capitalism-functions best with an efficient government that




I Winter 1992

commands the respect of its citizens and is entrusted with the critical duties that only such institutions can assume. It is past time that we accept this reality and get on with improving its capacity to govern competently, while recognizing the value that Americans attach to limited government. In our opening essay James Tallon and Richard Nathan, a nationally regarded Democratic state legislator and a distinguished academician who served in earlier federal Republican administrations, underscore the absence of a unifying plan for the government’s involvement and propose one that acknowledges the continental proportions of the United States. Lawrence Brown, a political scientist, discusses the ambivalence of Americans about whether the U.S. health care system should be guided by market-oriented policies or governmental regulation. Bradford Gray, a sociologist, probes the convoluted culture of policy making through a fascinating saga on how the new Agency for Health Care Policy and Research was created. Donald Moran and Allen Dobson, two savvy former government executives turned analysts, and their colleague Gary Young from Lewin-VHI focus on the role of Medicaid waivers in health policy innovation. Economist Gerard Anderson discusses how the courts are filling the vacuum left by ill-defined health policies, and Alan Otten, a veteran journalist, looks at the role of the media in health policy. Six DataWatches fill in some of the blanks in the equation: political action committee (PAC) contributions, state and local health spending, how the United States spends its health care dollar, Medicaid home and community-based care waivers, access to prenatal care for Medicaid beneficiaries, and trends in private insurance coverage. To demonstrate the worldwide search for new approaches, our Peer Review focuses on Australia’s attempt to meld cost-effectiveness criteria into drug payment. Update reports on lessons from international comparisons. And in GrantWatch, Penny Feldman and colleagues discuss how foundation-funded commissions are influencing policy making. Lastly, Health Affairs acknowledges the support of The Henry J. Kaiser Family Foundation in the publication of this issue. Its president, Drew Altman, and its vice-president, Dennis Beatrice, who directs the foundation’s ambitious effort to improve the value of the government’s (and thus the public’s) vast investment in health care, provided us with a grant and their opinions on this issue and then left us alone, in the best tradition of academic freedom. For this support, we pay tribute to the foundation. John K. Iglehart Founding Editor

America's health care system.

At the Intersection of Health, Health Care and Policy The online version of this article, along with updated information and services, is available a...
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