Joumal of Advanced Nursing, 1990,15, 487-497
The politics of American health care James P Smith OBE BSc(Soc) DER SRN RNT BTA Certificate FRCN FRSH Editor, Joumal of Advanced Nursing and Vtsiting Fellow in Nursing Studtes, Dorset Institute
Accepted for publicahon 12 June 1989
SMITH J P (1990) Joumal of Advanced Nursmg 15, 487-497 The politics of American health care The developments leading to the present Amencan health care organization are traced It is clear that hospitals have dominated at the expense of pnmary health care programmes Health care costs have soared dramatically There are particular problems inherent in a system shared between federal and state governments and a pnvate health care industry Attempts to provide a fully (or partially) tax-funded health service in the USA have been bedevilled by a number of factors These include opposition from labour unions, politicians, vested-interest groups and, in particular, the Amencan Medical Association As part of its opposition, the AMA politicized itself m 1950 But, in the pohtical literature, Amencan nurses are not portrayed as bemg very politically active Reasons for this are explored The introduction of Medicare and Medicaid programmes is discussed and the legal, social and political implications Recent attempts in the USA to control costs are assessed and new trends and new problems identified
HOSPITALS At the tum of the century, there were only a few hospitals m the USA and these were based in the major cihes They adopted the Bnhsh organizational structure — and served the poor 'The affluent and middle class were treated at home' (McMahon 1987) These early hospitals were financed almost exclusively from voluntary donahons Eventually, they grew m numbers, but m a fragmented and disorganized way, often idenhfymg with a particular geographical area m a aty or with a particular group, eg Catholic, Jewish In due course, voluntary subscnptions proved insufficient to support the hospitals and from the early 1900s many hospitals began to introduce a 'patient charge' By the late 1920s, because of the very high losses faced by the hospitals, not least because of the inability of many patients to pay for their care, a new system of payment was introduced — third party payment This as McMahon points out 'developed mto nongovernmental hospital insurance plans' Since then, the scale of hospital costs has contmued to mcrease dramatically as a result
of increasing use of high technology and the effects of mflahon Sick care dommation Inevitably, but sadly, hospitals dominate the US 'health' scene (as m all parts of the developed world) The dominance of hospital care at the expense of essential developments in pnmary health care are noted by Owen (1988) He pomts out that in 1987, when US national expenditure on 'medical care' had reached $275 billion, 'only 5% of that budget was devoted to health promotion with 95% devoted to disease care' Indeed, Fnedman & Rakoff (1977) argue that The central problem for US health pohcy' is that 'what passes for health policy appears m reality to be policy designed to deal with the cost, distnbution or access to Sick care ' This is due, they claim, to, among other thmgs, 'the problem of measunng health as opposed to measunng medical services' Further concem is expressed by Momson (1989) who claims that 'Studies have suggested that many surgenes are unnecessary' m the US, 487
JP Smith
and goes on to mdicate that 'perhaps half of lower back disc operations, up to 70% of hysterectomies and coronary bypasses' may have been performed without need m the US
GOVERNMENT HEALTH INSURANCE ADVOCATES Possibly the first advocacy of a governmental health insurance programme in the US was 'a plank in the platform ofthe Socialist Party in the early 1900s', accordmg to Myers (1970) Subsequently, when Theo Roosevelt founded the Progressive Party before the 1912 elections 'a plarJc supporting national health insurance was included m its platform' Myers also argues that the Amencan Association for Labour Legislation (AALL), a coalition of actuanes, lawyers, social saentists and economists founded m 1906, had a most important role m the legislahve movement for health insurance', particularly dunng 1912-1918 At its inception AALL was interested pnmanly m promoting state workmen's compensation laws as well as payments for medical care for mdustnal acadents and diseases, and Myers claims that 'it was extremely successful in that venture' AALL was active up to the Second World War (when it faded out of existence) The AALL was so impressed with the Bnhsh 1911 Nahonal Health Insurance legislation that, m 1912, it drafted a similar bill for 'state action' In 1915, a second bill, modelled more on the German eammgs-related system, was drawn up by AALL and this formed the model for bills introduced into several state legislatures But, generally, the states did not a d on these bills Instead, Myers points out, they merely appointed mveshgatmg committees to study the matter further
AMA 1917 'Most mterestmgly' (to use Myers' words), a committee of the Amencan Medical Associahon (AMA) worked 'actively and even enthusiastically' with the AALL on the 1912 project Myers refers to the Joumal of the AMA of 9 June 1917 where the view was expressed that' the time IS present when the profession should study earnestly to solve the queshons of medical care that will anse under vanous forms of soaal insurance Blind opposihon, mdignant repudiation, bitter denunaation of these laws is worse than useless ' This was a view that was however not followed m the later 'great Medical debate' of the 1950/ 60s, as Myers quickly points out In fad, the AMA was already not prachsmg the message preached m that arhde by the time it was wntten For 488
dunng 1917-1920 the bills modelled on the AALL's bill were introduced to about 15 state legislatures and the AMA was one of a 'wide vanety of sources of opposition', Myers (1970) notes Another vigorous source of opposition was the large insurance companies, not least (so it was supposed) because of a proposal to include a lump sum death payment Most employers and their organizations were also positively opposed to the proposed legislation as well as the Chnstian Science Organization 'But perhaps the crowning blow of all was the opposition of the AFL' (Amencan Federation of Labour) This, Myers suggests, was motivated by the belief that social insurance would divert workers from their 'real goal' of 'higher wages and shorter hours and would, at the same time, deaease the dependency of the workers on the union' There was also another major factor working against the proposed legislation The First World War was m progress and, therefore, domestic legislation had to take second place to the considerahons of war There was also a great deal of anti-German feeling in the US at the time and the 'Germanic latjel' of the proposed legislation was a hindrance After the war, the 'nse of the Bolsheviks provided another epithet', Myers contends Nevertheless, whilst all this activity was going on withm the state legislatures, there was also a good deal of federal activity related to soaal insurance developments In 1915, a US Commission on Industnal Relations recommended a system of soaal msurance payments for all workers, compulsory for workers 'engaged m inter-state commerce' and on a voluntary basis for other workers (Myers 1970)
Committee on Costs of Medical Care 1927 In 1927, a Committee on Costs of Medical Care was set up Dunng its 5 years' existence, the committee chairman was made a member of President Hoover's cabmet However, at the end of its dehberahons, the committee found it impossible to reach a consensus In the early 1930s, President F D Roosevelt attempted to fight the effects of the great depression by, among other thmgs, developing an extensive system of long-range social insurance and short-term pubhc assistance He appomted a Committee on Economic Secunty (CES) to study these matters and to develop draft legislation But, because it was rushed, controversial and met with much opposition, no immediate legislahon was proposed either by the CES or by President Roosevelt There was also another fear, Myers (1970) suggests, 'the possibihty that any such proposal would be declared unconshtutional' and pull down with it the old age and unemployment t^enefits But he adds that
Politics of Amencan health care
some have challenged that contention and associate it with undue timidity' on the part of the proponents of nationai health insurance at the tune In 1933, a group of Amencan physicians attempted to foster the cause of a 'universal system' of medical care Their New York-based Medical League for Socialized Medicine, which also had non-physiaans in membership, gained considerable support in the academic world but no widespread popular or legislative support The organization quickly died and, as Myers points out, there has been very little of that kind on advocacy in the US since By 1935, the AFL had modified its earlier opposition to social insurance 'In considerable part', Myers believes 'this was probably because of the effects of the depression' But also, he hastens to add, the AFL's then president (William Green) had a much more positive and constructive athtude towards social insurance than his predecessor (Gompers) had In any consideration of politics the influence of chansmatic personalities on progress and change can never be underestimated, it must be acknowledged, even if it is difficult to measure the impact of chansma
Social Security Act 1935 In spite of powerful opposition in some circles the Social Security Act of 1935 was passed, facilitating public assistance to blind, dependent and aged people and children Following the passage of this act. President F D Roosevelt established the Interdepartmental Committee to Coordinate Health and Welfare Activities This committee appointed a Technical Committee on Medical Care which was charged to formulate outlines for what was later to be the first formal proposal for a nationai health programme m the US The recommendations were presented at a Major National Health Conference in 1938 which was, m the view of Myers, 'the ftrst truly nationai discussion of the broad subject' A general consensus emerged from that conference about principles for improving the US nation's health but there was no accompanying consensus about the apportionment of costs of care between the federal and state govemments That problem seems to have persisted ever since m the USA An amended version of the recommendations however was presented by Senator Wagner (Democrat) in the form of the 'Wagner Bill 1939' On that occasion, there was strong support from consumer groups and the Senate subcommittee reported m its favour But 'm view of the opposition' from the AMA, state medical soaeties and other groups of professionals, the bill 'was not brought to the vote', Myers records In fact, the Wagner Bill was very
similar to the Medicaid programme enacted in 1965 (discussed later in this paper) — but the Wagner proposals were more comprehensive It was to be a state-by-state approach with a federal support grant After the failure of the Wagner Bill, 'the executive branch concentrated on nationai proposals for health insurance linked with, or integrated into' the national social insurance system of old age and survivors Bills along these lines were introduced in the late 1930s and the 1940s and 1950s But these times were not any less turbulent politically as Campion (1984) points out
START OF AMA POLITICIZATION 1950 In 1948, accordmg to Campion (1984), everyone in the US was expecting President Truman to make good his campaign promises for a health bill As a result, to strengthen opposition, the AMA decided on a strategy 'to take its case to the public' And, as Mayhew (1974) records, in 1950 those congressmen known to be supporters of health insurance found themselves confronted with the effects of a million dollar advertising campaign conducted by the AMA Individual AMA members started election committees which. Campion claims, are credited with bringing on the defeat of at least three senators m the 1950 elections That view is supported by Mayhew who says that 'By 1952, it was widely believed that the AMA had deaded some elections, and few congressmen were still mentiorung insurance' Later, in 1957, the AMA felt further threatened by the proposals in the Forand Bill which had a great deal of support from senators and others This bill proposed hospitalization msurance through soaal secunty for the retired population The professional ire of the AMA was roused because they saw this as part of the ultimate goal of 'compulsory nationai insurance for everyone' (Campion 1984) The AMA then determmed to strengthen the effectiveness of its opposition by begmmng to take a more active mterest m the formation of Political Action Committees (PACs) Dunng the 1950s, physicians in a few Amencan states joined m coahtion-style political action organizations, e g Indiana Health Organization for Political Education (I-HOPE) By October 1958, moves were already afoot m the AMA to start a PAC and the AMA sought legal views on the legal implications of such a move Though the idea of a PAC had many backers, the heat was taken out of the debate about the pros and cons of sudi a move by the blockmg (m 1959) of the Forand Bill by the Ways and Means Committee whose conservative chairman Wilbur Mills (Democrat Arkansas) was workmg with Robert Kerr 489
/ P Smith (Democrat Oklahoma) 'on a different kind of solution to the health needs of the elderly indigent'. Campion (1984) points out (The Kerr-Mills Bill which emerged received AMA support and was passed and signed in 1960 by President Eisenhower) In October 1959, an AMA subcommittee was set up to explore the idea of a PAC The subcommittee voted not to start a PAC but, instead, encouraged AMA members to participate in local PACs 'as citizens' According to an AMA survey conducted in February 1960 (cited by Campion), by then, groups of politically oriented physicians had helped to launch a number of state-wide PACs By Apnl 1960, the AMA board had voted $7500 for three regional meetings to educate physicians in political techniques and on the creation of PACs This development triggered off much debate in the organization but the AMA still did not reach any firm deasions about the creation of its own PAC
The Kennedy era — AMP AC formed The turning pomt occurred dunng the J F Kennedy presidential elections according to Campion This took place early m 1961 when Kennedy became known as 'a supporter of sweepmg health legislation', which made the AMA Board approve the formation of the Amencan Medical Political Action Committee (AMPAC) as an independent political arm of the AMA It was 'a non-profit, voluntary, bipartisan, unincorporated political action committee, with emphasis on bipartisanship' Membership was open to AMA members, their spouses and families — and others Its goal was a strong conservative (Democratic and Republican) coalition m the Congress It also aimed to maintain good communication with the leaders of both parties (and therefore would not be involved m presidential elections) In 1961, AMPAC had 13 416 members, this had increased to 126 220 by 1974 Within its first 15 months of existence, AMPAC had sponsored organized PACs in 45 Amencan states Campion (1984) claims that AMPAC's creation marked the beginning of 'a highly successful effort to give a political education to Amencan physicians' Initially, AMPAC concentrated its resources on candidates m elections that were expected to be close, but by the end of the 1970s AMPAC was backing 220—240 congressional races every 2 years, of which 30 to 40 were probably pnmary contests According to Campion, AMPAC has claimed that about 70-80% of the candidates it has backed 'have won their races', though given the amount of lobbying by other organizations, a common aspect of Amencan pohtical life, I suspect that AMPAC cannot claim the whole victories for themselves 490
Campion also argues that AMPAC has raised the level of 'sophistication with which organized medicine has been able to conduct its business with state and federal governments' He further argues that, thanks to AMPAC's 'trainmg ground', a new generation of AMA leaders came to power who had 'a more realistic understandmg of the political process' and 'were better equipped to operate within it'
AMA allies But, in truth, even without sophisticated political acumen, dunng the entire period after 1950, the AMA always seemed to organize an effective (in their view) opposition with the aid of its very strong and powerful allies Myers (1970) points out that the battle lines were by then clearly drawn between the opponents and the proponents of 'health benefits under social insurance' The AMA opposition had strong allies in the Amencan Hospitals' Association (AHA), the Blue Cross Association (BCA), the National Association of Blue Shield Plans, insurance companies and business groups, all of whom it should be pointed out had a great deal of vested interest in third party health insurance However, as Myers concedes, many of the opponents accepted there was a 'problem' for those over 65 But in spite of that they strongly opposed the 'social insurance pnnciple' In due course, as legislation seemed more imminent, the AHA and BCA apparently adopted a 'more neutral position'
UNIONS The proponents of social insurance pnnciples included social workers and organizations representing people over 65, as well as labour unions However, whilst it might be argued that any support for social progress is better than none at all, the intensity of the political clout of Amencan unions IS doubted by Wilson & Neuhauser (1982) because, m their view, the uruons tend to 'focus narrowly on pay, fnnge benefits, and working conditions, rather than on creating political parties or stnving for wide-rangmg social objectives' Nevertheless, they accept that US labour unions have played a role m US health care development 'through collective bargainmg for health insurance benefits with employers' Some unions have also helped to create Health Maintenance Orgaruzations (HMOs) HMOs provide a comprehensive health service for a monthly/annual premium (eg Kaiser-Permanente m California) The number of HMOs has nsen sharply since the Health Mainterumce Organization Act 1973 (a legislative response and reaction to the escalating costs of Medicare and Medicaid)
Politics of Amencan health care
and HMOs now account for around 30% of all US health care, according to Owen (1988)
MEDICARE INTRODUCED 1965 Medicare — the national programme of health msurance for the aged in the USA — was established in 1965 That year, in the view of Wilson & Neuhauser (1982), marked the culmination of many years of national and congressional debate and is of great histoncal significance' as the Social Secunty Amendments Act was passed which introduced Medicare and provisions for an expansion of the Kerr-MiUs medical assistance programme to groups other than the elderly These were known as 'Medicaid' programmes The Social Secunty Amendments Act of 1972 made extensive amendments to the Medicare and Medicaid programmes, 'many addressed to the control of costs' which had nsen as a result of massive inflation Thereafter, the persistent problem of escalating costs was dealt with in a number of Social Secunty Amendments Acts dunng 19741981 when vanous measures to control costs and improve cost-effectiveness were introduced In 1977, a new Federal Health Care Fmancmg Administration was created to assume pnmary responsibility for the Medicare and Medicaid programmes (Perhaps, it might be argued, this was the embryo of a potential centrally-financed national health service)
1988 Legislative changes The most recent legislation — the Medicare Catastrophic Coverage Act 1988 'is considered the largest expansion of Medicare in 23 years' according to Wilson (1989) This act will cover Medicare patients (l e those aged 65 + and the disabled) against nsing health care costs, including home care and outpatient drugs Extended coverage for the poor under Medicaid is also provided for in the 1988 Act Whilst some of the additional costs will be financed from extra tax payable by the Medicare beneficianes themselves, Wilson prophesies that 'it Cein be expected that the general population will be asked to finance the growth in medical expenditures', espeaally as the numbers of those over 65 in the Amencan population increase over the next 3 decades Already, Wilson points out. Medicare has become Amenca's largest single purchaser of physician and hospital services That, in my view, is of particular political significance, esf)eaally m view of the fact that this has resulted in the federal government's health care costs escalating faster than the general cost of hving In 1966, Medicare costs were $11 billion, these had reached $76 billion by 1986, according to Wilson And as Marmor (1983) pertinently
points out, this substantial expansion of governmental health expenditure since 1965 has pohtical implications and ramifications According to Marmor, by 1976 the US public sector was providing 42% of Amencan health expenditures, compared with only 26% in 1965 (and 13% in 1930) It is not surpnsing therefore to leam that the activities of the state have now been 'extended to determining the appropnateness of facilities, manpower training, accreditation, fee schedules, and even quality of medical care' Pohtical realities In reality, as Marmor further points out, the politics of health depend on the political factors that commonly affect other bnds of industry 'There is the same mixing and balancing between public and pnvate responsibility, the same marble cake of local, state and federal authonties and the same political culture and social structure' Record (1977) also argues that equivocation about the location of authonty, because of the ambiguities m the allocation of decision-makmg among all the entities noted by Marmor, not only exacerbate inflationary pressures but also encumber remedial action The political reality of public budgets and their sensitivity to politics. Record suggests, threatens health accomplishments and possibly has begun to erode credibility in the system Furthermore, he warns, 'Ambiguities often serve political needs' enablmg the Amencan Congress to play one sector off against another when 'the ultimate victor IS unpredictable at the time of legislative action' Record also argues that as a result of Congress acting with 'msensitivity to costs' in the legislation relating to health introduced in the 1960s and 1970s, Congress and the White House have now been forced mto acute cost consciousness by medical inflation He suggests that there is a new national mood m the US now which requires public accountability of the medical profession and competitiveness of the market, 'particularly when public monies are expended, the day of the federal regulator seems to have arrived' But McClure (1977) feels that the mcentives m the system which produce the problems are very strong and deep rooted to such an extent that strategies for change will 'require substantial change that will be politically difficult to achieve' Furthermore, m his view, a rational approach may well be frustrated by the lack of pubhc consensus as, he claims, Amencans have very genuine ideological and non-ideological options 'representing very different values, methods and consequences' However, Marmor argues, by way of explanation for the lack of national consensus, that for consumers m normal 491
JP Smith
health, the expected benefits or costs of a health care policy are, in any case, relatively unimportant to them For, he points out, their interests are diffuse and include not only health but also food, clothmg, shelter, education, recreation and employment (It is, however, interesting to note that the World Health Organization's definition of health as 'complete mental, physical and soaal well-being' would embrace all of these) Nonetheless, the situahon as descnbed by Marmor does, as he indicates, give the providers of Amencan health care (including doctors, hospital administrators, union officers, insurance underwnters) the greatest influence The reason is quite simple The providers are very knowledgeable and concemed about health care policy since it is important to their lives'
BLOOD SUPPLIES The vested interests of providers of health care in the USA have even been identified m those who supply blood for Amencan patients They too have power In 1962, after an investigation lasting several years, the Federal Trade Commission issued a complaint by two commeraal blood banks against the Kansas community (non-profit) blood banks They were charged with 'conspinng to boycott a commercial blood bank in the sale and distnbution of blood m commerce' (Titmuss 1970) In 1966, the Commission issued a ruling against the community banks (majonty three to two) Whilst the heanngs were in progress, bills were introduced into the two houses of Congress m 1964 and 1967 to exempt non-profit blood banks from anti-trust laws However, both bills failed, not least because of opposition from the commeracil blood banks and the pharmaceutical mdustnes (though the medical profession supported these bills') The ruling was later set aside in January 1969 by the 8th Circuit Court of Apjjeal m St Louis 'Though this may be the end of the particular case', Titmuss stresses that 'the fact that it happened is one illustration among many of the increasing commercializahon of the blood banking system ' That is fraught with dangers, he points out, for blood IS often bought from particularly nsky sources such as pnsoners and 'Skid Row' residents Titmuss's work in the US shows quite clearly that the paid blood donors there have a marked tendency to lie about past illnesses, especially about jaundice episodes
It was only in 1974 that the UK developed methods of detecting hepatitis B virus as Owen (1988) indicates Around that time therefore, he (as minister of health) issued instructions to the avil servants that the UK should become self-sufficient in blood supplies and products As it was, his instructions were ignored and, throughout the 1970s, US blood products continued to enter the UK 'As a result,' Owen argues, 'there can be little doubt that some of the people who are now HIV positive and had received blood for haemophilia and other reasons were given blood products from abroad which had HIV in them' If that is the case for the UK, it must be even more senous for the countnes in the Third World Titmuss (1970) also finds that, as the commercialization of blood and donor relationships extends, 'Concomitantly proportionally more blood is being supplied by the poor, the unskilled, the unemployed, Negroes and other low income groups and a new class is emerging of an exploited human population of high blood yielders Redistnbution in terms of 'the gift of blood and blood products' from the poor to the nch appears to be one of the dominant effects of the Amencan blood banking system This IS a very damning statement against the system Certainly a harsh political statement which cannot be Ignored £,
COSTS Fnedman & Rakoff (1977) express the view that The activities of health is especially prone to overstatement of rhetonc, oversimplification of issues and underestimation of costs' Whilst I do not have much sympathy ivith most of those views, their point about 'costs' is quite valid m the US Indeed their ating of a foreword by Daniel Moynihan in Federal Health Spending 1969-74 (Nahonal Planning Assoaation, Washington 1974) to illustrate the gap between intent and outcome m US health policy might be called an 'overstatement of rhetonc' but I think it makes a valid case Moynihan wntes There is m the federal process an illusion of accomplishment We proposed and passed legislation, signed some bills, set up an agency or two But one finds afterwards that nothing has actually occurred — something has only been incurred Years after you thought you had a big program going to solve a particular problem, you discover you have, in fact, nothing
International implications The dangers are not limited to the US for, as Titmuss shows, the US pharmaceuhcal companies have well developed international markets m blood products, mduding the United Kingdom 492
Capital expenditure There have, however, been some commendable attempts made by the federal government to restnct unnecessary
Politics of Amencan health care
capital expenditure on health care facilities, all of which REVENUE COST CONTROLS were legitimized by the 1974 National Health Planning Since the 1970s, there have been marked attempts to and Resources Development Act (Rafifel 1980) It was a control revenue costs of Amencan health care and this has valiant attempt to marry the work of new Health Systems resulted in activities related to Diagnosis Related Groups Agencies (HSAs) with that of the state planning agencies (DRGs) For, in the 1970s, research m the US began to focus The act authonzed a network of local health planning lnshin particular on the nature of the hospital 'industry', as tutions and called for more than 200 HSAs 'which conMcMahon (1987) indicates A key research goal was 'to sumers were to dominate' Marmor (1983) stresses, as identify sunilanties and explam differences between hospi'powerful forces in shaping local health plans' and to 'cut tals' The focus of this analysis 'was on the resources medical care costs, improve access to medical care, and expended, which had grown rapidly after the adoption of assure it high quality' It was also hof)ed that the act would the federal insurance programmes and with the inflationary remove the problem of the HSAs 'being hampered m sixties £ind seventies' making project reviews because of a lack of standards or It soon became evident that the hospitals' resource-use catena on which to make decisions', Raffel (1980) points was closely linked with its 'case mix' The concept of definout ing groups of similar patients for utilization review raised But Raffel regrets that the HSA was not provided with the prospect that these groups might be used as a 'template any authority over federal health facilities which, he for payment', McMahon suggests A major project was argues, are 'an important part of national health therefore undertaken at Yale University m conjunction resources and serve millions of people' This, together with with the Federal Social Secunty Administration and the the fact that there appears to have been little support for State of New Jersey The outcome of this was that 383 the HSAs from local govemments, community and progroups of DRGs were identified and tested in the State of fessional groups, pnvate health care providers and others New Jersey working in the health industry, impeded greatly the 'ability In December 1982, the HHS secretary Richard of the local and state health planning agenaes to carry out Schweiker outlined a 'prospective' payment system which the responsibilities given them by Congress' This has was based upon DRG pahent definitions and which was resulted m a 'relatively low level of optimism' being meant, McMahon points out, 'to ensure that Medicare expressed by HSA Board members would become a prudent purchaser of hospital care for its Marmor has an equally low level of optimism and beneficianes' believes that the HSA mandate is 'more symbol and Since then the DRG system of payments has expanded rhetonc than significant potenhal' which reaches far and has clearfinancialadvantages as the previous system of beyond the agenaes' capabilities, in his view He further retrospective payments often meant that one hospital argues that the HSA's authonty is so severely restncted might charge $1,500 to care for a patient with a 'heart that it IS 'almost certainly insufficient to reshape the local attack' and another would charge $900 politics of mediane' Even Wilson & Neuhauser (1982) accept that There has been disagreement as to the effectiveness of the HSAs and Advantages to the patient the future is problematical' For example, under 1981 Bevan (1987) cites the example of the impact of DRG federal budget legislation, Amencan states may now payments for hip replacement surgery in the US to demonrequest that health planning activities under the federal strate that there are more than economic advantages programme be camed out at state level only, eliminating the HSAs Furthermore, Wilson & Neuhauser add, by The average length of stay was reduced from 18 days to 9 1981, virtually all Amencan states had 'Certificate of Need' Not only hospital costs were reduced, patients suffered less statutes to control capital expenditure on health facilities pam, had fewer complications and enjoyed faster recovery This legislation requires evidence to be produced to and earlier retum to work and normal activihes the reason demonstrate the 'need' in the community for any proposed for these changes not being made previously appears to have new or expanded health service or faality But this, Wilson been a lack of incentive in a system of full-cost reimbursement & Neuhauser argue, is an outcome of the 1974 Nationai Health Planning and Resources Development Act as this And Jenkins (1987) is equally enthusiastic and argues that 'mandated the enactment of such statutes as a condihon of some encouragement is to be denved from the way the US receiving certain federal grants' Yet another example of health care industry has responded to the challenge of central influence on health care developments m the USA DRGs 'with positive results' 493
JP Smith
According to a recent article in Newsweek (1989), the growing emphasis on cost-consciousness m the US health care system has also, it is claimed, 'helped improve prevention — by pushing companies to do more health screenings, fund prenatal care and adopt employee "wellness" programs' Medicare has also been boosted to provide community care outside of hospitals With an eye to future trends, the article argues that, with no end to the cost spiral in sight, 'respected specialists are beginning to question whether the current, patchwork system of public and pnvate funded medical coverage can work anymore'
AMERICAN NURSES A N D POLITICS Given that Amencan nurses probably make up the largest nursing workforce in the world, it is somewhat surpnsing to note their lack of mention in the political literature as a potential (or actual) political force m Amencan health care Yet as long ago as 1930, Annie Warburton Goodnch, founder of the US army nursing school dunng the First World War and later the foundation dean of Yale University School of Nursing, was stating 'As a believer in soaalized educahon I am naturally a believer in soaalized mediane and nursing, since health, physical, mental and emotional, is as important for effective citizenship as educahon, or is indeed fundamental to it For the State to assume the responsibility for one and not the other seems inconsistent' (Goodnch 1973) It IS true, as Wilson & Neuhauser (1982) note, that the Amencan Nurses' Assoaation (ANA) is one of a number of organizations which are active lobbyists in Washington DC and which 'have to a greater or lesser degree activities directed toward general health problems and issues' But numencally the ANA is certainly not as strong as it could be Its Bntish counterpart, the Royal College of Nursing (RCN), with its membership neanng 290 000, now boasts of being the largest professional nursing organizahon m the world It certainly has a significantly larger proportion of the potential membership than the ANA has and a larger actual membership than ANA There has been an undoubted emphasis in Amencan nursing on both professionaLzation and speaalization and associated demand for appropnate levels of higher educahon to achieve these goals That may weU have contributed, madvertently, to the lack of a uruted (political) Amencan nursmg movement, for, m recent decades, there has been a proliferation of separate and mdependent specialist nursmg assoaahons m the USA The RCN constituhon provides faalihes for the provision of speaalist assoaahons and soaeties withm its total organization and 494
this may well account for its greater size and greater political clout m health matters It might be argued that the growth of the nurse practihoner movement in the US in the past 20 years has helped provide good and cheap health care, espeaally in pnmary health care settmgs, and that development could be construed as a 'political statement' by nurses in the US against high cost health care But I would argue that the nurse practitioner movement is more of a 'professional statement' in the cause of the goal of professionalization of Amencan nursmg Interestmgly, this seems implicit m Owen's (1988) assessment of US nurse practitioners The US expenence shows, he says, 'that the nurse practitioners do not challenge the role of doctors but complement their skills with different skills' One IS left therefore with the dishnct impression that Amencan nurses have much more to do to achieve an effechve level of group political consaousness m the way the AMA has done Amencan nurses today seem lightyears away from Annie Goodnch's claim and conviction (in 1925 at an lntemational conference), when she spoke of the 'significant fact' — 'the obvious importance of the rapid creahon of that genus of the health movement called nursmg', which, she hastened to add, 'must not be understood as asserting the super-value of the nurse'
NEW PROBLEMS There are new problems, identified by Newsweek The government has tightened its payments to hospitals It has clapped surtax on wealthy senior citizens to help pay for a new catastrophic-health msurance plan' But for the poor it IS becoming even more of a problem as coverage under Medicaid 'has eroded to a point where a family of four with an annual mcome of more than $4 248 is no longer eligible for benefits' As many as 37 milhon working Amencans (17% of the population), 'many self-employed or working for small businesses — have been left without any health msurance at all' Furthermore, Momson (1989) also pomts out that even though the US 'spends large sums for health and medical care', life expectancy m the US 'is no better than in nations that spend less'
Dumping the uninsured Another dilemma is ated by Ansberry (1988). In the past, US hospitals have, he claims, passed costs of 'chanty care' onto patients covered by insurance — but this has now changed because of the escalating costs That, together
Politics of Amencan health care Figure 1 Letter from AMA to the author
/ y ^ '^t\
-AMERICAN MEDICAL ASSOCIATION
\H\»^_y/y
S3SN0«tMD£A«»WNSTII£CT
CMtCAOO luiNdSKKlO
PHONE (31216*6 MOO F*i3121M5«lW
T«w,28-024B
January 23, 1989 Dear Mr. Smith The American Medical Association has not adopted a definitive position on 'socialized healthcare' but does have such an opinion on the Canadian Healthcare System, which is defined as such a system. That opinion is enclosed If there is more that we may provide for you in this area, please do not hesitate to call or write
Encl.
with the fad that fewer than 'two out of five poor Amencans are covered by Medicaid today', has resulted in some 15 million Amencans bemg denied care or 'don't seek it because they can't affort it' This, he claims, has resulted in an mcrease m the 'dumping' of the poor mto public hospitals 'While dumping is most closely associated with the uninsured', Ansberry wams that 'the country's 50 million underinsured are at nsk as well' Nevertheless, accordmg to the Newsweek article, there are changes afoot which could radically alter the Amencan health care system It predicts that m the next 10 years, up to 80% of the insured populahon will be enroUed in HMOs and Preferred Provider Organizahons (PPOs) Both HMOs and PPOs are prepaid 'managed care' plans which also use utibzation management companies' to monitor doctors' decisions This, as Newsweek points out, 'will demand a fundamental change m the way society thinks about medicine — a change some industry experts believe may be for the better' Citing two recent papers in the New England Joumal of Medicine, Newsweek finds support for its contention that there is a growing feeling m the US for 'a nationwide health care program that would mesh public and pnvate efforts' Not surpnsmgly, Newsweek is also forced to condude that Any such move is sure to draw strong opposition from
many companies' and others, mcludmg the AMA, 'who would see it as a step towards socialized medicine'
AMA POSITION ON SOCIALIZED MEDICINE 1989 History would certamly seem to support the contention that there is little, if any, support for anything relatmg to 'socialized' medicine from the AMA It was with some surpnse therefore that, in a personal communication from the AMA, I was mformed that the AMA 'has not adopted a definihve posihon on "sociabzed health care'" (Figure 1) But the AMA does have an opmion on the Canadian health care system (Figure 2) Perhaps this illustrates that the AMA as well as being politically astute is also cunnmgly pragmatic The AMA probably needs a bit of both, for Owen (1988) points to the irony of the situation, when assessmg the US medical profession today In the Uruted States, where the medical profession has hitherto been able to claim greater freedom than in the UK because oftixeabsence of governmental control, there is a real prospect that before the end of this century its members will be envying the clinical freedcnn of their professional 495
; P Smith Figure 2 AMA Statement on Canadian Health Care System
January 11, 1989 Statement is attributable to James S. Todd, M.D. Senior Deputy Executive Vice President American Medical Association AMA RESPONSE TO U S ADOPTION OF CANADIAN HEALTH CARE SYSTEM AS PROPOSED BY PHYSICIANS FOR A NATIONAL HEALTH PROGRAM IN THE JANUARY 12 ISSUE OF THE NEW ENGLAND JOURNAL OF MEDICINE For over 25 y e a r s , the American Medical A s s o c i a t i o n has been working to ensure u n i v e r s a l access t o h e a l t h care through improvements i n t h e United S t a t e s p l u r a l i s t i c methods of h e a l t h care d e l i v e r y Over t h e y e a r s , the AMA has proposed changes i n the c u r r e n t Medicare and Medicaid programs, t a x i n c e n t i v e s for employers who o f f e r h e a l t h insurance coverage t o t h e i r workers, and s t a t e r i s k pools t o cover those Americans who f a l l through t h e cracks i n t h e p r e s e n t system "Although Canadians have achieved l i m i t e d success in c o n t a i n i n g t h e i r h e a l t h care c o s t s , the AMA b e l i e v e s t h a t t h e American p u b l i c would s t r e n u o u s l y o b j e c t to the ' p r i c e ' Canadians paid for ' n a t i o n a l h e a l t h c a r e ' — l i m i t a t i o n s , cutbacks and delays i n s e r v i c e and treatment "The Canadian c o s t - c u t t i n g e f f o r t s have meant delaying new c o n s t r u c t i o n , l i m i t i n g the purchase of new equipment and c u t t i n g back on h o s p i t a l beds Waiting l i s t s for most non-emergency s u r g e r i e s a r e commonplace Cardiac bypass, h i p replacements, and c a t a r a c t o p e r a t i o n s a r e routinely scheduled on a c r i t i c a l need basis with less c r i t i c a l cases being put on waiting l i s t s . In Vancouver, the wait is one to three months for a psychiatric, neurological or routine orthopedic opinion; six to nine months for cataract extraction, two to four years for corneal transplantation, and six to 18 months for admission to a long-term placement bed "Another price the Canadian public has had to pay is slow introduction and bleak availability of some of the advances in high tech medical advances which U S citizens expect to have available. At last count, Canada had a total of 12 nuclear magnetic resonance units in the entire country Newfoundland has only one CAT scanner "Despite the problems experienced in Canada with their health care system, the AMA is not ignoring what the Canadians have done. Building on the strengths of our current system, the AMA will continue to work to improve access our p l u r a l i s t i c health care system for a l l Americans
colleagues in Britain It will be an odd reversal of roles if the Amencan Medical Assoaahon, the bitter aitic of soaalized mediane, has to swallow far more dinical controls within the orbit of market medicine than ever the state would dare to mipose on a vocal lobby like the Bntish Medical Assoaahon Only the future will tell whether or not there is any truth m the predichons produced by the irony (on either side of the Atlantic) A kno I d t ° Thanks are acknowledged to Dr Arthur Lipow, Lecturer m AmencanPobhcs,Birkbeck College, University of London, for his help and encouragement 496
References
Ansberry C (1988) Dumpmg the poor Wall Street Journal/Europ (30 November), 10 ^ ^ ^ ^ ^l^^^) Usmg DRGs to plan unproved health distnct performance In DRGs and Health Care (B^dsley M, Coles J & Jenkms L eds), Kmg Edward Hospital Fund for London, London, pp 111-118 Campion F D (1984) The AMA and US Health Policy since 19 Chicago Press Review, Chicago Fnedman KM & Rakoff SH (1977) TouwfrfflNflhowi/Hea/f/) Pohcy Heath, Lexington, Mass Goodnch AW (1973) The Soaal and Ethcal &gmfiama of Nursing A Senes of Addresses Yale University Press, New Haven
Politics of Amencan health care
Jenkins L (1987) Reimbursing hospitals by DRGs In DRGs and Health Care (Bardsley M , Coles J & Jenkins L eds). King Edward Hospital Fund for London, London, pp 43-60 Marmor T R (1983) Political Analysis and Amencan Medtcal Care Cambridge University Press, Cambndge Mayhew D R (1974) Congress The Electoral Connectton Yale University Press, New Haven and London McClure W (1977) The medical care system under National Health Insurance, Four Models In Toward a National Health Policy (Fnedman K M & Rakoff S H eds). Heath, Lexington, Mass,pp 189-230 McMahon LF (1987) The development of diagnosis related groups In DRGs artd Health Care (Bardsley M , Coles J & Jenbns L eds). King Edward Hospital Fund for London, London, pp 29-42 Momson M (1989) Health care — why the crisis? The Platn Truth (March) 3-6 Myers RJ {1970) Medtcare McCahan Foundation, Bryn Mawr, Penn
Newsweek (1989) The high cost of gettmg sick. Newsweek CXIII (5) 32-36 Owen D C (1988) Our NHS Pan Books, London, Sydney and Auckland Raffel M W (1980) The US Health System Ongtns and Functions Wiley, New York Record J C (1977) Medical politics and medical pnces the relation between who deodes and how much it costs In Toward a National Health Policy (Fnedman K M & Rakoff S H eds). Heath, Lexington, Mass, pp 71-106 Titmuss R M (1970) The Gift Relationship Allen & Unwm, London Wilson C N (1989) The USA Medicare Catastrophic Coverage Act (1988) Joumal of the Royal Soaety of Health 109(2), 57-59 Wilson F A & Neuhauser D (1982) Health Services in the United States Ind edn Ballinger, Cambridge, Mass
497
The politics of American health care James P Smith OBE BSc(Soc) DER SRN RNT BTA Certificate FRCN FRSH Editor, Joumal of Advanced Nursing and Vtsiting Fellow in Nursing Studtes, Dorset Institute
Accepted for publicahon 12 June 1989
SMITH J P (1990) Joumal of Advanced Nursmg 15, 487-497 The politics of American health care The developments leading to the present Amencan health care organization are traced It is clear that hospitals have dominated at the expense of pnmary health care programmes Health care costs have soared dramatically There are particular problems inherent in a system shared between federal and state governments and a pnvate health care industry Attempts to provide a fully (or partially) tax-funded health service in the USA have been bedevilled by a number of factors These include opposition from labour unions, politicians, vested-interest groups and, in particular, the Amencan Medical Association As part of its opposition, the AMA politicized itself m 1950 But, in the pohtical literature, Amencan nurses are not portrayed as bemg very politically active Reasons for this are explored The introduction of Medicare and Medicaid programmes is discussed and the legal, social and political implications Recent attempts in the USA to control costs are assessed and new trends and new problems identified
HOSPITALS At the tum of the century, there were only a few hospitals m the USA and these were based in the major cihes They adopted the Bnhsh organizational structure — and served the poor 'The affluent and middle class were treated at home' (McMahon 1987) These early hospitals were financed almost exclusively from voluntary donahons Eventually, they grew m numbers, but m a fragmented and disorganized way, often idenhfymg with a particular geographical area m a aty or with a particular group, eg Catholic, Jewish In due course, voluntary subscnptions proved insufficient to support the hospitals and from the early 1900s many hospitals began to introduce a 'patient charge' By the late 1920s, because of the very high losses faced by the hospitals, not least because of the inability of many patients to pay for their care, a new system of payment was introduced — third party payment This as McMahon points out 'developed mto nongovernmental hospital insurance plans' Since then, the scale of hospital costs has contmued to mcrease dramatically as a result
of increasing use of high technology and the effects of mflahon Sick care dommation Inevitably, but sadly, hospitals dominate the US 'health' scene (as m all parts of the developed world) The dominance of hospital care at the expense of essential developments in pnmary health care are noted by Owen (1988) He pomts out that in 1987, when US national expenditure on 'medical care' had reached $275 billion, 'only 5% of that budget was devoted to health promotion with 95% devoted to disease care' Indeed, Fnedman & Rakoff (1977) argue that The central problem for US health pohcy' is that 'what passes for health policy appears m reality to be policy designed to deal with the cost, distnbution or access to Sick care ' This is due, they claim, to, among other thmgs, 'the problem of measunng health as opposed to measunng medical services' Further concem is expressed by Momson (1989) who claims that 'Studies have suggested that many surgenes are unnecessary' m the US, 487
JP Smith
and goes on to mdicate that 'perhaps half of lower back disc operations, up to 70% of hysterectomies and coronary bypasses' may have been performed without need m the US
GOVERNMENT HEALTH INSURANCE ADVOCATES Possibly the first advocacy of a governmental health insurance programme in the US was 'a plank in the platform ofthe Socialist Party in the early 1900s', accordmg to Myers (1970) Subsequently, when Theo Roosevelt founded the Progressive Party before the 1912 elections 'a plarJc supporting national health insurance was included m its platform' Myers also argues that the Amencan Association for Labour Legislation (AALL), a coalition of actuanes, lawyers, social saentists and economists founded m 1906, had a most important role m the legislahve movement for health insurance', particularly dunng 1912-1918 At its inception AALL was interested pnmanly m promoting state workmen's compensation laws as well as payments for medical care for mdustnal acadents and diseases, and Myers claims that 'it was extremely successful in that venture' AALL was active up to the Second World War (when it faded out of existence) The AALL was so impressed with the Bnhsh 1911 Nahonal Health Insurance legislation that, m 1912, it drafted a similar bill for 'state action' In 1915, a second bill, modelled more on the German eammgs-related system, was drawn up by AALL and this formed the model for bills introduced into several state legislatures But, generally, the states did not a d on these bills Instead, Myers points out, they merely appointed mveshgatmg committees to study the matter further
AMA 1917 'Most mterestmgly' (to use Myers' words), a committee of the Amencan Medical Associahon (AMA) worked 'actively and even enthusiastically' with the AALL on the 1912 project Myers refers to the Joumal of the AMA of 9 June 1917 where the view was expressed that' the time IS present when the profession should study earnestly to solve the queshons of medical care that will anse under vanous forms of soaal insurance Blind opposihon, mdignant repudiation, bitter denunaation of these laws is worse than useless ' This was a view that was however not followed m the later 'great Medical debate' of the 1950/ 60s, as Myers quickly points out In fad, the AMA was already not prachsmg the message preached m that arhde by the time it was wntten For 488
dunng 1917-1920 the bills modelled on the AALL's bill were introduced to about 15 state legislatures and the AMA was one of a 'wide vanety of sources of opposition', Myers (1970) notes Another vigorous source of opposition was the large insurance companies, not least (so it was supposed) because of a proposal to include a lump sum death payment Most employers and their organizations were also positively opposed to the proposed legislation as well as the Chnstian Science Organization 'But perhaps the crowning blow of all was the opposition of the AFL' (Amencan Federation of Labour) This, Myers suggests, was motivated by the belief that social insurance would divert workers from their 'real goal' of 'higher wages and shorter hours and would, at the same time, deaease the dependency of the workers on the union' There was also another major factor working against the proposed legislation The First World War was m progress and, therefore, domestic legislation had to take second place to the considerahons of war There was also a great deal of anti-German feeling in the US at the time and the 'Germanic latjel' of the proposed legislation was a hindrance After the war, the 'nse of the Bolsheviks provided another epithet', Myers contends Nevertheless, whilst all this activity was going on withm the state legislatures, there was also a good deal of federal activity related to soaal insurance developments In 1915, a US Commission on Industnal Relations recommended a system of soaal msurance payments for all workers, compulsory for workers 'engaged m inter-state commerce' and on a voluntary basis for other workers (Myers 1970)
Committee on Costs of Medical Care 1927 In 1927, a Committee on Costs of Medical Care was set up Dunng its 5 years' existence, the committee chairman was made a member of President Hoover's cabmet However, at the end of its dehberahons, the committee found it impossible to reach a consensus In the early 1930s, President F D Roosevelt attempted to fight the effects of the great depression by, among other thmgs, developing an extensive system of long-range social insurance and short-term pubhc assistance He appomted a Committee on Economic Secunty (CES) to study these matters and to develop draft legislation But, because it was rushed, controversial and met with much opposition, no immediate legislahon was proposed either by the CES or by President Roosevelt There was also another fear, Myers (1970) suggests, 'the possibihty that any such proposal would be declared unconshtutional' and pull down with it the old age and unemployment t^enefits But he adds that
Politics of Amencan health care
some have challenged that contention and associate it with undue timidity' on the part of the proponents of nationai health insurance at the tune In 1933, a group of Amencan physicians attempted to foster the cause of a 'universal system' of medical care Their New York-based Medical League for Socialized Medicine, which also had non-physiaans in membership, gained considerable support in the academic world but no widespread popular or legislative support The organization quickly died and, as Myers points out, there has been very little of that kind on advocacy in the US since By 1935, the AFL had modified its earlier opposition to social insurance 'In considerable part', Myers believes 'this was probably because of the effects of the depression' But also, he hastens to add, the AFL's then president (William Green) had a much more positive and constructive athtude towards social insurance than his predecessor (Gompers) had In any consideration of politics the influence of chansmatic personalities on progress and change can never be underestimated, it must be acknowledged, even if it is difficult to measure the impact of chansma
Social Security Act 1935 In spite of powerful opposition in some circles the Social Security Act of 1935 was passed, facilitating public assistance to blind, dependent and aged people and children Following the passage of this act. President F D Roosevelt established the Interdepartmental Committee to Coordinate Health and Welfare Activities This committee appointed a Technical Committee on Medical Care which was charged to formulate outlines for what was later to be the first formal proposal for a nationai health programme m the US The recommendations were presented at a Major National Health Conference in 1938 which was, m the view of Myers, 'the ftrst truly nationai discussion of the broad subject' A general consensus emerged from that conference about principles for improving the US nation's health but there was no accompanying consensus about the apportionment of costs of care between the federal and state govemments That problem seems to have persisted ever since m the USA An amended version of the recommendations however was presented by Senator Wagner (Democrat) in the form of the 'Wagner Bill 1939' On that occasion, there was strong support from consumer groups and the Senate subcommittee reported m its favour But 'm view of the opposition' from the AMA, state medical soaeties and other groups of professionals, the bill 'was not brought to the vote', Myers records In fact, the Wagner Bill was very
similar to the Medicaid programme enacted in 1965 (discussed later in this paper) — but the Wagner proposals were more comprehensive It was to be a state-by-state approach with a federal support grant After the failure of the Wagner Bill, 'the executive branch concentrated on nationai proposals for health insurance linked with, or integrated into' the national social insurance system of old age and survivors Bills along these lines were introduced in the late 1930s and the 1940s and 1950s But these times were not any less turbulent politically as Campion (1984) points out
START OF AMA POLITICIZATION 1950 In 1948, accordmg to Campion (1984), everyone in the US was expecting President Truman to make good his campaign promises for a health bill As a result, to strengthen opposition, the AMA decided on a strategy 'to take its case to the public' And, as Mayhew (1974) records, in 1950 those congressmen known to be supporters of health insurance found themselves confronted with the effects of a million dollar advertising campaign conducted by the AMA Individual AMA members started election committees which. Campion claims, are credited with bringing on the defeat of at least three senators m the 1950 elections That view is supported by Mayhew who says that 'By 1952, it was widely believed that the AMA had deaded some elections, and few congressmen were still mentiorung insurance' Later, in 1957, the AMA felt further threatened by the proposals in the Forand Bill which had a great deal of support from senators and others This bill proposed hospitalization msurance through soaal secunty for the retired population The professional ire of the AMA was roused because they saw this as part of the ultimate goal of 'compulsory nationai insurance for everyone' (Campion 1984) The AMA then determmed to strengthen the effectiveness of its opposition by begmmng to take a more active mterest m the formation of Political Action Committees (PACs) Dunng the 1950s, physicians in a few Amencan states joined m coahtion-style political action organizations, e g Indiana Health Organization for Political Education (I-HOPE) By October 1958, moves were already afoot m the AMA to start a PAC and the AMA sought legal views on the legal implications of such a move Though the idea of a PAC had many backers, the heat was taken out of the debate about the pros and cons of sudi a move by the blockmg (m 1959) of the Forand Bill by the Ways and Means Committee whose conservative chairman Wilbur Mills (Democrat Arkansas) was workmg with Robert Kerr 489
/ P Smith (Democrat Oklahoma) 'on a different kind of solution to the health needs of the elderly indigent'. Campion (1984) points out (The Kerr-Mills Bill which emerged received AMA support and was passed and signed in 1960 by President Eisenhower) In October 1959, an AMA subcommittee was set up to explore the idea of a PAC The subcommittee voted not to start a PAC but, instead, encouraged AMA members to participate in local PACs 'as citizens' According to an AMA survey conducted in February 1960 (cited by Campion), by then, groups of politically oriented physicians had helped to launch a number of state-wide PACs By Apnl 1960, the AMA board had voted $7500 for three regional meetings to educate physicians in political techniques and on the creation of PACs This development triggered off much debate in the organization but the AMA still did not reach any firm deasions about the creation of its own PAC
The Kennedy era — AMP AC formed The turning pomt occurred dunng the J F Kennedy presidential elections according to Campion This took place early m 1961 when Kennedy became known as 'a supporter of sweepmg health legislation', which made the AMA Board approve the formation of the Amencan Medical Political Action Committee (AMPAC) as an independent political arm of the AMA It was 'a non-profit, voluntary, bipartisan, unincorporated political action committee, with emphasis on bipartisanship' Membership was open to AMA members, their spouses and families — and others Its goal was a strong conservative (Democratic and Republican) coalition m the Congress It also aimed to maintain good communication with the leaders of both parties (and therefore would not be involved m presidential elections) In 1961, AMPAC had 13 416 members, this had increased to 126 220 by 1974 Within its first 15 months of existence, AMPAC had sponsored organized PACs in 45 Amencan states Campion (1984) claims that AMPAC's creation marked the beginning of 'a highly successful effort to give a political education to Amencan physicians' Initially, AMPAC concentrated its resources on candidates m elections that were expected to be close, but by the end of the 1970s AMPAC was backing 220—240 congressional races every 2 years, of which 30 to 40 were probably pnmary contests According to Campion, AMPAC has claimed that about 70-80% of the candidates it has backed 'have won their races', though given the amount of lobbying by other organizations, a common aspect of Amencan pohtical life, I suspect that AMPAC cannot claim the whole victories for themselves 490
Campion also argues that AMPAC has raised the level of 'sophistication with which organized medicine has been able to conduct its business with state and federal governments' He further argues that, thanks to AMPAC's 'trainmg ground', a new generation of AMA leaders came to power who had 'a more realistic understandmg of the political process' and 'were better equipped to operate within it'
AMA allies But, in truth, even without sophisticated political acumen, dunng the entire period after 1950, the AMA always seemed to organize an effective (in their view) opposition with the aid of its very strong and powerful allies Myers (1970) points out that the battle lines were by then clearly drawn between the opponents and the proponents of 'health benefits under social insurance' The AMA opposition had strong allies in the Amencan Hospitals' Association (AHA), the Blue Cross Association (BCA), the National Association of Blue Shield Plans, insurance companies and business groups, all of whom it should be pointed out had a great deal of vested interest in third party health insurance However, as Myers concedes, many of the opponents accepted there was a 'problem' for those over 65 But in spite of that they strongly opposed the 'social insurance pnnciple' In due course, as legislation seemed more imminent, the AHA and BCA apparently adopted a 'more neutral position'
UNIONS The proponents of social insurance pnnciples included social workers and organizations representing people over 65, as well as labour unions However, whilst it might be argued that any support for social progress is better than none at all, the intensity of the political clout of Amencan unions IS doubted by Wilson & Neuhauser (1982) because, m their view, the uruons tend to 'focus narrowly on pay, fnnge benefits, and working conditions, rather than on creating political parties or stnving for wide-rangmg social objectives' Nevertheless, they accept that US labour unions have played a role m US health care development 'through collective bargainmg for health insurance benefits with employers' Some unions have also helped to create Health Maintenance Orgaruzations (HMOs) HMOs provide a comprehensive health service for a monthly/annual premium (eg Kaiser-Permanente m California) The number of HMOs has nsen sharply since the Health Mainterumce Organization Act 1973 (a legislative response and reaction to the escalating costs of Medicare and Medicaid)
Politics of Amencan health care
and HMOs now account for around 30% of all US health care, according to Owen (1988)
MEDICARE INTRODUCED 1965 Medicare — the national programme of health msurance for the aged in the USA — was established in 1965 That year, in the view of Wilson & Neuhauser (1982), marked the culmination of many years of national and congressional debate and is of great histoncal significance' as the Social Secunty Amendments Act was passed which introduced Medicare and provisions for an expansion of the Kerr-MiUs medical assistance programme to groups other than the elderly These were known as 'Medicaid' programmes The Social Secunty Amendments Act of 1972 made extensive amendments to the Medicare and Medicaid programmes, 'many addressed to the control of costs' which had nsen as a result of massive inflation Thereafter, the persistent problem of escalating costs was dealt with in a number of Social Secunty Amendments Acts dunng 19741981 when vanous measures to control costs and improve cost-effectiveness were introduced In 1977, a new Federal Health Care Fmancmg Administration was created to assume pnmary responsibility for the Medicare and Medicaid programmes (Perhaps, it might be argued, this was the embryo of a potential centrally-financed national health service)
1988 Legislative changes The most recent legislation — the Medicare Catastrophic Coverage Act 1988 'is considered the largest expansion of Medicare in 23 years' according to Wilson (1989) This act will cover Medicare patients (l e those aged 65 + and the disabled) against nsing health care costs, including home care and outpatient drugs Extended coverage for the poor under Medicaid is also provided for in the 1988 Act Whilst some of the additional costs will be financed from extra tax payable by the Medicare beneficianes themselves, Wilson prophesies that 'it Cein be expected that the general population will be asked to finance the growth in medical expenditures', espeaally as the numbers of those over 65 in the Amencan population increase over the next 3 decades Already, Wilson points out. Medicare has become Amenca's largest single purchaser of physician and hospital services That, in my view, is of particular political significance, esf)eaally m view of the fact that this has resulted in the federal government's health care costs escalating faster than the general cost of hving In 1966, Medicare costs were $11 billion, these had reached $76 billion by 1986, according to Wilson And as Marmor (1983) pertinently
points out, this substantial expansion of governmental health expenditure since 1965 has pohtical implications and ramifications According to Marmor, by 1976 the US public sector was providing 42% of Amencan health expenditures, compared with only 26% in 1965 (and 13% in 1930) It is not surpnsing therefore to leam that the activities of the state have now been 'extended to determining the appropnateness of facilities, manpower training, accreditation, fee schedules, and even quality of medical care' Pohtical realities In reality, as Marmor further points out, the politics of health depend on the political factors that commonly affect other bnds of industry 'There is the same mixing and balancing between public and pnvate responsibility, the same marble cake of local, state and federal authonties and the same political culture and social structure' Record (1977) also argues that equivocation about the location of authonty, because of the ambiguities m the allocation of decision-makmg among all the entities noted by Marmor, not only exacerbate inflationary pressures but also encumber remedial action The political reality of public budgets and their sensitivity to politics. Record suggests, threatens health accomplishments and possibly has begun to erode credibility in the system Furthermore, he warns, 'Ambiguities often serve political needs' enablmg the Amencan Congress to play one sector off against another when 'the ultimate victor IS unpredictable at the time of legislative action' Record also argues that as a result of Congress acting with 'msensitivity to costs' in the legislation relating to health introduced in the 1960s and 1970s, Congress and the White House have now been forced mto acute cost consciousness by medical inflation He suggests that there is a new national mood m the US now which requires public accountability of the medical profession and competitiveness of the market, 'particularly when public monies are expended, the day of the federal regulator seems to have arrived' But McClure (1977) feels that the mcentives m the system which produce the problems are very strong and deep rooted to such an extent that strategies for change will 'require substantial change that will be politically difficult to achieve' Furthermore, m his view, a rational approach may well be frustrated by the lack of pubhc consensus as, he claims, Amencans have very genuine ideological and non-ideological options 'representing very different values, methods and consequences' However, Marmor argues, by way of explanation for the lack of national consensus, that for consumers m normal 491
JP Smith
health, the expected benefits or costs of a health care policy are, in any case, relatively unimportant to them For, he points out, their interests are diffuse and include not only health but also food, clothmg, shelter, education, recreation and employment (It is, however, interesting to note that the World Health Organization's definition of health as 'complete mental, physical and soaal well-being' would embrace all of these) Nonetheless, the situahon as descnbed by Marmor does, as he indicates, give the providers of Amencan health care (including doctors, hospital administrators, union officers, insurance underwnters) the greatest influence The reason is quite simple The providers are very knowledgeable and concemed about health care policy since it is important to their lives'
BLOOD SUPPLIES The vested interests of providers of health care in the USA have even been identified m those who supply blood for Amencan patients They too have power In 1962, after an investigation lasting several years, the Federal Trade Commission issued a complaint by two commeraal blood banks against the Kansas community (non-profit) blood banks They were charged with 'conspinng to boycott a commercial blood bank in the sale and distnbution of blood m commerce' (Titmuss 1970) In 1966, the Commission issued a ruling against the community banks (majonty three to two) Whilst the heanngs were in progress, bills were introduced into the two houses of Congress m 1964 and 1967 to exempt non-profit blood banks from anti-trust laws However, both bills failed, not least because of opposition from the commeracil blood banks and the pharmaceutical mdustnes (though the medical profession supported these bills') The ruling was later set aside in January 1969 by the 8th Circuit Court of Apjjeal m St Louis 'Though this may be the end of the particular case', Titmuss stresses that 'the fact that it happened is one illustration among many of the increasing commercializahon of the blood banking system ' That is fraught with dangers, he points out, for blood IS often bought from particularly nsky sources such as pnsoners and 'Skid Row' residents Titmuss's work in the US shows quite clearly that the paid blood donors there have a marked tendency to lie about past illnesses, especially about jaundice episodes
It was only in 1974 that the UK developed methods of detecting hepatitis B virus as Owen (1988) indicates Around that time therefore, he (as minister of health) issued instructions to the avil servants that the UK should become self-sufficient in blood supplies and products As it was, his instructions were ignored and, throughout the 1970s, US blood products continued to enter the UK 'As a result,' Owen argues, 'there can be little doubt that some of the people who are now HIV positive and had received blood for haemophilia and other reasons were given blood products from abroad which had HIV in them' If that is the case for the UK, it must be even more senous for the countnes in the Third World Titmuss (1970) also finds that, as the commercialization of blood and donor relationships extends, 'Concomitantly proportionally more blood is being supplied by the poor, the unskilled, the unemployed, Negroes and other low income groups and a new class is emerging of an exploited human population of high blood yielders Redistnbution in terms of 'the gift of blood and blood products' from the poor to the nch appears to be one of the dominant effects of the Amencan blood banking system This IS a very damning statement against the system Certainly a harsh political statement which cannot be Ignored £,
COSTS Fnedman & Rakoff (1977) express the view that The activities of health is especially prone to overstatement of rhetonc, oversimplification of issues and underestimation of costs' Whilst I do not have much sympathy ivith most of those views, their point about 'costs' is quite valid m the US Indeed their ating of a foreword by Daniel Moynihan in Federal Health Spending 1969-74 (Nahonal Planning Assoaation, Washington 1974) to illustrate the gap between intent and outcome m US health policy might be called an 'overstatement of rhetonc' but I think it makes a valid case Moynihan wntes There is m the federal process an illusion of accomplishment We proposed and passed legislation, signed some bills, set up an agency or two But one finds afterwards that nothing has actually occurred — something has only been incurred Years after you thought you had a big program going to solve a particular problem, you discover you have, in fact, nothing
International implications The dangers are not limited to the US for, as Titmuss shows, the US pharmaceuhcal companies have well developed international markets m blood products, mduding the United Kingdom 492
Capital expenditure There have, however, been some commendable attempts made by the federal government to restnct unnecessary
Politics of Amencan health care
capital expenditure on health care facilities, all of which REVENUE COST CONTROLS were legitimized by the 1974 National Health Planning Since the 1970s, there have been marked attempts to and Resources Development Act (Rafifel 1980) It was a control revenue costs of Amencan health care and this has valiant attempt to marry the work of new Health Systems resulted in activities related to Diagnosis Related Groups Agencies (HSAs) with that of the state planning agencies (DRGs) For, in the 1970s, research m the US began to focus The act authonzed a network of local health planning lnshin particular on the nature of the hospital 'industry', as tutions and called for more than 200 HSAs 'which conMcMahon (1987) indicates A key research goal was 'to sumers were to dominate' Marmor (1983) stresses, as identify sunilanties and explam differences between hospi'powerful forces in shaping local health plans' and to 'cut tals' The focus of this analysis 'was on the resources medical care costs, improve access to medical care, and expended, which had grown rapidly after the adoption of assure it high quality' It was also hof)ed that the act would the federal insurance programmes and with the inflationary remove the problem of the HSAs 'being hampered m sixties £ind seventies' making project reviews because of a lack of standards or It soon became evident that the hospitals' resource-use catena on which to make decisions', Raffel (1980) points was closely linked with its 'case mix' The concept of definout ing groups of similar patients for utilization review raised But Raffel regrets that the HSA was not provided with the prospect that these groups might be used as a 'template any authority over federal health facilities which, he for payment', McMahon suggests A major project was argues, are 'an important part of national health therefore undertaken at Yale University m conjunction resources and serve millions of people' This, together with with the Federal Social Secunty Administration and the the fact that there appears to have been little support for State of New Jersey The outcome of this was that 383 the HSAs from local govemments, community and progroups of DRGs were identified and tested in the State of fessional groups, pnvate health care providers and others New Jersey working in the health industry, impeded greatly the 'ability In December 1982, the HHS secretary Richard of the local and state health planning agenaes to carry out Schweiker outlined a 'prospective' payment system which the responsibilities given them by Congress' This has was based upon DRG pahent definitions and which was resulted m a 'relatively low level of optimism' being meant, McMahon points out, 'to ensure that Medicare expressed by HSA Board members would become a prudent purchaser of hospital care for its Marmor has an equally low level of optimism and beneficianes' believes that the HSA mandate is 'more symbol and Since then the DRG system of payments has expanded rhetonc than significant potenhal' which reaches far and has clearfinancialadvantages as the previous system of beyond the agenaes' capabilities, in his view He further retrospective payments often meant that one hospital argues that the HSA's authonty is so severely restncted might charge $1,500 to care for a patient with a 'heart that it IS 'almost certainly insufficient to reshape the local attack' and another would charge $900 politics of mediane' Even Wilson & Neuhauser (1982) accept that There has been disagreement as to the effectiveness of the HSAs and Advantages to the patient the future is problematical' For example, under 1981 Bevan (1987) cites the example of the impact of DRG federal budget legislation, Amencan states may now payments for hip replacement surgery in the US to demonrequest that health planning activities under the federal strate that there are more than economic advantages programme be camed out at state level only, eliminating the HSAs Furthermore, Wilson & Neuhauser add, by The average length of stay was reduced from 18 days to 9 1981, virtually all Amencan states had 'Certificate of Need' Not only hospital costs were reduced, patients suffered less statutes to control capital expenditure on health facilities pam, had fewer complications and enjoyed faster recovery This legislation requires evidence to be produced to and earlier retum to work and normal activihes the reason demonstrate the 'need' in the community for any proposed for these changes not being made previously appears to have new or expanded health service or faality But this, Wilson been a lack of incentive in a system of full-cost reimbursement & Neuhauser argue, is an outcome of the 1974 Nationai Health Planning and Resources Development Act as this And Jenkins (1987) is equally enthusiastic and argues that 'mandated the enactment of such statutes as a condihon of some encouragement is to be denved from the way the US receiving certain federal grants' Yet another example of health care industry has responded to the challenge of central influence on health care developments m the USA DRGs 'with positive results' 493
JP Smith
According to a recent article in Newsweek (1989), the growing emphasis on cost-consciousness m the US health care system has also, it is claimed, 'helped improve prevention — by pushing companies to do more health screenings, fund prenatal care and adopt employee "wellness" programs' Medicare has also been boosted to provide community care outside of hospitals With an eye to future trends, the article argues that, with no end to the cost spiral in sight, 'respected specialists are beginning to question whether the current, patchwork system of public and pnvate funded medical coverage can work anymore'
AMERICAN NURSES A N D POLITICS Given that Amencan nurses probably make up the largest nursing workforce in the world, it is somewhat surpnsing to note their lack of mention in the political literature as a potential (or actual) political force m Amencan health care Yet as long ago as 1930, Annie Warburton Goodnch, founder of the US army nursing school dunng the First World War and later the foundation dean of Yale University School of Nursing, was stating 'As a believer in soaalized educahon I am naturally a believer in soaalized mediane and nursing, since health, physical, mental and emotional, is as important for effective citizenship as educahon, or is indeed fundamental to it For the State to assume the responsibility for one and not the other seems inconsistent' (Goodnch 1973) It IS true, as Wilson & Neuhauser (1982) note, that the Amencan Nurses' Assoaation (ANA) is one of a number of organizations which are active lobbyists in Washington DC and which 'have to a greater or lesser degree activities directed toward general health problems and issues' But numencally the ANA is certainly not as strong as it could be Its Bntish counterpart, the Royal College of Nursing (RCN), with its membership neanng 290 000, now boasts of being the largest professional nursing organizahon m the world It certainly has a significantly larger proportion of the potential membership than the ANA has and a larger actual membership than ANA There has been an undoubted emphasis in Amencan nursing on both professionaLzation and speaalization and associated demand for appropnate levels of higher educahon to achieve these goals That may weU have contributed, madvertently, to the lack of a uruted (political) Amencan nursmg movement, for, m recent decades, there has been a proliferation of separate and mdependent specialist nursmg assoaahons m the USA The RCN constituhon provides faalihes for the provision of speaalist assoaahons and soaeties withm its total organization and 494
this may well account for its greater size and greater political clout m health matters It might be argued that the growth of the nurse practihoner movement in the US in the past 20 years has helped provide good and cheap health care, espeaally in pnmary health care settmgs, and that development could be construed as a 'political statement' by nurses in the US against high cost health care But I would argue that the nurse practitioner movement is more of a 'professional statement' in the cause of the goal of professionalization of Amencan nursmg Interestmgly, this seems implicit m Owen's (1988) assessment of US nurse practitioners The US expenence shows, he says, 'that the nurse practitioners do not challenge the role of doctors but complement their skills with different skills' One IS left therefore with the dishnct impression that Amencan nurses have much more to do to achieve an effechve level of group political consaousness m the way the AMA has done Amencan nurses today seem lightyears away from Annie Goodnch's claim and conviction (in 1925 at an lntemational conference), when she spoke of the 'significant fact' — 'the obvious importance of the rapid creahon of that genus of the health movement called nursmg', which, she hastened to add, 'must not be understood as asserting the super-value of the nurse'
NEW PROBLEMS There are new problems, identified by Newsweek The government has tightened its payments to hospitals It has clapped surtax on wealthy senior citizens to help pay for a new catastrophic-health msurance plan' But for the poor it IS becoming even more of a problem as coverage under Medicaid 'has eroded to a point where a family of four with an annual mcome of more than $4 248 is no longer eligible for benefits' As many as 37 milhon working Amencans (17% of the population), 'many self-employed or working for small businesses — have been left without any health msurance at all' Furthermore, Momson (1989) also pomts out that even though the US 'spends large sums for health and medical care', life expectancy m the US 'is no better than in nations that spend less'
Dumping the uninsured Another dilemma is ated by Ansberry (1988). In the past, US hospitals have, he claims, passed costs of 'chanty care' onto patients covered by insurance — but this has now changed because of the escalating costs That, together
Politics of Amencan health care Figure 1 Letter from AMA to the author
/ y ^ '^t\
-AMERICAN MEDICAL ASSOCIATION
\H\»^_y/y
S3SN0«tMD£A«»WNSTII£CT
CMtCAOO luiNdSKKlO
PHONE (31216*6 MOO F*i3121M5«lW
T«w,28-024B
January 23, 1989 Dear Mr. Smith The American Medical Association has not adopted a definitive position on 'socialized healthcare' but does have such an opinion on the Canadian Healthcare System, which is defined as such a system. That opinion is enclosed If there is more that we may provide for you in this area, please do not hesitate to call or write
Encl.
with the fad that fewer than 'two out of five poor Amencans are covered by Medicaid today', has resulted in some 15 million Amencans bemg denied care or 'don't seek it because they can't affort it' This, he claims, has resulted in an mcrease m the 'dumping' of the poor mto public hospitals 'While dumping is most closely associated with the uninsured', Ansberry wams that 'the country's 50 million underinsured are at nsk as well' Nevertheless, accordmg to the Newsweek article, there are changes afoot which could radically alter the Amencan health care system It predicts that m the next 10 years, up to 80% of the insured populahon will be enroUed in HMOs and Preferred Provider Organizahons (PPOs) Both HMOs and PPOs are prepaid 'managed care' plans which also use utibzation management companies' to monitor doctors' decisions This, as Newsweek points out, 'will demand a fundamental change m the way society thinks about medicine — a change some industry experts believe may be for the better' Citing two recent papers in the New England Joumal of Medicine, Newsweek finds support for its contention that there is a growing feeling m the US for 'a nationwide health care program that would mesh public and pnvate efforts' Not surpnsmgly, Newsweek is also forced to condude that Any such move is sure to draw strong opposition from
many companies' and others, mcludmg the AMA, 'who would see it as a step towards socialized medicine'
AMA POSITION ON SOCIALIZED MEDICINE 1989 History would certamly seem to support the contention that there is little, if any, support for anything relatmg to 'socialized' medicine from the AMA It was with some surpnse therefore that, in a personal communication from the AMA, I was mformed that the AMA 'has not adopted a definihve posihon on "sociabzed health care'" (Figure 1) But the AMA does have an opmion on the Canadian health care system (Figure 2) Perhaps this illustrates that the AMA as well as being politically astute is also cunnmgly pragmatic The AMA probably needs a bit of both, for Owen (1988) points to the irony of the situation, when assessmg the US medical profession today In the Uruted States, where the medical profession has hitherto been able to claim greater freedom than in the UK because oftixeabsence of governmental control, there is a real prospect that before the end of this century its members will be envying the clinical freedcnn of their professional 495
; P Smith Figure 2 AMA Statement on Canadian Health Care System
January 11, 1989 Statement is attributable to James S. Todd, M.D. Senior Deputy Executive Vice President American Medical Association AMA RESPONSE TO U S ADOPTION OF CANADIAN HEALTH CARE SYSTEM AS PROPOSED BY PHYSICIANS FOR A NATIONAL HEALTH PROGRAM IN THE JANUARY 12 ISSUE OF THE NEW ENGLAND JOURNAL OF MEDICINE For over 25 y e a r s , the American Medical A s s o c i a t i o n has been working to ensure u n i v e r s a l access t o h e a l t h care through improvements i n t h e United S t a t e s p l u r a l i s t i c methods of h e a l t h care d e l i v e r y Over t h e y e a r s , the AMA has proposed changes i n the c u r r e n t Medicare and Medicaid programs, t a x i n c e n t i v e s for employers who o f f e r h e a l t h insurance coverage t o t h e i r workers, and s t a t e r i s k pools t o cover those Americans who f a l l through t h e cracks i n t h e p r e s e n t system "Although Canadians have achieved l i m i t e d success in c o n t a i n i n g t h e i r h e a l t h care c o s t s , the AMA b e l i e v e s t h a t t h e American p u b l i c would s t r e n u o u s l y o b j e c t to the ' p r i c e ' Canadians paid for ' n a t i o n a l h e a l t h c a r e ' — l i m i t a t i o n s , cutbacks and delays i n s e r v i c e and treatment "The Canadian c o s t - c u t t i n g e f f o r t s have meant delaying new c o n s t r u c t i o n , l i m i t i n g the purchase of new equipment and c u t t i n g back on h o s p i t a l beds Waiting l i s t s for most non-emergency s u r g e r i e s a r e commonplace Cardiac bypass, h i p replacements, and c a t a r a c t o p e r a t i o n s a r e routinely scheduled on a c r i t i c a l need basis with less c r i t i c a l cases being put on waiting l i s t s . In Vancouver, the wait is one to three months for a psychiatric, neurological or routine orthopedic opinion; six to nine months for cataract extraction, two to four years for corneal transplantation, and six to 18 months for admission to a long-term placement bed "Another price the Canadian public has had to pay is slow introduction and bleak availability of some of the advances in high tech medical advances which U S citizens expect to have available. At last count, Canada had a total of 12 nuclear magnetic resonance units in the entire country Newfoundland has only one CAT scanner "Despite the problems experienced in Canada with their health care system, the AMA is not ignoring what the Canadians have done. Building on the strengths of our current system, the AMA will continue to work to improve access our p l u r a l i s t i c health care system for a l l Americans
colleagues in Britain It will be an odd reversal of roles if the Amencan Medical Assoaahon, the bitter aitic of soaalized mediane, has to swallow far more dinical controls within the orbit of market medicine than ever the state would dare to mipose on a vocal lobby like the Bntish Medical Assoaahon Only the future will tell whether or not there is any truth m the predichons produced by the irony (on either side of the Atlantic) A kno I d t ° Thanks are acknowledged to Dr Arthur Lipow, Lecturer m AmencanPobhcs,Birkbeck College, University of London, for his help and encouragement 496
References
Ansberry C (1988) Dumpmg the poor Wall Street Journal/Europ (30 November), 10 ^ ^ ^ ^ ^l^^^) Usmg DRGs to plan unproved health distnct performance In DRGs and Health Care (B^dsley M, Coles J & Jenkms L eds), Kmg Edward Hospital Fund for London, London, pp 111-118 Campion F D (1984) The AMA and US Health Policy since 19 Chicago Press Review, Chicago Fnedman KM & Rakoff SH (1977) TouwfrfflNflhowi/Hea/f/) Pohcy Heath, Lexington, Mass Goodnch AW (1973) The Soaal and Ethcal &gmfiama of Nursing A Senes of Addresses Yale University Press, New Haven
Politics of Amencan health care
Jenkins L (1987) Reimbursing hospitals by DRGs In DRGs and Health Care (Bardsley M , Coles J & Jenkins L eds). King Edward Hospital Fund for London, London, pp 43-60 Marmor T R (1983) Political Analysis and Amencan Medtcal Care Cambridge University Press, Cambndge Mayhew D R (1974) Congress The Electoral Connectton Yale University Press, New Haven and London McClure W (1977) The medical care system under National Health Insurance, Four Models In Toward a National Health Policy (Fnedman K M & Rakoff S H eds). Heath, Lexington, Mass,pp 189-230 McMahon LF (1987) The development of diagnosis related groups In DRGs artd Health Care (Bardsley M , Coles J & Jenbns L eds). King Edward Hospital Fund for London, London, pp 29-42 Momson M (1989) Health care — why the crisis? The Platn Truth (March) 3-6 Myers RJ {1970) Medtcare McCahan Foundation, Bryn Mawr, Penn
Newsweek (1989) The high cost of gettmg sick. Newsweek CXIII (5) 32-36 Owen D C (1988) Our NHS Pan Books, London, Sydney and Auckland Raffel M W (1980) The US Health System Ongtns and Functions Wiley, New York Record J C (1977) Medical politics and medical pnces the relation between who deodes and how much it costs In Toward a National Health Policy (Fnedman K M & Rakoff S H eds). Heath, Lexington, Mass, pp 71-106 Titmuss R M (1970) The Gift Relationship Allen & Unwm, London Wilson C N (1989) The USA Medicare Catastrophic Coverage Act (1988) Joumal of the Royal Soaety of Health 109(2), 57-59 Wilson F A & Neuhauser D (1982) Health Services in the United States Ind edn Ballinger, Cambridge, Mass
497
