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NATIONAL HEALTH CARE POLICY: WHERE ARE THE CHOICES COMING FROM?

The question “National Health Care Policy: What are the Choices?” suggests contending master plans with differing approaches to the various aspects of the nation’s health care. Actually, the choice is much more limited. The development of health policy in the United States tends to be incremental,’ with small pieces added in response to the balance of pressures from different interest groups. National health plans such as the Forward Plan for Health of the Department of Health, Education and Welfare (HEW)’ integrate reforms of this kind. Even as comprehensive a proposal as Kennedy’s Health Security:’ covers only financing and some aspects of administration, delivery, manpower, and quality control of health care. It links up with amended Social Security and Public Health Service Acts and leaves environmental and occupational health to other legislation. In addition to the need to coordinate new proposals with existing and pending laws, a further restraining factor is a set of influences which lay out, unofficially but effectively, what may and may not be done in health policy. The point was made several years ago that the health care system is very efficiently organized for the benefit of health industries and health-related industries and of health professionals.4 It has also been explained how national health policy in the U.S. is under the control of the small ruling group that controls the nation’s overall economy.5 Because of these constraints (i.e., the incremental nature of health policy and integration of new proposals with existing laws, as well as political-economic control of the health care system) the main national health policy proposals in congress and in the executive branch of government display only a relatively narrow range of positions on issues. For example, several major national health insurance proposals in the 95th Congress ( 1977-78) were Kennedy-Corman’s AFL-CIO-endorsed Health Security Act, S3; the Health Insurance Association of America’s National Health Care Act, S5; the American Medical Association’s Comprehensive Health Insurance Act. S218; and the catastrophic health insurance proposals. They differ significantly with respect to coverage, benefits, regulatory mechanisms and the role of the federal government in administration of the programs. However, they share several features, such as the health insurance approach (as contrasted with the health service approach), a relatively non-progressive financing, reimbursement of providers that includes fee-for-service, no regionalization of administration at the primary care or community level (S3 subdivides the nation into 200 subregions, a much larger unit), no participation of elected consumers representative of their constituencies in the governance of the programs, and little or no role for lay health care initiatives. Even so, the Health Security Act must have been thought to deviate too much. for Kennedy