Download Policymaking for Health Care and the Environment: Chapter

Policymaking for Health Care and the Environment: Chapter 19
Chapter Summary
I. Health Care Policy (588-598)
A. The Health of Americans
Americans are generally healthy but statistics show that they still lag behind
other countries in some key health care categories, such as life expectancy
and infant mortality rates.
B. The Cost of Health Care
Health is one of the largest components of America’s economy, accounting for
one-seventh of the gross domestic product. Costs of health care have been a
major obstacle to balancing the federal budget and investing in the economy.
Costs are rising for several reasons. Health providers have overbuilt medical
care facilities. New technologies, drugs, and procedures have added to the
costs. Patients do not ask for cheaper care because they do not face the full
financial consequences of their care. Increased medical costs have caused
insurance rates to skyrocket.
C. Access to Health Care
Inequalities in health and health care are serious problems. Access to health
care is not universal in the United States. Many people contract with a Health
Maintenance Organization (HMO) that directly provides all or most of a person’s
health care for a yearly fee. Most Americans have health insurance, but 16
percent of the public is without for the entire year. Millions of others are
without insurance for shorter periods. Getting and keeping health insurance are
often linked to having a job, especially a high-paying job. Many small
companies do not offer insurance. Also part-time workers often do not get
insurance. Even with group insurance, people may have to pay a large share of
the cost. Access to health care in America is tied to race and income. The
higher a family’s income, the more likely it is that its members are insured.
Discrepancies in access to health care are reflected in the health of different
groups. Whites have higher life expectancy and lower infant mortality rates
than African Americans. A major consequence of not having health insurance is
lack of access to a family doctor or someone to administer prenatal and
neonatal care. Even among those who have insurance, coverage is often
incomplete.
One of the biggest constraints on obtaining health insurance is cost. Private
market forces have transformed health care. Health maintenance organizations
(HMOs) are restricted physician lists for the provision of care. Managed care
grew on the strength of its claims to provide better service at lower cost. It is
intended to improve health care by focusing on prevention rather than
treatment and by designating a single doctor as a patient’s primary care
provider rather than having patients treated by different specialists with no
central coordination or oversight. These measures are designed to contain the
costs of health care, but they have done nothing to ease the plight of those
without health insurance.
D. The Role of Government in Health Care
The United States has the most thoroughly privatized medical care system in
the developed world with 46 percent of the country’s total health bill paid for
by government compared to an average of 75 percent for all industrialized
nations. Private insurance companies cover one-third and Americans pay nearly
one-fifth of their health care cost out of their own pockets. Most countries
have a national health insurance, a compulsory insurance program to finance
all medical care. In 1965 Congress passed Medicare as part of Social Security
to provide hospitalization insurance and short-term nursing care and
inexpensive coverage for doctor fees for elderly Americans. Medicaid is a
means-tested program designed to provide health care for the poor and serves
about 35 million people.
E. Policymaking for Health Care
One of the reasons why the United States emphasizes expensive and
high-tech solutions to complicated health problems is that no single institution
pays the medical bills. Many lifesaving procedures are very expensive, so
allocating their use involves complicated question of public policy. Dollars spent
on expensive procedures to save a few lives cannot be spent on other, equally
pressing health needs. Powerful lobbies representing hospitals, doctors, and
the elderly want Medicare to pay for the latest techniques. Other groups are
unrepresented in government. The elderly are one of the most powerful voting
and lobbying forces in politics. They have successfully lobbied for their health
care needs. Workers in low-paying service jobs that do not include health
insurance, and for those who are unemployed and cannot afford private
insurance, there is no organization capable of exerting such influence in
government. The groups that enjoy good healthcare coverage are those that
are well organized to influence the government.
Business groups have been calling for relief in the health care field. Insurance
companies have been making it more difficult for doctors and hospitals to pass
along the costs of others’ unpaid bills to them, causing a cost crunch for some
institutions, including inner-city hospitals and trauma centers that serve the
poor.
President Clinton made health care reform the centerpiece of his first
administration. His main concern was guaranteeing health care coverage for all
Americans. The program was to be paid for by a requirement that employers
provide health insurance for their employees or pay a premium into a public
fund. The reform failed because it was seen as bureaucratic and complicated.
The middle class felt its health care threatened. After a long battle it died in
Congress.
Opponents to managed care claim that its cost-cutting bureaucrats impose
stifling rules on physicians, block sick patients from seeing specialists, and
delay or deny coverage for recommended treatments or medications. There
has been a wave of state legislative action to protect patients’ rights,
including an effort by President Clinton, which was killed by the Republican
Congress in 2000. There have also been efforts, especially by the elderly, to
add the cost of prescription drugs to Medicare.
II. Environmental Policy (598-609)
A. Economic Growth and the Environment
Environmental controls figure prominently in the debate about local and state
economic development. States compete for economic development. Sometimes
stringent pollution standards drive businesses away; sometimes they attract
businesses. Business and government battle over the impact of pollution
control. Concern for the environment and concern about economic
development can overlap. When Congress set standards for ambient air in 1970
environmentalists argued that higher standards be set for areas with cleaner
air. Thus the nondegradation standard was adopted in which communities were
not allowed to degrade their air quality. The result of this policy was that
industries were discouraged from relocating in clean-air environments (the
Sunbelt). Concern for the environment has increased in the United States
since the 1950s. Steadily increasing percentages of Americans are willing to
see the government spend money to clean up and protect the environment.
B. Environmental Policies in America
The Environmental Protection Agency (EPA) is the nation’s largest federal
regulatory agency charged with administering policies dealing with land use, air
and water quality, and wilderness and wildlife preservation. The centerpiece of
federal environmental policy is the National Environmental Policy Act (NEPA)
created in 1969. This law requires both government and private agencies to
complete environmental impact statements (EIS) detailing possible effects of
the policy. An EIS is merely a procedural requirement. Although it does not
does give the environmental groups the right to stop environmentally unsound
activities, it does give them the opportunity to delay construction so much
that agencies simply give up.
The Clean Air Act of 1970 charges the Department of Transportation with the
responsibility of reducing automobile emissions. In 1990 Congress passed a
reauthorization of the Clean Air Act, which significantly increased the controls
on cars, oil refineries, chemical plants, and coal-fired utility plants, as well as
permitting utility plants to use emissions trading. Congress acted to control
pollution in lakes and rivers with the Water Pollution Control Act of 1972.
Wilderness has been given special attention through the national park system
and national forests. The United States has been a world leader in wilderness
preservation. The Endangered Species Act of 1973 created an endangered
species protection program and required the government to protect actively
each of the hundreds of species listed as endangered—regardless of the
economic effect on the surrounding towns or region.
C. Energy, the Environment, and Global Warming
Energy issues continually present thorny problems for policymakers to resolve,
and government is constantly involved in battles concerning what forms of
energy the country should be producing, and from what sources. Coal is
America’s most abundant fuel, but also the dirtiest. Oil is cleaner, but reliance
on imports often result in oil spills. The most controversial energy source is
nuclear power. The wave of environmental concern over radiation leaks and
accidents in the late 1960s devastated the nuclear power industry, and no
new plants were built in the United States after 1978. Each source of energy
poses potential risks to the environment. Interest in conservation, renewable
energy supplies, and alternative fuels has increased. The 1992 energy bill
encourages the development of renewable energy sources and alternative
“clean” fuels. As the twenty-first century began, America was once again
faced with high energy costs and shortages.
One of the most intractable and potentially most serious issues relating to
energy and the environment is global warming. Many scientists argue that the
earth is warming at a rapid rate and will result in potential environmental, social
and economic disasters. There is no technology to control carbon emissions, so
the only way to reduce greenhouse gases is to burn less fuel or find alternative
sources of energy. In 1997 150 nations met in Kyoto, Japan, and agreed in
principle to require 38 industrial nations to reduce their emissions of
greenhouse gases below 1990 levels by about 2010. Opponents of the treaty
in the U.S. fear that cutting greenhouse gases will cost too much and that it is
unfair that the developed nations should bear the burden of cutting emissions.
D. Toxic Wastes
Long before the environmental movement, polluters created problems that we
are still trying to solve. In 1980, Congress established the Superfund (created
by taxing chemical products) to deal with toxic waste. It established the
principle that those who polluted the land were responsible for paying to clean
it up. The Superfund law has virtually eliminated haphazard dumping of toxic
wastes, but has been less successful in cleaning up existing waste due to
endless rounds of litigation. The EPA has found it more difficult to clean up
toxic sites than it had hoped. The damage at some sites is so serious they may
never be cleaned up. Another serious environmental challenge is the disposal of
nuclear wastes, such as that from nuclear reactors and the production of
nuclear weapons. The question is where to store the nation’s nuclear waste.
E. Making Environmental Policy
Environmental concerns often conflict with equally legitimate concerns about
foreign trade, economic growth, and jobs. Those who generate pollution do so
in their efforts to make cars, produce electricity, and provide food and
consumer products. Federally owned land is rich in resources that many believe
should be tapped. One of the biggest changes in environmental policy in recent
years is the increasing presence of new interest groups, which complain about
pollution and press for government action. The 1960s and 1970s saw an
explosion in the size and number of environmental interest groups. The nature
of environmental policymaking has changed. The environmental movement has
spawned a backlash against vigorous protection of the environment.
Opponents argue that employment, economic growth, and international
competitiveness must be part of the policymaking equation. Furthermore local
groups have begun to resist planned development complicating environmental
policymaking.
III. Understanding Health Care and Environmental Policy (610-611)
A. Democracy and Health Care and Environmental Policy
High-tech issues strain the limits of public participation in a democracy. The
issues associated with high technology are often so complex that many
different levels of government become heavily involved. Maintaining the right
balance between public participation and technological competence is not an
easy task. High-technology issues make it especially difficult to include the
public in reasoned political debate. Policymaking for technological issues seems
to rely heavily on groups as opposed to individual citizens.
B. The Scope of Government and Health Care and Environmental Policy
Americans do not hesitate to call for government to play a greater role in
high-technology issues, and the scope of the federal government has grown in
response to these demands. At the same time, important forces rein in the
federal government, as occurred with President Clinton’s health care proposal.
There is a tension between demands for government services and protections
and a concern about the government providing those services and protections.
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