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Policymaking for Healthcare and ...
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 lowpaying 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.