Table of contents for Health policy : crisis and reform in the U.S. health care delivery system / [edited by] Charlene Harrington, Carroll L. Estes.

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HEALTH POLICY
Crisis and Reform in the U.S. Health Care Delivery System
Fifth Edition
HEALTH POLICY
HEALTH POLICY
Crisis and Reform in the U.S. Health Care Delivery System
FIFTH EDITION
Edited by
CHARLENE HARRINGTON, PhD, RN
Professor of Sociology and Nursing
CARROLL L. ESTES, PhD
Professor of Sociology
Department of Social and Behavioral Sciences School of Nursing 
University of California, San Francisco
With assistance from 
BROOKE HOLLISTER
HEALTH POLICY
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Library of Congress Cataloging-in-Publication Data
Health policy: crisis and reform in the U.S. health care delivery system/edited by Charlene Harrington and Carroll L. Estes.¿4th ed.
 p.; cm.
Includes bibliographical references and index.
 ISBN 0-7637-0753-8
1. Medical policy¿United States. 2. Health care reform¿United States. 
3. Medical care¿United States. 4. Medical care¿United States¿Finance.
[DNLM: 1. Delivery of Health Care¿economics¿United States. 2.
Delivery of Health Care¿trends¿United States. 3. Health
Policy¿United States. 4. Nursing¿United States. W 84 AA1 H43478
 RA395.A3H42554 2004
 362.1'0973¿dc22	2003021413
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08 07 06 05 04 10 9 8 7 6 5 4 3 2 1
 
CONTENTS
FOREWORD XI
INTRODUCTION xiii
ACKNOWLEDGMENTS xvii
PART I	HEALTH POLICY 1
CHAPTER 1	HEALTH POLITICS AND POLITICAL ACTION 3
HEALTH POLICY: WHAT IT IS AND HOW IT WORKS 4
Lester E. Block
PLAY TO WIN: KNOW THE RULES 18
Catherine J. Dodd
PRIMER ON POLICY: THE LEGISLATIVE PROCESS AT THE FEDERAL LEVEL 15
Sara Hart and Nadine Jackson
IT¿S THE INSTITUTIONS STUPID 15
Sven Steinmo and Jan Watts
PART II	HEALTH STATUS AND ACCESS TO CARE 41
CHAPTER 2	HEALTH STATUS OF THE POPULATION AND VULNERABLE GROUPS 45
WHY NOT THE BEST? RESULTS FROM A NATIONAL SCORECARD ON U.S. HEALTH SYSTEM PERFORMANCE 46
The Commonwealth Fund Commission on a High Performance Health System
HEALTH DISPARITIES BASED ON SOCIOECONOMIC INEQUALITIES: IMPLICATIONS FOR URBAN HEALTH CARE 51
Kevin Fiscella and David Williams
MORTALITY OF WHITE AMERICANS, AFRICAN AMERICANS AND CANADIANS: THE CAUSES AD CONSEQUENCES FOR HEALTH OF WELFARE STATE INSTITUTIONS AND POLICIES 67
Stephen J. Kunitz and Irena Pesis-Katz
THE GENDER GAP: NEW CHALLENGES IN WOMEN¿S HEALTH 59
Gloria E. Sarto
CHILD POVERTY IN RICH COUNTRIES 78
United Nations International Childrens Emergency Fund
 
CHAPTER 3	ACCESS TO CARE 83
INCOME, EARNINGS, AND POVERTY: DATA FROM THE 2005 AMERICAN COMMUNITY SURVEY 88
U.S. Census Bureau
WHO ARE THE UNINSURED? 84
Kaiser Commission on Medicaid and the Uninsured
ACCESS TO CARE AND UTILIZATION AMONG CHILDREN: ESTIMATING THE EFFECTS OF PUBLIC AND PRIVATE COVERAGE 100
Thomas M. Selden and Julie L. Hudson
THE EFFECTS OF STATE PARITY LAWS ON THE USE OF MENTAL HEALTH CARE 94
Catherine M. Harris, Christopher Carpenter, and Yuhua Bao
CHAPTER 4	AGING AND LONG-TERM CARE 113
OLDER PEOPLE 138
Carroll Estes and Steven P. Wallace
MEDICARE AND CHRONIC CARE AT THE BEGINNING OF THE 21ST CENTURY: IMPROVING BUT A LONG WAY TO GO 123
Marty Lynch, Carroll Estes, and Mauro Hernandez
UNMET NEED FOR PERSONAL ASSISTANCE SERVICES: ESTIMATING THE SHORTFALL IN HOURS OF HELP AN D ADVERSE CONSEQUENCES
Mitchell P. LaPlante, Stephen H. Kaye, Taewoon Kang, and Charlene Harrington
WOMEN¿S HEALTH AND ECONOMIC SECURITY 138
Brooke Hollister and Carroll Estes 
SOCIAL SECURITY PRIVATIZATION AND OLDER WOMEN: A FEMINIST POLITICAL ECONOMY PERSPECTIVE 138
Carroll Estes
INFORMALIZATION OF LONG-TERM CAREGIVING: A GENDER LENS 147
Carroll L. Estes and Donna M. Zulman
PART III	HEALTH CARE DELIVERY SYSTEM ISSUES 157
CHAPTER 5	ORGANIZATIONAL CHANGE 161
EXPLODING THE MERGER MYTH IN U.S. HEALTH CARE 162
Martin Kitchener
THE TRANSITION FROM EXCESS CAPACITY TO STRAINED CAPACITY IN U.S. HOSPITALS 174
Gloria J. Bazzoli, Linda R. Brewster, Jessica H. May, and Sylvia Kuo
HEALTH INDUSTRY PRACTICES THAT CREATE CONFLICTS OF INTEREST 184
Troyen A. Brennan, David J. Rothman, Linda Blank, David Blumenthal, Susan C. Chimonas, Jordan J. Cohen, Janlori Goldman, Jerome P. Kassirer, Harry Kimball, James Naughton, and Neil Smelser
THE U.S. LONG-TERM CARE FIELD: A DIALECTICAL ANALYSIS OF INSTITUTIONAL DYNAMICS 188
Martin Kitchener and Charlene Harrington
PRIMARY CARE, RACE, AND MORTALITY IN U.S. STATES 188
Leiyu Shi, James Macinko, Barbara Starfield, Robert Politzer, and Jiahong Xu 
CHAPTER 6	LABOR ISSUES 195
FROM THE DOCTOR¿S WORKSHOP TO THE IRON CAGE? EVOLVING MODES OF PHYSICIAN CONTROL IN US HEALTH SYSTEMS 201
Martin Kitchener, Carol A. Caronna, and Stephen M. Shortell
PROJECTIONS AND TRENDS IN RN SUPPLY: WHAT DO THEY TELL USE ABOUT THE NURSING SHORTAGE 201
Lynn Y. Unruh and Myron D. Fottler
COSTS OF OCCUPATIONAL INJURY AND ILLNESS WITHIN THE HEALTH SERVICES SECTOR 216
Geetha Waehrer, J. Paul Leigh, and Ted R. Miller
CHAPTER 7	QUALITY OF CARE 223
THE NATIONAL HEALTHCARE QUALITY AND DISPARITIES REPORTS: AN OVERVIEW 224
Ed Kelley, Ernest Moy, Daniel Stryer, Helen Burstin, and Carolyn Clancy
QUALITY OF CARE IN FOR-PROFIT AND NOT-FOR-PROFIT HEALTH PLANS ENROLLING MEDICARE BENEFICIARIES 227
Eric C. Schneider, Alan M. Zaslavsky, and Arnold M. Epstein
IMPROVING NURSE-TO-PATIENT STAFFING RATIOS AS A COST-EFFECTIVE SAFETY INTERVENTION 236
Michael B. Rothberg, Ivo Abraham, Peter K. Lindenauer, and David N. Rose.
STATE NURSING HOME ENFORCEMENT SYSTEMS 233
Charlene Harrington, Joseph T. Mullan, and Helen Carrillo
RELATIONSHIP OF NURSING HOME STAFFING TO QUALITY OF CARE 236
John F. Schnelle, Sandra F. Simmons, Charlene Harrington, Mary Cadogan, Emily Garcia, and Barbara M. Bates-Jensen
INITIAL HOME HEALTH OUTCOMES UNDER PROSPECTIVE PAYMENT 236
Robert E. Schlenker, Martha C. Powell, and Glenn K. Goodrich
PART IV	THE ECONOMICS OF HEALTH CARE 243
CHAPTER 8	FINANCING HEALTH CARE 249
ECONOMIC ANALYSIS IN HEALTH CARE 260
Wendy Max
HIGH AND RISING HEALTH CARE COSTS. PART 1: SEEKING AN EXPLANATION 271
Thomas Bodenheimer
HIGH AND RISING HEALTH CARE COSTS. PART 3: THE ROLE OF HEALTH CARE PROVIDERS 271
Thomas Bodenheimer
EMPLOYER HEALTH BENEFITS 277
The Kaiser Family Foundation
SQUEEZED: WHY RISING EXPOSURE TO HEALTH CARE COSTS THREATENS THE HEALTH AND FINANCIAL WELL-BEING OF AMERICAN FAMILIES 324
Sara R. Collins, Jennifer L. Kriss, Karen Davis, Michelle M. Doty, and Alyssa L. Holmgren, The Commonwealth Fund
CHAPTER 9	PUBLIC FINANCING 281
MEDICAID AT FORTY 282
Diane Rowland 
HOW WELL DOES MEDICAID WORK IN IMPROVING ACCESS TO CARE? 287
Sharon K. Long, Teresa Coughlin, and Jennifer King
MEDICARE AT A GLANCE 293
The Kaiser Family Foundation
ARE WOMEN BETTER OFF BECAUSE OF THE NEW MEDICARE DRUG LEGISLATION?
MARILYN MOON
MEDICARE AND MEDICAID: TRENDS AND ISSUES AFFECTING ACCESS TO CARE FOR LOW-INCOME ELDERS AND PEOPLE WITH DISABILITIES 29
Ellen O¿Brien
PRIVATIZATION OF MEDICARE: TOWARD DISENTITLEMENT AND BETRAYAL OF A SOCIAL CONTRACT 29
John P. Geyman
CHAPTER 10	PRIVATE INSURANCE AND MANAGED CARE 317
NATIONAL ESTIMATES OF THE EFFECTS OF MANDATORY MEDICAID MANAGED CARE PROGRAMS ON HEALTH CARE ACCESS AND USE, 1997-1999 318
Bowen Garrett and Stephen Zuckerman
MEDICARE BENEFICIARY OUT-OF-POCKET COSTS: ARE MEDICARE ADVANTAGE PLANS A BETTER DEAL? 324
Brian Biles, Laura H. Nicholas, and Stuart Guterman, The Commonwealth Fund
THE RISE AND FALL OF MANAGED CARE 332
David Mechanic
COMPETITION AND HEALTH PLAN PERFORMANCE: EVIDENCE FROM HEALTH MAINTENANCE ORGANIZATION INSURANCE MARKETS 336
Dennis Scanlon, Shailender Swaminathan, Michael Chernew, James E. Bost, and John Shevock
THE EFFECTS OF RECENT EMPLOYMENT CHANGES AND PREMIUM INCREASES ON ADULTS¿ INSURANCE COVERAGE 336
Jack Hadley
HEALTH SAVINGS ACCOUNTS AND HIGH-DEDUCTIBLE HEALTH PLANS: WHY THEY WON¿T CURE WHAT AILS U.S. HEALTH CARE 336
Sara Collins, The Commonwealth Fund
PART V	REFORMING THE U.S. HEALTH CARE SYSTEM 339
CHAPTER 11	INTERNATIONAL HEALTH SYSTEMS 343
THE WORLD HEALTH SITUATION 372
Vincente Navarro
HEALTH, POVERTY AND MILLENNIUM DEVELOPMENT GOALS 344
World Health Organization
RISING HEALTH CARE COSTS PUT PRESSURE ON PUBLIC FINANCES 344
Organisation for Economic Co-operation and Development
ACCESS TO CARE, HEALTH STATUS, AND HEALTH DISPARITIES IN THE UNITED STATES AND CANADA: RESULTS OF A CROSS-NATIONAL POPULATION-BASED SURVEY 344
Karen E. Lasser, David U. Himmelstein, and Steffie Woolhandler
NHS PLC: THE PRIVATISATION OF OUR HEALTH CARE 344
Allyson M. Pollok with Colin Leys, David Price, David Rowland, and Shamini Gnani
MULTINATIONAL CORPORATIONS AND HEALTH CARE IN THE UNITED STATES AND LATIN AMERICA: STRATEGIES, ACTIONS, AND EFFECTS 344
Rebeca Jasso-Aguilar, Howard Witzkin, and Angela Landwehr
COMPARED TO OTHER COUNTRIES: HOW EXCEPTIONAL ARE THE HEALTH AND INCOME SECURITY ARRANGEMENTS OF THE UNITED STATES? 344
Joseph White
CHAPTER 12	HEALTH REFORM FOR THE FUTURE 381
MYTHS AS BARRIERS TO HEALTH CARE REFORM IN THE UNITED STATES 29
John P. Geyman
WHY CONGRESS DID NOT ENACT HEALTH CARE REFORM 36
Vincente Navarro
WHY THE U.S. HAS NO NATIONAL HEALTH INSURANCE: STAKEHOLDER MOBILIZATION AGAINST THE WELFARE STATE 36
Jill Quandagno
CROWD-OUT AND THE POLITICS OF HEALTH REFORM 36
Judy Feder
IMPROVING MEDICAL PRACTICE AND THE ECONOMY THROUGH UNIVERSAL HEALTH CARE 36
Donald Light
CONCLUSIONS 409
GLOSSARY 411
INDEX 417
 
FOREWORD
The issues discussed in this fifth edition of Health Policy are truly the issues of the millennium, though many of them have remained the same over the years since the first edition was published. That they seem so intractable should not surprise us because views of universality, the poor, access to care and organization of care are difficult for all of the countries in the world, whether industrialized or developing. However, American¿s idiosyncratic views about money and justice, among other things, lead to ambivalence and changeability with regard to political solutions on local and national levels. There appears to be little question that the public has great concern about the current state of health care, and the flaws in current approaches. In fact, as this edition is being published there are polls that place concerns about health care at the top of American¿s priorities and there are various political approaches anticipated to quell these concerns. It is unfortunate that some of these approaches seem beneficial to much of the public but have potentially negative outcomes for costs of pharmaceuticals and for the continuing power of the private for-profit sector in dominating health care delivery.
There has not been a strong national coalition behind the development of a public movement for a universal health care system. As a result of the inability to mobilize the political force of the nation at this time, there are a number of state efforts to get the question of universal care on the agenda. The value placed on quality of care and access to care by the American public has to be revealed in the voting booths. If that value is high, change is inevitable; however, if the American public is fearful of the consequences of an inclusive health care policy, decades will pass with millions of people unserved, underserved, and receiving care of questionable quality.
The fifth edition of Health Policy has a few articles from the previous edition. These articles are classic in that they provide a frame of reference and backdrop for understanding the problems in the U.S. health care system and the basic health policy issues. Most articles in the volume are new, and are vital to permit us to keep up with the constantly changing issues in health policy issues at the leading edge of current discussions. Part I begins with a review of what health policy is and how the political system operates. Focusing on issues of health status of the population and vulnerable groups, Part II details issues of race, gender, and income disparities as well as discrimination. Some of the issues at the core of access are the uninsured, social inequality, mental health, aging, long term care, and end-of-life care policies.
In discussing health care delivery system issues, articles in Part III deal with organizational change, labor issues, and quality of care. Mergers and restructuring, primary care, staffing issues in hospitals and nursing homes, shortages in the workforce, errors in health care, and public reporting of quality indicators are invaluable reading for health professionals on first reading and as references for repeated readings and use.
Part IV of the book discusses the economics of health care with articles on public and private financing and insurance and managed care, while Part V deals with reform of the health care system in the United States. The outstanding analysts of health care systems discuss trends and systems in Canada, the United Kingdom, and other industrialized countries. In addition, definitions of health policy, failures in policy, crises in nursing caused by misapplied policy and public inaction, and finally solutions through two discussions of health reform for the future are presented.
The fifth edition of Health Policy is designed for all health professionals and anyone interested in or involved in the health care field. The authors are experts in their subject matter. As a composite, the most challenging issues facing the nation are explicated. The content provides information to enrich one¿s own understanding of the specifics and generalities of the problems we Americans face in health care, it¿s present and future. It also provides the impetus for individual and collective action.
Claire M. Fagin, Ph.D., FAAN
 
INTRODUCTION
This edited volume is designed for health professionals and for students of health policy and economics. Health policy and economics are constantly changing and the literature in the area is growing at an alarming pace. This makes it difficult for those learning about the area to identify the most important topics for study and the changing issues and trends. This volume attempts to identify the key issues and trends that we use in our policy courses in the Department of Social and Behavioral Sciences at the University of California, San Francisco. We have selected our favorite articles about health status and access, delivery systems, costs and economics, politics and health reform.
Health policy is a new arena for many health professionals, and many realize that they must become knowledgeable in this area in order to improve health care for their patients and for the public. Health professionals working in organizations, public health, primary and specialty care, private practice, and management positions are all directly affected by the organization and financing of the health care system including the policies and politics that shape the system. Health policy does not come naturally to many health professionals who have had long and arduous clinical training focusing on caring for individuals and families. The organizational, systemic, and political issues sometimes seem too overwhelming to comprehend. Health professionals must move beyond their basic training to become more politically aware and active in shaping policy and advocating for their own interests and those of their patients. They also must move beyond clinical research into policy-relevant research, addressing the larger issues impacting their patients and the health professions. A research and policy focus on organizations, financing, and systems of care can have more impact than clinical studies.
This book is designed to focus on the big picture issues and to present the viewpoints of sociologists, economists, political scientists, and health experts. The language these experts use is different and sometimes difficult, but understanding the language is essential to be able to communicate with public policy makers and health services and policy researchers.
Health professionals come to the policy arena with many strengths and liabilities. Their greatest strength is that they are viewed positively by the public and the policy makers as caring providers with a real commitment to patients and the health of the public. Consequently, the public and the policy makers are willing to listen to their viewpoints on health issues. They are knowledgeable about the day-to-day problems of their patients and families and are able to present these problems in a way that the public and policy makers can understand. Moreover, health professional organizations can use their size and energy to have a major influence on policy making.
In the past, health professionals have had relatively little political impact and power because they have not exercised their potential influence. Many health professionals have had little education about policy and system issues. In addition to having a wide range of political views from liberal to conservative, and affiliations from Republican, Demo¬crat, to Independent, health professionals are divided into many specialty groups and organizations with only a small percentage participating in their national organizations. They are frequently reluctant to pay membership dues and to volunteer their time and energy to do organizational work. This is understandable because health professionals are often managing jobs, families, caring for sick parents and children, and going to school, among many other day-to-day responsibilities, leaving little time for political action. As the overall job market competition intensifies, professional work pressures and stress may further reduce health professionals¿ participation in professional and political organizations.
This book is designed to persuade health professionals that they need to add political work to their lives. The strength to influence health policy can only come when health professionals are better informed about policy, economics, and politics and by uniting behind some common goals. In order to be effective, political and professional actions should be undertaken through organizations rather than as individual health professionals. Enthusiasm for specialty organizations should not divert health professionals from participation in the local, state, and national organizations that address the broader issues of the health profession.
This book focuses on the important policy issues of our times. It attempts to arm health professionals with facts about the system and the names of key policy shapers. Because health care statistics are updated frequently, it is important not to memorize facts but to learn the most important sources for information so that current information can be retrieved when needed. We also attempt to show trends that tend to move forward until public policy changes or private system changes are made.
Public policies are the public actions that can be taken by policy makers at the federal, state, and local levels. These actions can include budgetary changes, legislative changes, regulatory changes, and often judicial rulings. Before health professionals can advocate for public policy changes, they need a clear understanding of the current federal policies that are impacting the health system and how the system operates, including the financial incentives that influence health providers and organizations.
Part I of the book begins with the understanding health policy and the political process. The vested interests in and politics of the failure of President Clinton¿s health plan are examined, as well as the potential role of health professionals in changing the health system. Part II examines the health status of the U.S. population, examining health disparities and discrimination among different population groups, including issues of access to care, aging, disability, and long-term care. The overall poor health status of the U.S. population is, in part, the result of limited access to services, especially for the poor, uninsured, and vulnerable populations. Part III discusses dramatic changes occurring in the health care delivery system and in organizations, including labor issues and quality of care.
Part IV focuses on how economics drives the entire health system in the United States and impacts the day-to-day operations of health care organizations and professionals. Trends in financing health care services and the health industry are described, including the growth in public financing of Medicare and Medicaid and private financing. Private insurance and managed care are emphasized because of the rapid shift to managed care. Part V, the final section of the book, is dedicated to health care reform. Articles examine health systems in other countries, particularly in Canada, as potential models for the United States. Finally, a vision for the future of health-care reform is presented.
This book is not designed to represent a broad spectrum of political ideas but rather the perspectives of expert health services researchers as well as policy leaders who are consumer-oriented and advocates for health reform. Most articles are critical of the existing health care system and hold the underlying assumption that changes in the system are needed. The status quo of millions of individuals in the United States continuing without access to health insurance, and millions of women and children with unacceptably poor health status must be corrected.
To this end, reform is needed, and yet a consensus has not emerged among health professionals and the public about how such reform should be accomplished. We show the urgent need for reform and urge health professionals to become politically active using their political power and influence. Although the political problems of our health care system seem overwhelming, the system can be changed if we develop an understanding of the underlying problems and can unite behind reform strategies. The failed efforts of health reform in the early 1990s can be corrected in the coming decade.
 
ACKNOWLEDGMENTS
We would like to thank Brooke Hollister, doctoral student in Sociology at the University of California, San Francisco, for her extensive work in identifying and collecting the articles, editing the articles, and obtaining the permissions for this edition. We would also like to thank ---- for their editorial assistance.

Library of Congress Subject Headings for this publication:

Medical policy -- United States.
Health care reform -- United States.
Medical care -- United States -- Finance.
Delivery of Health Care -- economics -- United States.
Delivery of Health Care -- trends -- United States.
Health Care Reform -- United States.
Health Policy -- United States.
Health Services Accessibility -- United States.