The Nixon years: failed national health reform from both parties

In the November 1991 elections, popular support for national health reform (NHR) enabled Harry Wofford to become a U.S. Senator from Pennsylvania. Since then a bevy of congressional proposals to reform America's health care system have emerged, with even national health insurance, or a single payer system, becoming a prominent contender for the first time in 20 years. National health reform is now a regular feature on the evening news. However, this is not the first time that NHR has attracted national attention. As pointed out in the first article in this series (Physician Executive, March-April 1992, page 23), there have been numerous efforts to enact NHR in the U.S. Each has failed because of strident opposition by interest groups, lack of active presidential interest in the specific legislation, and the absence of strong popular interest.     

Truman and the medical profession: replay or lesson for the nineties

This article describes the first serious effort on the part of an American president to enact national health insurance (NHI). President Truman considered his inability to enact NHI the single most important defeat during his presidency. While a variety of factors led to the demise of NHI, three are most notable. The dynamic interplay of these factors, integrated with references to the current accelerating debate over national health reform, will serve as the focus for this seventh article in a series on historical efforts to enact national health reform in the United States.     

The paradoxes of national health reform during the Wilson era

The current debate over health care reform may represent yet another opportunity to establish a national health policy. A similar level of activity occurred during the presidency of Woodrow Wilson. In many ways, the failure to enact national health reform (NHR) in the early 20th Century represents a paradigm for subsequent failed attempts to enact NHR.     

What will future historians say about the Clinton health reform act

In a series of articles that began in the March-April 1992 issue of Physician Executive, the author has provided historical background on the debate that currently rages on the nature and course of national health reform. In addition to tracing past efforts to expand access to health care for Americans, Dr. Goldfield has provided unique insights into the American political process and into the American psyche. In this final article in the series, Dr. Goldfield provides his personal assessment of what the chances for real reform of the health care delivery system are and his views on what that reform will ultimately look like. He calls himself a skeptic, not a cynic, saying that the likelihood of meaningful change is small, given the numerous proponents of the status quo.     

The impact of health care reform on group practice

Just two years ago, it would have been very difficult to imagine that reform of the health care system would today be a national domestic priority and that Congress would be considering one of the most significant and far-reaching pieces of legislation in the past 50 years. The issue is still in doubt, but it seems clear that, in this session of Congress or the next, legislation of far-reaching consequences will likely be passed. In fact, change on a widespread scale has already begun. During 1993, every state legislature except those of Nevada and Wyoming considered measures that would alter the way medical care is financed and delivered. Of the states that acted, both last year and in recent legislative sessions, eight have passed laws with the ultimate objective of ensuring access to medical care for all citizens. Government, at both the state and federal level, is clearly taking on the health care issue. The impact of reform on physicians, and thus on group practices, will be substantial. This article outlines the current course of health care reform and addresses its specific implications for the management of group practices.     

Effects of medical practice structure on resource use

The drive to national health care reform has made a central issue of variations among physicians in the use of resources to treat similar cases. While much research exists on this issue, little of it concentrates on the impact of practice structure on resource use. In this column, the author comments on that research. This column is intended as a point of ongoing analysis of health services research of importance to physician executives. The column is edited by John Kralewski, PhD, who heads the Institute for Health Services Research at the University of Minnesota.     

Constitutional guarantees to health care in Spain

This analysis of the Spanish health care system is one in a series of such studies undertaken by the author, following a grid of factors that influence the delivery and financing of health care. The purpose of the national analyses is to facilitate a comparison of the United States' and other health care systems in terms of anticipated reform of the U.S. system. Analyses of the U.S. and nine other national systems are included in a book that has just been published by the College. Spain and nine additional countries will be studied in a book due for publication later this year. A final book with ten additional national analyses will appear in 1996.     

National health reform advocates retrench and prepare for Medicare

With the failure of President Truman's efforts to pass compulsory health insurance for all, national health reform (NHR) advocates began to redirect their political attention to a politically powerful group of Americans who were simultaneously vulnerable from a health care point of view--the elderly. This effort culminated in the passage of Medicare under President Johnson. This article will focus on antecedents to passage of Medicare that can be found in the Eisenhower and Kennedy administrations. It will also discuss other facets of health reform proposals from the Eisenhower administration. While most proposals never became law, the legislative intent of many of them--outlawing cancellation of policies, a minimum standard health benefit package, establishment of regional health authorities, preference for prepayment plans, and establishment of a reinsurance pool administered by the federal government--is currently under active discussion by the Clinton health reform task forces.     

Computer-based patient records: a building block for health care reform

The fundamental need for better information management capabilities in health care is at risk of being overlooked in the proposals for major national changes aimed at providing health security, controlling costs, enhancing quality, and expanding access for citizens. In addition to these proposed macro changes (e.g., universal access, guaranteed benefit package, national health board, regional health alliances), successful reform will require transformation of health care delivery at the micro level. We must overcome provider-dependent variations in clinical practice patterns, in quality of performance, and in costs of services. We must ensure movement toward appropriate care rather than simple rationing. Individual health care professionals and institutions must acquire and use tools that will enable them to provide their services cost-effectively with consistent results. We must be able to assess and ensure value--i.e., appropriateness, effectiveness, and cost--of health services, apply that knowledge in each and every patient encounter, and track the impact of clinical decisions through an analysis of aggregated databases.     

Getting the most for your consulting dollars

Major changes in the health care financing and delivery system have usually been accompanied by an increase in demand within the health care field for consulting services. The passage of Medicare/Medicaid in 1965 is one example. The passage of the DRG-based prospective pricing system in 1983 is another. Both spawned a substantial amount of work, and income, for consulting firms. Now the health care field is engaged in nearly total transformation as the forces of health care reform at the national level are met with myriad adjustments at the local and regional levels. Managed care, already a byword, is being strengthened by a multitude of so-called integrated system initiatives. It is not easy to survive, and the call is out to consultants to save the day, or at least stave off disaster. In the following four articles, Marilyn Kennedy, a member of the ACPE faculty and a consultant herself, gives some advice on how to make the consulting arrangement successful; three physician executives provide a glimpse at consults that have worked, and some that did not work.     

Building a vertical provider system

There is probably no geographic area in the United States in which the health care environment is more turbulent than that of Southern California. Long before President Clinton's proposals began serious national debate on health care reform, a massive provider-driven realignment of the system was occurring in that region of the country. Multispecialty medical groups have generally led the way and have acquired ever larger managed care populations through merger and acquisition of other groups and practices. Hospitals, hampered by large fixed capital bases, have struggled to reinvent themselves as cost-effective and primary care-friendly environments in order to be attractive to managed care physicians. Almost ignored in this reconfiguration has been the university teaching hospital. This article discusses one attempt to reconcile contractually an integrated, capitated, and managed care-oriented health care system with an academic medical center in a strategic alliance.     

中国电力工业发展:改革进程与配套改革

本文简单回顾了电力体制改革及近期的电力市场改革。文章分析了电力市场改革应先考虑几个重要宏观问题和一系列相关的配套改革,详细地讨论了中国电价机制经历的一系列变革,目前改革的长期目标和中短期改革重点,说明了国有企业的高度集中是电力行业许多基本问题的根源和国有企业改革的重要性。文章还对“煤电联动”、煤价改革,以保证煤电协调发展提出了建议。文章进一步讨论了中国能源问题,提出能源是中国经济增长的“硬约束”,节能、环保和能源战略规划的重要性和机构保证,以及开展充分的能源经济研究是能源战略规划的必需条件。     

The consumer choice model: a humane reconstruction of the U.S. health care system

"Consumer choice," "defined contribution health programs," "voucher systems," and "health marts" are variations on a theme: employees buying their own health care. This new approach to health care purchasing, which is designed to minimize the role of employers, is being proposed by an array of economists and by both Republican and Democratic legislators as the best way to address the nation's health care ills. Although enabling national legislation is unlikely to pass soon, the debate will nevertheless change the face of health care in America. The prospect is reminiscent of the debate over "Clinton Care" in 1993--although legislation was never passed, managed care rapidly came to dominate the U.S. health care system. As this reform takes hold, beneficiaries will make their own health plan selections but will have more responsibility and may bear more cost. Providers will have to adapt to new, customer-driven requirements for performance, accountability, and communications but will also find opportunities in a marketplace that they will have a major role in shaping. Physicians, health plans, and insurers should understand how these proposals will transform their role in health care.     

国有企业的外部人控制问题

在中国国有企业改革和发展的过程中 ,大家都注意到内部人控制问题。但是 ,内部人控制问题在世界各国现代企业都可能出现 ,在不同产权制度下的所有权和经营权分离的企业都时有发生 ,而在中国由计划经济向市场经济转轨过程中 ,国有企业的内部人控制问题发生与外部人控制问题紧密相关。对于大家没有集中注意到或没有明确提出的中国国有企业的外部人控制问题 ,本文试从理论基础、概念要点和案例说明等方面进行论述。     

Elements of the American Health Security Act of 1993

Over the past several decades, there has been a plethora of proposals that were developed in response to the ongoing debate on how best to solve the problems of the American health care delivery system. In the past decade, calls for modification of our health system have become even more resonant, as measures to control rising costs were unsuccessful and access to basic services was diminished for many Americans. The most recent addition to the list of proposals for modifying the health care system is the American Health Security Act of 1993, introduced by President Clinton in September 1993. This article will examine the position of the Clinton Administration on health reform and the core elements of the reform package.     

Bureaucracy in Three Different Worlds: The Assumptions of Failed Public Sector Reforms in Korea

Why is it so difficult to implement Western reform programs in Asian bureaucracies? To address this question, this study explores cultural aspects of national bureaucracies. A government bureaucracy is shaped by its cultural and historical context, and this paper specifically focuses on contrasting models of government bureaucracy in the USA, Korea, and Germany. Differences between the models are explained by examining both internal operations as well as the relative relationships of the state to society. Based on this, the incompatible assumptions of Korean reformers are examined. This study is useful for developing countries engaged in Western-style bureaucratic reform.     

A conversation on the future of health care

An extensive amount has been written, reported, and spoken on health care reform. It is a time of turmoil and uncertainty in the health care field. There is a great deal of talk at the federal level on reform, but efforts there seem to be at least temporarily stymied. Much is happening at the local and regional level, however, as the health care field itself wrestles with the changes that have already occurred and with the promise of changes that lie ahead. In the following conversation between two fictional physician executives, one with many years experience, the other his junior, some of the issues surrounding health care reform are discussed. Although the specific environment for the conversation is managed care, most physician executives will find themselves somewhere in the conversation. let's eavesdrop as they speak, in the late summer of 1994.     

The new production theory for health care through clinical reengineering: a study of clinical guidelines--Part II

In Part I of this two-part article, in the December 1994 issue of the journal, the author discussed the manufacturing theories of Peter Drucker in terms of their applicability for the health care field. He concluded that Drucker's four principles and practices of manufacturing--statistical quality control, manufacturing accounting, modular organization, and systems approach--do have application to the health care system. Clinical guidelines, a variation on the Drucker theory, are a specific example of the manufacturing process in health. The performance to date of some guidelines and their implications for the health care reform debate are discussed in Part II of the article.     

Health‐Care Reform and ESI: Reconsidering the Relationship Between Employment and Health Insurance

The health‐care reform promised by the Patient Protection and Affordable Care Act of March 2010 continues our dependence on a central feature of the American health‐care system: employer‐sponsored insurance (ESI). In this article I will criticize the assumptions regarding market and welfare concerns on which this dependence is based and argue that efforts to mandate ESI ignore both the dynamics of the employment relation and the nature of health‐care needs. A comparison between investing in employee education and investing in employee health will reveal the pragmatic challenges to ESI and the covert appeal to employer beneficence on which ESI rests. This paper argues that relying on ESI to guarantee appropriate care for a significant segment of the population is undesirable and unsustainable from both market and moral perspectives.