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.     

Defining the health care product to ensure quality and manage costs

The frenzy of health care reform activity now led by the Clinton Administration's American Health Security Act of 1993 might end in the worst of all possible outcomes: a new government entitlement program financed by business and a global budget. Unbridled entitlement could drive utilization of benefits to the maximum and, with a budget cap, guarantee rationing. So far, the administration has talked about expanding access and controlling costs--not about the health care product. Given the threat that change poses for vested interests, time will undoubtedly lapse before final implementation of a new system. Unless physicians involved in health management seize the opportunity during this window of opportunity to help shape the future of health care delivery, the likelihood of preserving the U.S. health care delivery system as we know it will be dim indeed.     

The Clinton health care proposal: reform squandered again!

Unlike the other articles in this series on efforts to reform the American health care system, this article is necessarily somewhat personal. I lived through it--not as a participant in the process but as a very interested bystander. To President Clinton's credit, his proposal was the first comprehensive proposal from a President since at least President Nixon and strictly speaking since President Truman. Yet, in the final analysis, the results were extremely depressing, not merely because of the obvious failure of the effort, but, even more important, because of the impact it has had on Americans' belief in the possibility for significant government role/responsibility in health care or, for that matter, in any significant domestic initiative. This article will trace portions of the failed Clinton health care initiative proposal--not the myriad other proposals that percolated through Congress. Realistically, only a proposal that had the support of the President had any chance of legislative success. This article will trace the development of the proposal and, while focusing on the universal coverage aspect, point to critical decisions that led to its legislative demise.     

What happened, what next?

Many physicians and other health care professionals breathed a collective sigh of relief when the 103rd Congress adjourned without passing the Clinton Health Security Act or any other health care reform legilsation. The ambition of this brief paper is to describe why health care reform did not pass in 1994, the issues that need to be resolved if we are to pass legislation, the political forces that will need to be addressed before legislation is passed, and the type of struggles we can expect to see in the coming session of Congress.     

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.     

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.     

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.     

The Republican task force health reform proposal: loyal opposition or bipartisan collaboration?

In the November-December issue of Physician Executive, Drs. Fickenscher and Kindig explored the major elements of the Clinton health reform initiative, the Health Security Act of 1993. Although the Clinton proposal represents one of the major health reform proposals presently before Congress, it is by no means the only proposal. Over the next several issues, this column will provide an overview of other major proposals pending before Congress that will receive serious consideration in the coming months.     

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

Drucker writes that the emerging theory of manufacturing includes four principles and practices: statistical quality control, manufacturing accounting, modular organization, and systems approach. SQC is a rigorous, scientific method of identifying variation in the quality and productivity of a given production process, with an emphasis on improvement. The new manufacturing economics intends to integrate the production strategy with the business strategy in order to account for the biggest portions of costs that the old methods did not assess: time and automation. Production operations that are both standardized and flexible will allow the organization to keep up with changes in design, technology, and the market. The return on innovation in this environment is predicated on a modular arrangement of flexible steps in the process. Finally, the systems approach sees the entire process as being integrated in converting goods or services into economic satisfaction. There is now a major restructuring of the U.S. health care industry, and the incorporation of these four theories into health care reform would appear to be essential. This two-part article will address two problems: Will Drucker's theories relate to health care (Part I)? Will the "new manufacturing" in health care (practice guidelines) demonstrate cost, quality, and access changes that reform demands (Part II)?     

The health care system should produce health

Reform of the U.S. health care system along the lines to be proposed by the Clinton Administration will not be an easy task, and it will not be accomplished quickly. A fundamental objective of the changes should be a health system whose purpose is improvement in the health of U.S. citizens, and not just the provision of services to all. This column is jointly edited by Kevin M. Fickenscher, MD, and David A. Kindig, MD, PhD, chair and member, respectively, of the College's Forum on National Health Policy. Dr. Fickenscher is participating in various advisory capacities on health care in the Clinton Administration, and Dr. Kindig is Senior Advisor to HHS Secretary Donna Shalala.     

Mandated benefits: a misguided effort

The U.S. Congress is toying with the creation of universally mandated benefits for health care, most specifically in the health care reform proposal offered by the Clinton Administration. The notion of mandated benefits has already become a part of the health care scene in insurance and managed care plans. Instead of benefiting U.S. citizens as a whole, however, mandated benefits are likely to result in a reduction in health care accessibility and quality. The reason is that mandated benefits consume a continuously growing portion of the health care pie. Deming demonstrated that quality brings lower costs, but to obtain quality we must commit adequate resources. The free allocation of resources is negated by mandated benefits.     

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.     

A historic, geographic, cultural, and economic guide to Australian health care

This is the first in a series of articles that will explore the health care systems of countries around the world. To begin the series, the President of the Royal Australian College of Medical Administrators describes the current status of the health of his country's people, its health care delivery system, and how it has responded to historic, geographic, cultural, and economic factors that characterize the growth and development of Australia.     

Applied health services research: responding to the changing health care environment

Health care in America is changing rapidly. The forces that are reforming our health care system are both numerous and compelling. Americans are requesting access to more affordable health care. At the same time, many Americans want to build upon what is considered the best and most technologically advanced health care system in the world. Especially during economically troubled times, innovative and well-formulated solutions to respond to these fundamental challenges are needed to improve the quality and accessibility of health care. It is essential that policy markers base their health care decisions on sound medical research that specifically examines which aspects of medical care improve patient outcomes.     

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.     

The AMA faces down FDR and wins

There are two types of change that can occur via federal health care legislation: expansion in access and cost containment. Without passing judgment on the advisability of legislative change, I will argue that federal legislation is unlikely to occur unless both the executive and the legislative branches of government are controlled by the Democratic party. I am not suggesting that the change is necessarily an "improvement," only that Democratic Party control is necessary, particularly as the change pertains to access.     

The Health Insurance Flexibility and Accountability (HIFA) Demonstration program. A new initiative to cover the uninsured.

Seeking to keep his promise to give states more flexibility while expanding health insurance coverage to low-income people, President George W. Bush released a proposal to reform Medicaid and The Children's Health Insurance Program. This initiative, the Health Insurance Flexibility and Accountability Act (HIFA), represents a significant change in Medicaid policy. Whether states will find this proposal a useful tool to expand coverage remains to be seen.     

Leading health care into the 21st century.

If there is a consistency in the professional lives of those who manage in the health care field, surely it is characterized by inconsistency. Change. For more nearly two decades now, since the full impact of the Medicare/Medicaid legislation hit, the health care industry has undergone profound, continual, and lasting change. Success can be measured largely in terms of how well a professional or an organization accommodates and manages these changes, making sure that they work for the organization and the career and not against them. The 1990s can be expected to be just as full of change and turmoil as have the past two decades. "What's past is prologue," Shakespeare wrote. The health care field is not apt to see the murderous machinations of The Tempest, but clearly exciting and challenging times lie ahead, and perhaps the outcome will be as positive as Shakespeare's. The scenario that follows provides a glimpse at the issues of change that will occupy the time and energy of physician executives for the coming decade.     

Management,Competition and Professional Practice: Medicine and the Marketplace

Within the context of the creation of the internal market for health care, the paper examines the role of clinical directors, that is doctors who have retained their professional clinical positions whilst at the same time assumed roles as managers within increasingly well-defined corporate organizations providing health care. This represents considerable change from previous contexts in which doctors could always contract out of difficult managerial decisions. The role of clinical director is examined in terms of its own directorate and its involvement in contracting, co-operation and competition both within its own corporate organization and within the wider market place for health. Key issues are raised for the individuals and organization by these changes, they are discussed in terms of time, succession, managing colleagues, financial and human resources, market behaviour, support and terms of reference. These changes occasion wider discussion in terms of the challenge of coping with future demands for innovation, changes in the distribution of power within an emerging market for health care and the relationship among health care organizations, professionals and lay clients.     

Re‐Organizing Work Roles in Health Care: Evidence from the Implementation of Functional Flexibility

Functional flexibility has been advocated as a mechanism for improving efficiency and service quality and is, it is argued, especially appropriate to service environments. In recent years the UK public health service has been subject to an ongoing programme of reform, designed to modernize the way in which health services are provided. A central feature of the reform involves breaking down traditional boundaries and the re‐organization of work roles. This article is concerned with examining the implementation of functional flexibility in three health‐care settings. Case‐study data are presented, focusing on the responses of employees and managers to initiatives to work more flexibly. For managers the implementation achieved efficiency gains and improvements to service quality, in spite of some resistance from employees. For employees the outcomes were more mixed. There was evidence of ‘humanization’ through greater job variety, challenge and access to training, but there were also costs in terms of intensification, role confusion and stress. The implications of these findings both for understanding the issues raised by the use of functional flexibility and for the implementation of policies in the NHS involving job redesign are discussed.