The Rhetoric and the Reality of Health Care Reform Legislation. 6th Annual Herbert Lourie Memorial Lecture on Health Policy

A plethora of political autopsies have been performed on the Clinton Administration's failed health care reform of 1994--it was too much; it was too late; there was too much pandering; there was too little pandering. Such critiques of this complex undertaking are at least partially correct. It was probably hubris to believe that such a comprehensive health care reform package could be proposed and passed in a single year. But much of the instant analysis of its failure has repeated the rhetoric of the debate rather than stepping back and placing the events of 1994 in perspective. Here I focus on five areas where rhetoric confused the debate, and compare them with the underlying realities of health care reform: (1) Financing. Proponents of the Administration proposal argued that universal coverage could be achieved primarily by redirecting existing revenue flows. It offered almost no new revenue sources--aside from a "sin tax" on tobacco. The reality is that to achieve universal coverage, we all have to pay for it, either directly or indirectly. And indirect payments can cause serious problems. (2) Controlling Costs. In an attempt to make cost containment efforts seem less onerous on individuals, the rhetoric offered two somewhat contradictory strategies of imposing *price controls* on health care providers and introducing market reforms, called *managed competition*. Presumably, managed competition would also automatically eliminate fraud, waste, and abuse, and in some unspecified way painlessly discipline the market for health care. The reality is tht people must face difficult choices if we are to control the costs of health care. Cost containment is a much more controversial issue than the Administration admitted. Many persons are nervous about the impacts of such controls. (3) Choice. The Administration went out of its way to promise choice, often in ways that complicated the plan. Opponents countered that the Administration's plan would actually limit choice. But what did they mean by choice? If they meant choice of doctors and hospitals, or choice of insurance plans, the Administration's plan stacked up very well. But the right to choose any kind of health care at any time would have been restricted under the Clinton proposal. Moreover, choice has long been eroding for most Americans as employers and insurance companies have imposed more control on insurance. In this case, the rhetoric of the opponents won out over the reality of what is already happening in our health care system. (4) Incremental Reform. Opponents of the Administration's proposal claimed that successful health care reform could be achieved by "tinkering around the edges," keeping what was right about the health care system and getting rid of what was wrong. The reality is that changes in one area of health care provision affect other areas, in ways that are not always understood or anticipated, and there is little consensus on what should be kept and what should be changed under an incremental approach. (5) Nostalgia. Many of those who opposed health care reform altogether expressed a longing to return to a health care system that they remember and think still exists, but that probably hasn't been in place for the last decade. Their warning that we should not surrender what we have for something less was given more credence than the Administration and other reformers realized. The reality is that health care has already changed rapidly and will continue to change with or without health care reform legislation. The Clinton Administration assumed that Americans understood the current status of national health care, including its flaws, and assumed this meant they had a mandate for change.

The Rhetoric and the Reality of Health Care Reform Legislation

A plethora of political autopsies have been performed on the Clinton Administration\u27s failed health care reform of 1994--it was too much; it was too late; there was too much pandering; there was too little pandering. Such critiques of this complex undertaking are at least partially correct. It was probably hubris to believe that such a comprehensive health care reform package could be proposed and passed in a single year. But much of the instant analysis of its failure has repeated the rhetoric of the debate rather than stepping back and placing the events of 1994 in perspective. Here I focus on five areas where rhetoric confused the debate, and compare them with the underlying realities of health care reform: (1) Financing. Proponents of the Administration proposal argued that universal coverage could be achieved primarily by redirecting existing revenue flows. It offered almost no new revenue sources--aside from a sin tax on tobacco. The reality is that to achieve universal coverage, we all have to pay for it, either directly or indirectly. And indirect payments can cause serious problems. (2) Controlling Costs. In an attempt to make cost containment efforts seem less onerous on individuals, the rhetoric offered two somewhat contradictory strategies of imposing *price controls* on health care providers and introducing market reforms, called *managed competition*. Presumably, managed competition would also automatically eliminate fraud, waste, and abuse, and in some unspecified way painlessly discipline the market for health care. The reality is that people must face difficult choices if we are to control the costs of health care. Cost containment is a much more controversial issue than the Administration admitted. Many persons are nervous about the impacts of such controls. (3) Choice. The Administration went out of its way to promise choice, often in ways that complicated the plan. Opponents countered that the Administration\u27s plan would actually limit choice. But what did they mean by choice? If they meant choice of doctors and hospitals, or choice of insurance plans, the Administration\u27s plan stacked up very well. But the right to choose any kind of health care at any time would have been restricted under the Clinton proposal. Moreover, choice has long been eroding for most Americans as employers and insurance companies have imposed more control on insurance. In this case, the rhetoric of the opponents won out over the reality of what is already happening in our health care system. (4) Incremental Reform. Opponents of the Administration\u27s proposal claimed that successful health care reform could be achieved by tinkering around the edges, keeping what was right about the health care system and getting rid of what was wrong. The reality is that changes in one area of health care provision affect other areas, in ways that are not always understood or anticipated, and there is little consensus on what should be kept and what should be changed under an incremental approach. (5) Nostalgia. Many of those who opposed health care reform altogether expressed a longing to return to a health care system that they remember and think still exists, but that probably hasn\u27t been in place for the last decade. Their warning that we should not surrender what we have for something less was given more credence than the Administration and other reformers realized. The reality is that health care has already changed rapidly and will continue to change with or without health care reform legislation. The Clinton Administration assumed that Americans understood the current status of national health care, including its flaws, and assumed this meant they had a mandate for change

Serving Older Adults with Complex Care Needs: A New Benefit Option for Medicare

Medicare was originally designed to protect beneficiaries from the financial burden of acute episodes of illness. As lifespans lengthen, Medicare must adapt to serve beneficiaries with substantial long-term physical or cognitive impairment who need personal care assistance. These beneficiaries often incur high out-of-pocket costs for Medicare-covered services as well as home and community care not covered by Medicare. This latter category of care is often key to continued independence. To improve Medicare's capacity to serve such beneficiaries, and to prevent unnecessary institutionalization, this issue brief, one in a series on Medicare's future challenges, proposes a complex care benefit option that would include home and community services, and describes how it might be structured to balance the goals of improving care for beneficiaries and ensuring affordability

Soft-tissue abnormalities associated with treatment-resistant and treatment-responsive clubfoot: Findings of MRI analysis

BACKGROUND: Clubfoot treatment commonly fails and often results in impaired quality of life. An understanding of the soft-tissue abnormalities associated with both treatment-responsive and treatment-resistant clubfoot is important to improving the diagnosis of clubfoot, the prognosis for patients, and treatment. METHODS: Twenty patients with clubfoot treated with the Ponseti method were recruited for magnetic resonance imaging (MRI) of their lower extremities. Among these were seven patients (six unilateral cases) with treatment-responsive clubfoot and thirteen patients (five unilateral cases) with treatment-resistant clubfoot. Demographic information and physical examination findings were recorded. A descriptive analysis of the soft-tissue abnormalities was performed for both patient cohorts. For the patients with unilateral clubfoot, we calculated the percentage difference in cross-sectional area between the affected limb and the unaffected limb in terms of muscle, subcutaneous fat, intracompartment fat, and total area. With use of the Wilcoxon signed-rank test, we compared inter-leg differences in cross-sectional areas and the intracompartment adiposity index (IAI) between treatment-responsive and treatment-resistant groups. The IAI characterizes the cross-sectional area of fat within a muscle compartment. RESULTS: Extensive soft-tissue abnormalities were more present in patients with treatment-resistant clubfoot than in patients with treatment-responsive clubfoot. Treatment-resistant clubfoot abnormalities included excess epimysial fat and intramuscular fat replacement as well as unique patterns of hypoplasia in specific muscle groups that were present within a subset of patients. Among the unilateral cases, treatment-resistant clubfoot was associated with a significantly greater difference in muscle area between the affected and unaffected limb (−47.8%) compared with treatment-responsive clubfoot (−26.6%) (p = 0.02), a significantly greater difference in intracompartment fat area between the affected and unaffected limb (402.6%) compared with treatment-responsive clubfoot (9%) (p = 0.01), and a corresponding higher inter-leg IAI ratio (8.7) compared with treatment-responsive clubfoot (1.5) (p = 0.01). CONCLUSIONS: MRI demonstrated a range of soft-tissue abnormalities in patients, including unique patterns of specific muscle-compartment aplasia/hypoplasia that were present in patients with treatment-resistant clubfoot and not present in patients with treatment-responsive clubfoot. Correlations between MRI, physical examination, and treatment responsiveness may aid in the development of a prognostic classification system for clubfoot. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence