On the Archeology of Health Care Policy Periods and Paradigms, 1975-2000 (2001) / Chapter Skim
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arise while older ones disap- HSAs, a nationwide system of local health pear as different eras come and go. A sample of systems agencies, established by the national health planning legislation of 1974, which 1An earlier version of this paper was commissioned for the 25th Anniversary of the Robert Wood Johnson Health Policy Fellowships Program.
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, the era that Similarly, the experiences of 25 classes of RWJ began at the same time as President Clinton's health policy fellows have also varied. The tra- first term and has seen most of the popula jectory of events over this period, however, was tion move to managed care plans in both pri "Each of the policy not predicted, nor, even in retrospect, is it easy vate and public coverage programs.
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, technology assessment Benefits from prescription for Coverage for 30 million plus Slowing of Medicare and Lowest rates of inflation in new national health policies elderly and poor, rapid expan- Medicaid cost increases national health care costs in sion of health care system over 30 years Unintended side effects of Hyperinflation of health care Cost shifting to employers, Public backlash against mannew prescription costs, ERISA preemption of most increased gaming of price aged care, competition on the state reforms controls basis of price rather than quality Enacted legislation National health planning, Hill- National Medicare price con- Medicare+Choice reforms, Burton law repealed, reduced trols, Medicaid price controls, expanded coverage for chil support for expanding physi- COBRA, DSH legislation for dren (SCHIP) , tax deduction for cian supply, ERISA uncompensated care, Medicaid health insurance premiums for expansions (OBRA 90)
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Public and industry and development of national health private payers, however, would probably refer to reform proposals that featured consumer this era as "the dark ages." The enactment of choice and "managed competition" among Medicare and Medicaid in response to crises in HMOs. The new "market" approach to coverage for more than 30 million of the health policy was developed most promi nation's elderly and poor marked the start of this nently by Paul Ellwood, M.D., a Minneapolis period.
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This era also saw the launching of the RWJ · an improvement in access to care in rural areas by increasing payment rates relative to Health Policy Fellowships Program (1973) to the rates in urban areas; help outstanding midcareer health professionals in academic settings learn first-hand how health · a rationalization of rural delivery of care policies and programs are developed in the through special programs for rural hospitals Nation's capital and to contribute clinical (e.g., the "Essential Access Community expertise to health care proposals.
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, the Prospective Payment on the more generous payments available for Advisory Commission (ProPac) , the Physician outpatient care; and Payment Review Commission (PPRC)
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Cost man agement technologies such as negotiated prices and health plan networks quickly became mainstream, and the use of quality 4As Paul Ellwood and Alain Enthoven continued to work on managed care and market reform, they met regularly with health sector and business leaders in Jackson Hole, Wyoming, where Ellwood owned a vacation home. The national health care reform proposal that resulted from these meetings came to be known as the "Jackson Hole Plan" and the people who contributed to it were known as the "Jackson Hole Group." 5The health alliances were based on the Jackson Hole proposal for health insurance purchasing cooperatives (HIPCs)
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The upcoming legislative agenda will include a · Following the failures of comprehensive patient bill of rights in managed care plans and reforms, Congress and President Clinton a Medicare prescription drug coverage proposal implemented a series of incremental meas- that would be administered by private sector ures, including: firms instead of government-administered price the 1997 Balanced Budget Act Medicare controls. provisions created a new market system The leading proposal for the next round of (Medicare+Choice)
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There is no longer much point in engaging in politically ideological controversy about health care reforms. Government health programs, as well as private employers, offer competing health plans instead of socialized medicine.
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Health Education and Welfare 10
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MEWA multiple employer welfare arrangement MSA medical savings accounts NCQA National Committee for Quality Assurance OBRA 90 Omnibus Budget Reconciliation Act of 1990 OTA Office of Technology Assessment PCH primary care hospital POS point of service plan PPO preferred provider organization PPRC Physician Payment Review Commission PRO Peer Review Organization ProPac Prospective Payment Assessment Commission PSN provider Service networks PSRO Professional Standards Review Organizations (now PROs) QMB qualified Medicare beneficiaries RBRVS resource-based relative value scale SCHIP State Children's Health Insurance Program SLMB specified low-income Medicare beneficiaries TQM total quality management 11
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The Robert Wood Johnson Health Policy Fellowships Program The Robert Wood Johnson Health Policy Fellowships Program is designed to develop the capacity of outstanding mid-career health professionals in academic and community-based settings to assume leadership roles in health policy and management. The program, initiated in 1973, is funded by The Robert Wood Johnson Foundation and conducted by the Institute of Medicine (IOM)
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