Discussion 8

Chapter 7 describes five reasons why health care reform is hard to pass; describe these five reasons, and elaborate on which one you think is the most critical and why.

Weissert, W. G. & Weissert, C. S. (2012).

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Governing health: The politics of health policy


ed.). Baltimore, MD: Johns Hopkins University Press. ISBN –

Although prominent Republicans such as Senate Majority Leader Bill Frist and Rep. Bill Thomas, chairman of the House Ways and Means Committee, have said that the health system needs comprehensive reform, the short-run prospects for such legislation seem dim.42 Indeed, the political climate is so unfavorable that even modest incremental changes are not under serious consideration.

Obstacles to reform.

Satisfaction with status quo.

There are numerous obstacles to comprehensive reform, not the least of which is that many individuals and organizations are satisfied with the status quo. Even if as much as two-thirds of the public were dissatisfied with the present system, that would leave a sizable minority who do not want any reform.43

Single-issue groups.

A second obstacle comes from single-issue constituencies. These groups want change in the system, but they each want different changes. Some press for better coverage for particular demographic groups; others want more attention and resources devoted to people with particular diseases; and still others press for more preventive care, more patient involvement in care, or more attention to the needs of rural areas. While often giving verbal support to comprehensive reform, single-issue constituencies tend to concentrate their lobbying efforts on their particular issues.

U.S. system of government.

The U.S. system of government, with its checks and balances and divided responsibilities, constitutes another obstacle to comprehensive reform. The founding fathers deliberately set in place political institutions that are inherently resistant to radical change of any kind—economic, social, or political.

Any comprehensive change in the health care system is likely to result in winners and losers. Prospective losers are likely to be much more involved and effective in blocking change than prospective winners will be in promoting it. As Machiavelli, one of the shrewdest political analysts of all time, noted, “There is nothing more difficult to carry out, nor more doubtful of success, nor more dangerous to handle, than to initiate a new order of things. For the reformer has enemies in all those who profit by the old order, and only lukewarm defenders in all those who would profit by the new order.”44 The challenge for reformers is to design mechanisms that will mitigate the unfavorable effects on potential losers while creating major gains for society as a whole.

Even those who are uncertain about how reform will affect them may oppose it because they are risk-averse. They may agree that there are problems with the current system with regard to cost or access or quality of care, or even all three, but at least the problems are known. Except in unusual times, most people prefer “the devil they know” to the one they don’t know.

Differences of opinion.

Last, but not necessarily least, any particular reform proposal must overcome resistance from those who favor comprehensive reform but differ strongly over the changes they would like to see enacted.45 These differences may arise because of analytical disagreements—the effect of alternative approaches on total spending, quality of care, or disparities in care—or because of differences in values—how egalitarian the system should be, how important is freedom of choice, and how large a share of the nation’s resources should be devoted to health care.

Possible precipitators of reform.

The foregoing list of obstacles to reform is so imposing that one might be tempted to think that comprehensive reform is impossible. But that would be a mistake. The prospects for changing the Articles of Confederation into a Constitution for a unified country seemed dim in 1787, as indicated by the quotation from John Jay at the beginning of this paper. The first meeting of the Constitutional Convention in Annapolis was quickly adjourned because of poor attendance. When it reconvened in Philadelphia, supporters of radical change had little hope of victory, but they succeeded, and even strong opponents came around to supporting the new Constitution. Or consider a sample of major social and economic changes that the United States has adopted over the past hundred years: the Federal Reserve System, Social Security, civil rights, and protection of the environment. Anyone analyzing the political climate in the decades preceding enactment would have difficulty finding evidence of widespread support for such momentous changes. But they did occur.

What might set the stage for comprehensive reform of health care? A major war, a depression, or large-scale civil unrest might well set in motion a change in the political climate that would overpower the obstacles that prevail in normal times. A national health crisis, such as a flu pandemic, might also light the fuse of change. Short of a major economic, social, political, or health crisis, there might be a confluence of forces that together would propel the nation toward comprehensive reform over the next decade, such as widespread dissatisfaction of the business community with employer-based insurance; state governments’ inability to sustain the ever-growing fiscal drain of federally mandated, means-tested insurance; or a financial crisis with Medicare. Leadership from the business community and states might together galvanize comprehensive reform. Finally, there might be a growing realization by average Americans that the risks of the current system to them personally and to the country as a whole outweigh the risks of comprehensive reform.

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