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Discusses implementation of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (PDIMA), and political implications for the Democratic and Republican parties; US.

The demographic revolution—engendered in large part by modern medicine—which has led to the extraordinary and continuing increase in the number and proportion of elderly persons in the population has profound implications for health services. The elderly are disproportionately heavy utilizers of health care, primarily because of the prevalence of chronic disease. In the United States most health care for the elderly is financed through public funds, and costs have been increasing at an alarming rate. There is wide consensus that, for all the excellence of performance of the medical care system in treating acute episodes, care of chronic disease is frequently unsatisfactory in both quality and cost. Given the demographic imperatives, reform of mechanisms for chronic care is thus essential.

The demographic revolution -- engendered in large part by modern medicine -- includes an extraordinary & continuing increase in the number & proportion of elderly persons in the population, which has profound implications for health services. The elderly are disproportionately heavy utilizers of health care, primarily for chronic disease. In the US, most health care for the elderly is financed through public funds, & costs have been increasing at an alarming rate. There is wide consensus that, for all the excellence of the medical care system in treating acute episodes, care of chronic disease is frequently unsatisfactory in both quality & cost. Given the demographic imperatives, reform of mechanisms for chronic care is thus essential. 1 Table, 11 Figures. HA.

There has been considerable interest in the development of theories of public policy formation, but theoretical efforts to date have not demonstrated adequate recognition of the distinctive qualities of the dependent variable as a focus of research. Facets of public policy are far more difficult to study systematically than most other phenomena investigated empirically by political scientists. Our attempt to test hypotheses with some rigor demonstrated that public policy becomes troublesome as a research focus because of inherent complexity–specifically because of the temporal nature of the process, the multiplicity of participants and of policy provisions, and the contingent nature of theoretical effects. We use examples of policy making taken from the case study literature to show concretely how such complexity makes it essentially impossible to test apparently significant hypotheses as they are presented by Lowi, Dahl, Banfield, and others. Our effort here is to enhance theoretical development by carefully specifying and clarifying the major shortcomings and pointing out the apparent directions of remedy.