Suchergebnisse

While most commentators decry our peculiar ability to combine insecurity with high cost, the substantial reform of American medicine at the national level has been enormously difficult to achieve, and comprehensive reform has been impossible. This is not simply a description of the Clinton Health Plan debacle of 1993–1994. On many occasions before and after the Second World War, comprehensive national reform was attempted (and in 1973–1974, appeared imminent). In all those instances, reform fell short of the necessary political majorities. Each of these failures has its own history, and in each there are many contributing causes. One fact remains: Americans have long been dissatisfied with the nation's medical arrangements, but our political system has been unable to come up with a solution that satisfies enough of the public to overwhelm the institutional and interest group barriers to reform.

A discussion of health care reform in the US looks to past reform efforts for insights. Health reform is traced from the Progressive Era through Depression Era pursuit of universal health insurance to Truman's Fair Deal UHI to the fight for Medicare in 1965 to another quest for UHI, 1970-1974. This brief history highlights three important constants in US politics: (1) Compulsory health insurance is ideologically controversial with large symbolic, financial, & personal stakes. (2) The limits of political feasibility are much less distinct than many realize. (3) The role of language & emotive symbols cannot be underestimated. In this light, a proposal for health care reform is advanced, beginning with the establishment of a commission, a set of five common goals, & a set of five areas of common ground found among prominent extant reform proposals. In addition, the worst fears generated by each reform model should be addressed. Some remarks are offered on place of health care reform in the current political context as the 2008 US presidential election approaches. D. Edelman

International meetings about health-care issues—conferences, symposia, cyber-gatherings—have become something of an epidemic in the past decade. There is a brisk trade in the latest panaceas offered for the various real and imagined ills of modern medical care systems. When policy fixes fail in their country of origin, they are regularly offered to unsuspecting audiences elsewhere. Moreover, what travels as comparative analysis is often simply a collection of parallel descriptions of national health arrangements. So when there is a flurry of systematic comparative studies of health care by political scientists, a development illustrated by the four books under review, one ought to pay attention.

There is a remarkable consensus that American medical care—particularly its financing and insurance coverage—needs a major overhaul. The critical unanimity on this point—what Paul Starr has rightly termed a "negative consensus"—bridges almost all the usual cleavages in American politics—between old and young, Democrats and Republicans, management and labor, the well paid and the low paid. We spend more on and feel worse about medical care than our economic competitors, with nine out of ten Americans (including Fortune 500 executives) telling pollsters that our health system requires substantial change. That is the good news for medical reformers in the Clinton administration, the Congress, and the polity at large.The bad news for these reformers is that, for a variety of ideological and institutional reasons, American politics makes it very difficult to coalesce around a solution that reasonably satisfies the requirements for a stable and workable system of financing and delivering modern medical care. We have no assurance that the rare agreement on the seriousness of the nation's medical ills will generate the legislative support required for a substantively adequate and administratively workable program of reform.

This paper seeks to clarify choices in income maintenance, not to advocate a particular policy alternative. It makes explicit the trade-offs between competing objectives that are required of policymakers, but often obscured by polemics about the advantages or disadvantages of particular transfer mechanisms (e.g., negative income taxes, child allowances, demogrants). The paper first presents a critique of contemporary public debate on welfare reform and antipoverty cash transfer schemes. The next section distinguishes among the goals of reforming the present system of public assistance, substantially reducing American poverty, and making both the tax system and the social distribution of income more equitable. There follows a discussion of six criteria for evaluating and comparing alternative measures to one or another of these goals. The paper concludes with an application of the evaluative scheme to the welfare reform alternatives considered by the Nixon Administration in the spring of 1969.