POLITICS, ECONOMY AND HEALTH
Eva
Hirwe
Because most public
health endeavors in the U.S are funded by the public health sector, public
health practitioners need to be adept at working within the political system.
However, the 1988 Institute of Medicine report, The future of Public Health,
found that many public health professionals are ignorant and disdainful of
political processes and will not participate in activities they perceive to be
political. Studies have been done which examined the health policy and politics
curricula of the accredited schools of public health in the US, finding that
most public health students are not exposed to these areas during their
graduate course work.
If politics is the art
of the possible and economics is focused on the effective utilization of scarce
resources, this chapter should be concerned with the political economy of
public health. Advances in preventive medicine or public health depend on the
prior allocation of scarce economic resources, primarily through actions in the
political arena. There is nothing easy about eliciting a favorable response
through the political process to attract the required economic resources even
in the face of the probability of significant health gains being achieved. The
health of the public is anchored in the fundamentals of life: how people eat,
work and play. No political leadership, even the most securely ensconced
autocracy, will enter upon new policies or programs that are a direct challenge
to the status quo without strong reasons. The trouble that such a frontal
attack will engender is uncertain: the benefits problematic. Even if the
benefits appear substantial, the leadership might still hesitate to start
innovations on the grounds that the existing political equilibrium should not
be jeopardized. A second reason for caution: most innovations require
investments that can be made only to the extent that government is able to
extract from the tax paying public some part of their income or capital. But
all peoples, those who live close to the level of subsistence as well as those
who are citizens of affluent nations, are resistant to transferring their money
to the state. Even when one third or one half of the gross national product
flows through the government sector, as is the case in most developed nations,
the public authorities are not free to spend what they like on health. Demands
for health expenditures must compete with other priority areas such as defense,
education, social security, and housing. There is yet another reason why
innovations in health programming are seriously constrained. The knowledge base
is never broad or as deep as one would wish. Not enough is known about the
direct, much less indirect, consequences of various types of societal
interventions. The softness of the knowledge base affects the selection of
means even in the face of prior agreement as to goals. For a legislature that
has determined to allocate additional funds for preventive medicine or public
health, it is not easy to choose among the following: the establishment or
enlargement of school feeding programs, neighborhood health centers,
anti-venereal disease programs, health educational programs. And the complexity
of the choice is that much greater if the legislature has reached a level of
sophistication to recognize that it may make a more significant contribution to
the nation’s health by introducing new control and expenditure measures in
fields other than health, such as housing allowances for poor families, higher
standards for automotive manufacturing, or intensified efforts to interdict
drug trade.
IMPROVEMENT IN THE
PUBLICS HEALTH.
Some paradoxes: 1995
the United States spent more than 1000 billion dollars in health expenditure.
Since the United States and major industrialize countries spend more than 10%
of their gross national product on health, one must conclude that health looms
high on the expenditure priorities of affluent countries. The matter is more
complicated, however. The conventional wisdom holds that smoking, overeating,
lack of exercise, and excessive use of alcohol are among the principal reasons
that many men and some women die before reaching age 70 and those who survive
beyond that age are likely to be afflicted by chronic illnesses. Since these
personal behavior patterns are life shortening, how can one explain the
apparent paradox in a society that spends so much on health care services and
yet so many follow a lifestyle destructive of their health. There are several
explanations. Those who abuse themselves may be ignorant of the likely
consequences of their actions; they may be gamblers who believe that while the
odds are against them, they, like Winston Churchill, may be lucky and live a
long life despite their over indulgence; some may choose a life-style they
prefer, with its attendant risks, over one that that seems long and dull. There
are still other possible explanations, including the uncertainties that attach
to moderation: a person who follows the preferred regimen may still develop
cancer or other lethal disease. The constant barrage in the media of the
wonders of modern medicine may lead many to over estimate what physicians can
do for them if they encounter health problems. The limited capacity of modern
medicine to respond is not generally appreciated. The paradox of large public
and private expenditures for personal health care and the disregard of such
life-extending practices as adequate sleep, balanced diet, reasonable exercise,
and abstention from smoking and the excessive use of alcohol bring two policy
issues in developed countries to the fore. The first involves the potential for
redirecting health expenditures from the curative to the preventive frontier:
the second is the appropriate role of state intervention in limiting the
freedom of the individual to jeopardize his own health and that of others.
McKeown and other British leaders of social medicine, whose works presented
substantial evidence that curative medicine has added relatively little to the
reduction of mortality and the elongation of life, the Canadian minister of
health and welfare presented a proposal to the government in 1974 for a
reduction of its health expenditures away from therapeutics and toward
strengthened preventive and public health efforts. The difficulties that this
counter cultural approach has encountered arise less from its critique of the
low productivity of present investments in health and more from its failure to
delineate specific targets for investments that would unequivocally contribute
to raising the health status of the population. Open-heart surgery is both
expensive and of uncertain value, but for many who suffer from angina it offers
greater prospect of relief than an expanded program of health education or
improved highway construction, which might contribute more to the reduction of
mortality many decades, governments in the industrialized West, despite their
reluctance to interfere with the private lives of their citizens, have not
hesitated to do so where failure to intervene has placed large numbers of
innocent citizens at risk. Hence the mandatory reporting of certain infectious
diseases, compulsory vaccination, rules and regulations affecting food
handlers, and still other restrictions on the freedom of the individual to do
what she or he may prefer. The question that now arises is whether the state
should expand the use of its police powers to alter the behavior of its
citizens in order that they may enjoy a longer and healthier life. The positive
reasons for such an intensified interventions are the gains that would accrue
to the society at large from a reduction in unnecessary morbidity and
mortality. In time of war, armies discipline soldiers who contact venereal
disease or frostbite; especially if the officer in charge can prove that the
sick and injured failed to take preventive or prophylactic actions that were
known and available to them. Soldiers who become ineffective by failing to
follow rules place an added burden on their fellow servicemen; hence the
justification for punitive measures. In the US experiment with prohibition,
initiated in 1920, was entered upon in belief that the social costs of drinking
exceed the benefits and that many innocent women and children were victimized
by husbands and fathers who deflected much needed income from food and other
essentials to pay for their drink. The public terminated the experiment after
13 years because of its restiveness with the costs of the system of control.
The larger sector of the public that wanted to drink in moderation no longer
had the opportunity to do so except by breaking the law. Rampant corruption
among government agents, illegal distributors, and the consuming public became
a source of growing concern. The economic losses attendant upon the legal
production and sale of alcoholic beverages were substantial. The direct and
continuous confrontation between government and many of its citizens over what
they were permitted or not permitted to drink came to be viewed as a distortion
and perversion of the role of government in a society of free men and women.
The interdiction of cigarette advertising on television, the levying of
ever-higher taxes, and the prohibition of smoking in public places reflect on
the part of the concerned nation a preference for a more moderate approach. We
are probably not far away from the indifference zone, where further controls
must be weighed against the costs of enforcing them- in Toronto, Canada the
penalty for smoking in a prohibited area (public elevators) was raised to
$1000- in terms of public acceptance as well as the secondary behavioral
consequences of a more effective program of control. Some people who give up
smoking gain excessive weight, resorting to overeating to compensate for their
loss of tobacco. Over the long run, it may turn out that many who are seriously
addicted cannot be cured; all one can hope to do is to alter the nature of
their addiction. If that turns out to be the case, the limits of appropriate
governmental policy to interfere with the citizens easy access to tobacco
becomes ever more difficult to chart. The issues up to this point revolve
around the boundaries between the freedom of individuals to follow lifestyles
of their own choosing, including actions that may be injurious to their health
(in the absence of direct adverse effect on their neighbors), and the latitude
of government to intervene and interdict certain types of behaviors on the
grounds of enhancing the general welfare. Several observations are pertinent.
In the face of a constantly enlarging base of reliable knowledge, the
boundaries should not be as fixed but rather adjustable. Next there should be a
presumption against extending the intrusion of the state into the private lives
of its members. The costs of intervention are never small, and the secondary
consequences (e.g., corruption after Prohibition) may turn out to be
horrendous. Finally, health scientists constantly remind us that most
disabilities reflect the interactions between individuals' genetic endowment
and the environment in which they have been reared and live. This establishes a
high order of variability as to how people who engage in dysfunctional
activities will be affected: some will suffer seriously from minimum lapses,
and others will remain largely free of adverse effects even in the face of
pronounced deviations. In the face of such uncertain outcomes from identical
behavior, effective intervention by the state becomes much more difficult. .
THE POLITICAL ASPECTS
OF HEALTH PLANNING.
Planning is concerned with relationships of
power or of influence, generally within the context of government. A change in
these relationships is apt to be either a prerequisite for or a consequence of
successful health planning. In a field as broad as the one under consideration,
the planner must carefully assess the validity of the various observations made
here in the light of the local situation in which he works.
Health planning
antedates by many years the formal organization of planning units. As long as
organized health agencies have existed, systematic efforts have been made to
improve delivery of health care. Regrettably, they have not been accompanied by
parallel efforts to record and understand the political context within which
health authorities operate. There is general agreement that the planner’s
ability to understand and turn the political process to his advantage is a
prime determinant of success. In the US, the failure of many planners and
health authorities to give adequate attention to the political component of
their jobs has perhaps not had as adverse an effect on their activities as
could have been anticipated. Various authors have pointed out past tendencies
of politicians and the public alike to defer to the health professions in all
matters pertaining to health care. Within the limits of the resources made
available to him, the health administrator has had greater freedom from outside
influence to dispose of such resources as he thought best than have his
counterparts in other sectors such as education, welfare, and housing.
Health authorities
have tended to foster such deference by presenting a public image of dignity
and aloofness to controversial matters, which extend beyond their immediate
professional concerns. The reluctance of health professionals to participate in
the rough and tumble of program and inter agency politics, or their
perpetuation of the myth of the non-political character of public health, has
meant lost opportunities for constructive action or has needlessly generated
conflicts through ignorance of the political process.
All this is not likely
to be the case in the future, for the situation has changed drastically in
recent years. The spontaneous rise in community activism, reinforced by
legislation promoting consumer participation in matters of public policy, and
the growing awareness of the inability of the health professional to provide
comprehensive care at reasonable cost have combined to bring the public and
politicians into the debate on health policies than ever before. Whereas in the
past health officials received a mandate to discharge the traditional public
health responsibilities, now find themselves obliged to generate one for the
expanding responsibilities of providing medical care.
Even more than the
health administrator, the planner has sought to insulate himself from the
vagaries and hazards of the political process. To minimize interference with
his work, he has experimented extensively with the organizational chart in an
attempt to find an administrative location with the utopian combination of
proximity to the sources of power as well as independence from “politics.” It
is impossible for a planning agency to be both autonomous and effective. A plan
that is to have a good chance of being implemented must be a joint project of
those who have to carry it out and must express their coordinated aspirations
in the context of a common goal. Moreover, the very essence of planning, indeed
the very decision to begin planning is political. There is no way of avoiding
this even if it were desirable.
The planner’s desire
to disassociate himself from the political process reflects a misunderstanding
of his primary responsibilities, defined as the illumination of choices for the
political decision maker, and as a natural consequence, the persistent
restraint and prevention of the foolish, the wasteful and the cynical. As the
planner strives for an improved world and not a perfect one, he must accept the
impossibility of simultaneously satisfying all the values present in any
political system. The extreme expression of the planner’s ultimate value (that
no proposal should be compromised) must inevitably clash with others such as
those of radicalism (all proposals should be adopted), conservatism (no
proposal should be adopted), checks and balances (the distribution of authority
should be wide) and democracy (all actors are autonomous)
Effective planning is
unavoidably controversial and indeed many underestimate the degree to which the
public and politicians oppose planning. Allocation of scarce resources
necessitates the unpopular task of deferring the attainment of lower priority
objectives. Most people accept the need to plan their own affairs but are
reluctant to allow others to plan for them because of the loss of independence
that this may entail. Moreover planning implies change, a difficult and
unpleasant process for both individuals and societies. To induce planned
change, health planners in many countries can offer neither strong incentives
nor sanctions as means to ensure implementation. Often they may not even have
much occupational security or visibility and as their actions progressively
extend into the field of medical care, they come into direct conflict with the
anti-planning sentiment of most private physicians. They must therefore make efficient
use of what little power they have and capitalize on the convergent interest of
others.
There are several
practical considerations in getting the planning process underway for the first
time and to developing appropriate relationships between planning agencies and
other participants in the planning process. Since planners are more apt to
exercise their craft through intermediaries such as administrators, consumers,
and professional groups than through direct contact with politicians, primary
attention is given to how best they can utilize these groups to assess the
political feasibility for change and to promote plan implementation.
The first few months
for a new health-planning unit are apt to be the most difficult. Expectations
are high and perhaps unrealistic, planning staff must be recruited and trained,
and many division chiefs within the health agency may view the advent of
planning with great apprehension, if not open hostility. The way the first few
planners approach their task during this period will do much to determine
eventual effectiveness.
The will to plan: A
first and crucial question to be answered, particularly in countries which have
only recently started to plan, is whether a discernible “will to develop”
exists and, by inference, a “will to plan”. Insufficient government support is
the prime reason why most plans are never carried out successfully. No
conclusive text was found by the author on the will to plan, although various
indicators can provide suggestive evidence. One can begin by examining the
following questions. Is the countries ideological framework congenial to
planned change? Are political and other leaders to change and what tangible
evidence exists of this commitment? Do matters relating to internal politics
consume an excessive amount of leadership time? Do graft and corruption siphon
off an inordinate proportion of the resources necessary for plan
implementation? To what extent have previous plans been oriented primarily
toward meeting short-term political objectives or obtaining international
assistance rather than as part of a continuing developmental effort? Does the
will to plan exist at both the policymaking and implementation levels? What
priority is given to health programs and to what extent does a consensus exist
regarding the major problems confronting the health sector?
For countries with a
previous history of planning, perhaps the best test of the will to plan is the
confrontation of past plans with subsequent performance. The observed gaps
between promise and performance can be considered as a measure of political
administrative efficiency and provide the planner with a valuable correction
factor for bringing theoretically feasible targets more in line with reality.
The will to plan is
not monolithic; wide differences may exist in the readiness of health and other
authorities to consider change, depending on the policy under consideration.
When the overall planning environment is relatively unfavorable, the planner
can begin with those policy areas where the opportunities for improvement are
greatest. Conversely, when the commitment is generally high, the planner can
complement his regular activities with efforts directed at increasing the
awareness of and concern for problem areas not well recognized. The importance
you attach to one or another criterion of the will to plan will vary greatly
depending on the country situation in which you find yourself. As in the
development process itself, the minimal acceptable standards for getting
started cannot be made too high or otherwise nothing will be done. Furthermore,
if careful appraisal of the planning environment suggests that the chances for
success are slight, it may be wise to limit the your objectives to promoting
the necessary preconditions to planning.
A priority task for a
newly creates planning agency is recruitment of staff. Competence and integrity
must obviously take precedence over other selection criteria but candidates’
political preferences may also have to be considered, particularly in an unstable
or highly politicized situation. The top planning job will often be a position
“of confidence” of the chief executive and hence dependent on the party in
power. While the political affiliation of the staff planners is not so
important, experience suggests that planning effectiveness and continuity will
be improved if staff members are drawn from all major political groups.
Broadening the support
for planning; as he begins to apply his knowledge of organizational dynamics,
the planner should try to avoid excessive dependence on only one or several
persons, no matter how important they may be at a given point in time.
Occupational vulnerability tends to increase as one nears the top levels of an
organizational hierarchy: in most organizations, the top job is the most
vulnerable of all. In a new or unstable situation, linking planning to the
support of one of several strong officials may help ensure short term survival
and prominence, though it may retard institutionalization of the planning
process and ultimately decrease its long term effectiveness.
Keeping others
informed; A planning unit must devote considerable time to information and
communication functions. Aside from their many outside contacts in connection
to data gathering, planners will need to keep others continually apprised of
the results of their studies, of parallel program and research efforts being
carried out elsewhere, and of the implications of their work for future
policies. They will also want to use these opportunities to learn of new developments
and to gain continual feedback on the extent to which proposed plans are likely
to be understood and accepted. Before deciding what procedures to use, the
planner would be well advised to clear them with his administrative superiors.
It is not much of an exaggeration to say that he who controls an organizations
access to and release of processed information is virtually in control of the
organization itself. Moreover, plans and planning have to do with man’s
aspirations for the future, which in turn are the central concerns of the
politician and senior executive. The planner is anxious to enhance his
political stature and to widen his power base beyond that afforded by his
parent agency, and his control over specialized information affords a good opportunity
to further these objectives. If pursued too openly, however, he may run into
direct conflict with his superiors to the ultimate detriment of both the
planning and himself. It is especially important to check with appropriate
authorities before discussing with outside interest groups major study findings
or policy issues.
Involvement of others
in the planning process: It is commonly accepted that those who are to be
affected by planning should be directly involved in the planning process. In
this way planners can help ensure that the priorities have been properly
identified, that the plan is feasible, and that most importantly, the
implementation phase will enjoy broad support.
There is much less
unanimity as to ways in which meaningful involvement can be attained. Indeed,
in a highly politicized or controversial situation, planners may conclude that
early involvement of the contending interests would aggravate rather than
improve relationships, and in any event be too demanding on their time. While
such arguments may occasionally be valid, one should recognize that he is only
postponing the controversy, not eliminating it, and that failure to confront
issues early may lead to unrealistic assumptions regarding plan feasibility.
One of the more difficult
tasks is deciding who represents the “community” of consumers and providers and
how should he make this “representation” operative. Is it preferable to have
persons able to interpret accurately the interests of the groups they
represent, even though they may have little power to influence policy, or to
have persons with the potential of power even though they may be poor
interpreters of current group thinking? These attributes- power and the ability
to interpret group interests- are not necessarily found in the same persons.
You may also want to know how best to balance the representation of health
service providers, other direct interest groups and consumers. How many
participants can be realistically accommodated in the planning process? Too few
and you get poor representation, too many will either frustrate active
participation or lead to a parceling of council responsibilities among many
subcommittees (resulting in a tendency for professional specialists to dominate
subcommittee deliberations).
The central arguments
are that the political process is often of decisive importance in determining
the outcome of plans and planning, and that there is no effective way of
isolating planning from the political process. Good planning is inevitably
controversial since it introduces technical analysis and an explicit value
system for decision making into a process up to now to now have relied largely
on personal judgments and the politics of power. The planner must therefore be
continually alert to opportunities to incorporate into his planning efforts
such measures as will help assure eventual acceptance by political and
administrative authorities.
HEALTH LOBBIES: VESTED INTEREST AND
PRESSURE POLITICS.
Health lobbies are
highly fragmented; they often fight with each other with almost no ability to
look beyond their own particular interests. The terms “lobbies,” “lobbyists,”
and “pressure groups” have acquired a connotation in the public’s mind that is
unwholesome if not outright evil. It is often implied that if we could abolish
them, our government would function better and would operate on a higher moral
plane. It is further implied that any elected or appointed public official who
listens to them, consorts with them, or acts in accordance with any of their pleas
is ipso facto either a kept man or a dupe. I would suggest that such a view is
both fallacious and naive. Further, if as health professionals we tend to
embrace this view, our individual impact on the future delivery of health care
may well be minuscule, which is about what we may deserve. And finally, our
failure to look beyond the superficialities of publicly held stereotypes- i.e.,
“some lobbies have committed corrupt acts, therefore all lobbies are corrupt”-
is in itself an abandonment of a rational position in favor of an
anti-intellectual prejudicial position that will do no one any good. Although
the principal objective for government at all levels is to continuously improve
the quality of life for all people, it is obvious that some groups have contributed
more to this objective than others. It is difficult to pinpoint any one group
or individual and declare honestly that its positions and activities have been
all good or all bad in terms of the overall objective. Our society is a
conglomerate of highly competing forces, composed of many special interest
groupings, and it is government’s role to moderate these forces to the optimum
benefit of the total society. Admittedly, sometimes the machinery for
moderating breaks down, and some segments of our society gain a greater
advantage than others, but in the long term it is even more productive to try
to repair the machinery than it is to ignore it in disdain because some part of
it appears evil. Over the long term the government has responded to its task
albeit at times slowly, as well as, if not better than, any other such
institutions created by man at any time in history.
LOBBIES AND PRESSURE
GROUPS:
The American Medical Political Action
Committee (APAC), the political arm of the American Medical Association (AMA),
contributed $2.4million to candidates for Congress during the 1989-1990
campaign and $2.9million during the 1991-1992 campaign and, with $1.4 million
in contributions, led in campaign giving among health-care related political
action committees that reported a total of $7.6 million in contributions since
Jan. 1, 1991. While consumer groups contend that such special interest giving
provides clout in health care policy decision-making, others say money doesn’t
buy votes, only access to candidates and lawmakers. It is not known whether
these funds preferentially benefited representatives who supported the AMA's
positions on public health issues.
In our society lobbies
and pressure groups are an essential part of the government process. Over the
last century, their importance has increased, not decreased. They derive their
authority from the constitution, that is, the explicit right of citizens,
singularly or collectively, to petition their government. As our society
becomes more complex, as communications continue to become more rapid and
thereby capable of creating a greater mass of concern, as our societal problems
become more acute and visible, as the complexities of dependent urban life
engulf our pastoral heritage of personal independence, the effect will be to
intensify the function of persuasion of government by paid advocates
representing certain segments and interests in our society. Complexity of
itself demands this. This does not mean, however that lobbying and pressure
group activity should go unregulated or unexposed to the general public; but at
the same time their usefulness, in fact their essentiality to the government
cannot be denied.
What is the usefulness
of lobbying activity to the process of government? Essential it is the act of
providing a specialized information input into the legislative and
administrative process on a day-to-day basis that would be unavailable to the
government otherwise. If it did not have this source of information, government
would have to find or create another specialized source that might produce even
more lopsided results, at least for a period of time. Pressure groups through
their lobbyists provide a consensus of opinion from those involved in their
groupings; they provide reactions to given courses of action; they provide a
major technical input into highly complex matters; they provide a pathway for
the public official into thinking of at least a portion of that official’s
constituency. The last is much too complex to describe in its entirety, but
each pressure group tends to create a consensus of opinion on given issues in
certain segments of a government official’s constituency that could have, when
combined with the consensus of other groups, a profound effect upon the number
of years he occupies office. This is not to say that the public official,
either in the legislature or the administration, should bow to any consensus.
But at least he needs to know when and where the trend is running against his
position so that he can advance the arguments of his persuasion more
forcefully. Then, if he loses the argument and consequently, the next election,
at least the public has had an opportunity of hearing and weighing both sides
of the question. For better of worse, this is how issues are resolved; it
constitutes a large part of the democratic process and is one of the major
guiding forces of change in our society.
LOBBYING GROUPS.
There have been many
types of lobbies in our society- far too many to describe even a significant
portion here. But let us lay to rest the connotation of evil or corruption as a
general description of the lobbying process. Although there have been corrupt
lobbies as there have been corrupt people, institutions, corporations, and
businesses, the answer is the creation of sound laws governing lobbying
activities and the enforcement of these laws, not the denial of the right to
have organized input of information and opinion into government at all levels.
What we have to assume in the essence is that if we elect persons of integrity
to office, the information and opinions thus provided to the governmental
process by lobbies will be properly evaluated when used. There are two broad
categories in which we could place lobbies. Certainly we will find lobbies that
fit into both categories, and it may be difficult to argue that any of the
lobbies, at least in the health field belong exclusively in any one category.
But we can say that the dominant part of their activities do fall into one
category or other. The first category we might label as “protectors of the
status quo.” These lobbyists devote most of their activities to preventing
change. When they support change, it is usually to better the conditions of
individual members and not necessarily to enhance the good of the general public.
Often their sole efforts are devoted to preventing passage of a proposed
legislation or obtaining amendments, which would make the resulting change as
insignificant as possible in legislation, which is difficult to stop. In the
event that the new legislation is passed, much of their effort is then turned
on the administration to prevent rules and regulations, which would provide
what in their opinion is too liberal an interpretation of the new law. The
second category of lobbies might be termed “the promoters of change” These
groups are usually less well organized, have fewer resources at their disposal,
and generally pass in and out of existence with far greater frequency than
those who are “protectors of the status quo.” There have been numerous examples
of the promoters of change category in the health field. Most have been
groupings of individuals and organizations interested in narrow specific
problems related to health care. For example, a number of organizations early
in this century joined together to form a Washington lobby in support of the
creation of a program concerned with maternal and child welfare. Such groups as
the National Consumers League, the National Child Labor committee, several
women’s organizations, labor groups, and church groups collectively supported
the drive that led to the formation of the Children’s Bureau and ultimately to
the inclusion of a crippled children’s medical benefits program in the Social
Security Act of 1935. Over a quarter of a century, efforts, including mothers’
marches and similar activities organized to support legislative change, were
devoted to improving services for the young. Once a significant portion of the
objectives was accomplished, the coalition and its efforts began to fade away.
The American Parents Committee and the Crippled Children’s Society continued to
be supportive, but the original drive for change and improvement was not
sustained nor refocused on other similar health problems. During the period
after the Second World War, many looked up to the American Public Health
Association (APHA) as the vehicle through which efforts could be focused to
bring about improvements in health care. APHA contained the diversity of
interests that could perhaps insure its longevity as a political force focused
on Washington. But this internal diversity of interest, ranging from pollution
to medical care with a full range of political views from conservative to
liberal, plus a lack of adequate resources, made highly effective action at the
legislative level impossible. Although there have been renewed efforts by APHA
to focus on Washington as an instrument of change, its internal structure makes
this difficult. Numerous groups devoted to single purposes or one-time actions
continue to emerge as advocates of change with seemingly little chance of
longevity. The Committee of One Hundred, containing many of the nation’s
leading advocates of change in our health care delivery system, was formed to
support the enactment of national health insurance legislation. Financed
largely by organized labor, it admittedly aimed its efforts at one specific
type of change and focused, for all practical purposes, on one piece of
legislation. Although it might continue as a permanent pressure group if its
proposed legislation is enacted, its future source of financial support would
undoubtedly have to be broadened and its controlling forces would undoubtedly
undergo change. Stability on the promoter of change side is hard to come by. In
another kind of grouping in the advocates of change classification was the Ad
Hoc Committee on Health Care Crisis in 1968-1969 and the subsequent loose
affiliation of groups known as the “Coalition for Full Funding” in 1970-1971.
Composed of leaders in health organizations, -essentially the associations were
devoted to specific categorical diseases-these two groups organizes to urge
Congress to appropriate larger amounts of funding of health programs than was
proposed by the administration in the health budgets presented to Congress. In
both cases, it was a banding together of those who believed that the programs
in which they each had a specific interest were not being properly funded and
that by joining together not only did they present a formidable voice, but they
also reduced the chances of one program being cut in order to aid another that
might have a stronger lobbying capability. Lacking permanent staff, or a means
to pay the housekeeping costs of a year round organization, this type of
coalition usually folds up its tent at the end of the appropriation period and
heads towards oblivion. Unlike the military budget, where there is continuous
effort on behalf of appropriations by those who produce military goods and
those who have employment as a result of military expenditures, there is little
continuous support for health appropriations.
LOBBY’S ROLE IN THE
HEALTH FIELD.
Lobbying is divided
into two main categories. Direct lobbying refers to communications with
lawmakers that take a position on a specific legislation, and grassroots
lobbying includes attempts to persuade members of the general public to take
action regarding legislation. Even public charities may engage in some direct
lobbying and a smaller amount of grassroots lobbying. Much public health
advocacy however is not lobbying, since there are several important exceptions
to the lobbying rules. These exceptions include “non partisan analysis, study,
or research” and discussions of broad social problems. Lobbying with federal or
earmarked foundation funds is generally prohibited. To understand the role of
pressure groups and lobbying in the health field it is helpful if we put into
perspective some of the events, which motivated government to become involved
in health care. It is a fallacy to assume that government intervention is a recent
phenomenon. Either local or federal government has paid for care of the poor as
well as other special groups of citizens since the early days of this nation.
During the first half of this century public tax dollars paid for as much as
24% of the total costs of medical care in the nation. Recent statements from
the Department of Health, Education, and Welfare (HEW) indicate that of the 70
billion spent per year for health care in the United States, 37% comes from
federal tax dollars. Add local tax dollar contributions, and the total
percentage paid out of tax sources amounts in excess of 40%. Through many
channels government is and has been throughout our history a large purchaser of
health care for the better part of this nation’s history, its interest in the
quality and quantity of care is relatively recent. Most health historians give
the Flexner study, conducted in 1910 on medical education in the United States,
credit for awakening many national leaders to the need for regulating certain
aspects of health care. An unusual amount of publicity resulted from the
report, forcing several inferior medical schools to close and others to raise
their standards. There were brief moves to extend government control over
medical educational standards but the American Medical association (AMA) moved
to establish continuous supervision in this area, thus averting government
intervention on a broader scale.
William Welch A
short time later William Welch, MD, one of the founders of Johns Hopkins and
often referred to as the “Dean of American Medicine,” began a lifelong effort
to improve health conditions in the United States. He perhaps more than any
other man interested government leaders in trying to solve some of the nation’s
health problems through government action. As a personal friend of United
States Presidents, senators, and congressmen, as well as local government
officials, he worked as a one-man lobby to gain government regulation of water
supplies, passage of the pure food and drug bill, establishment of disease
control measures, and support by public funds of the hygienic laboratories
which later became the National Institutes of Health (NIH). Additionally, he
carried out a public campaign to make government assume a greater
responsibility for health care for the poor. In short, Welch used all the
techniques now associated with high -quality lobbying to gain government
intervention in the health field. The efforts of his public life represented a
major turning point in government’s relationship to health care.
Social security. Next came the social security debates of the
early and mid-1930s. The early versions of social security legislature made
reference to the study of national health insurance, inferring that health
insurance might become a part of social security program. Although the
Roosevelt Administration supported this approach, even the study of national
health insurance was strongly opposed by organized medicine. This was perhaps
the first genuine test of organized medicine’s lobby fight against any form of
a compulsory health insurance system. A lobbying effort was organized against
the one sentence in the bill that would have mandated the study. Members of
Congress received so many telegrams opposing the study that supporters of the
social security bill believed the entire proposal was in danger. When the bill
came before the Ways and Means Committee, the sentence proposing the study was
unanimously struck from the bill. This action marked the beginning of the AMA
lobby’s determined effort to oppose any proposal that would create a compulsory
health insurance program. As part of its opposition, the AMA politicized itself
in 1950.After the social security confrontation there was a succession of bills
designed to create a national health insurance system. Nearly every session of
Congress saw the introduction of at least a few proposals on the subject, first
by Senators Wagner and Capper in the late 1930s, others in the 1940s and 1950s,
and the King-Anderson bill of the 1960s which focused on the aged. It became a
major of the AMA lobby to oppose most of these bills. At the same time, it
caused more and more of the AMA’s resources to be devoted to lobbying efforts
in Washington. The budget for any group’s lobbying is directly related in size
to the emotional concern that can be generated among the members against any
given proposal and, in this sense, the various NIH bills caused the lobby of
organized medicine to become substantially oriented to one subject. Prior to
1933 organized medicine had taken up positions both for and against health
insurance. Their position solidified in the mid-1930s as one of opposition to
virtually all forms of health insurance, voluntary and compulsory. Then by the
late 1940s, the more moderate leaders within medicine prevailed, the need for
insurance protection against the costs of illness was recognized, the political
need to have a positive proposal with which to counter the popular appeal of
national health insurance was reluctantly acknowledged, and both the American
Hospital Association and the AMA began a campaign to promote Blue Cross and
Blue Shield plans as voluntary alternatives to meet the nation’s needs. They
were to continue this technique of fighting one proposal with another-one more
to their liking- up to more recent times.
HEALTH CARE AS AN
ISSUE:
Several events have
propelled health care into the position of a major domestic issue. Inflation of
costs, poor distribution of manpower, the complexities of access to health care
for many citizens, the variations in quality, underutilization of expensive
facilities due to poor planning- all have contributed to making it an issue of
importance. But there are other less obvious reasons for its ascendancy that
should be discussed if we want to fully appreciate the nature of the political
process. I stated that William Welch acted as a one-man lobby for improved
health care and that he was instrumental in promoting governmental support for
the hygienic laboratories that later became the National Institutes of Health.
Other fortuitous events occurred. The chairmen of the appropriate committees in
both houses of Congress became strong supporters of NIH programs. NIH also
developed strong support from key people in successive administrations. In a
little over a decade, the NIH has appropriated from $50 million to better than
$1.5 billion. Where Congress had refused to pass a national health insurance
program until the enactment of Medicare, support for research and related
matters enjoyed strong support. It is not the rapid increase in financial
support, however, that is important to us today. Instead it is the side effect
this support produce with the public and the general reactions that occurred as
a result of it. It is doubtful that even William Welch realized the extent to
which his favored hygienic laboratories would ultimately be responsible for
raising the issue of health care high on the list of major priority domestic
issues
NIH PROGRAMS.
The programs of NIH,
in effect, caused the public to become more “health conscious.” As research
grew in scope and began to bear results, literally reams of press stories
covering these results appeared in the news media. The press was eager for
articles covering medical discoveries and the vast majority of articles
expressed a hope that some medical problem had been alleviated as a result of
research. It was difficult to read a major daily paper for a week without
seeing at least one article that provided hope for relief or cure from illness
that had not existed before. The majority of articles or announcements were
highly favorable to medical care; they made it appear as if medical care was
worth seeking (where there had been some doubt before.) and it would only be a
short time before all medical problems would be solved. Whatever any subject
receives this degree of favorable publicity, the public wants some of whatever
it is. The favorable publicity occurred over a number of years. In fact, it
still occurs today except that its effect is modulated by stories of lack of
care and the high cost of care. Medical care grew into prominence, at least
partly on the basis of new hope, and in doing so its basic problems and
weaknesses were exposed to an ever-expanding percentage of the public. Health
care was declared a “right of all citizens” by Congress and affirmed by
Presidents (even though earlier in our history no one had seemed to care when
it had been so declared). The lines were drawn for the making of an issue. The
unprecedented growth of the NIH budget had other side effects in addition to
the publicity that stimulated the public’s interest in health care. Certainly
it had a decided effect on the attitude and structure of medical education. But
more important in terms of pressure groups, it created a cadre of medical
professionals both in and out of government who had to influence the
governmental process in order to survive. In addition it spurred the interest
of scores of marginal groups who were interested in one or more of the
categorical diseases. Although unorganized as a single focus of pressure on the
government, these separate groups did tend to generate interest in health care
at both the government and the public level. At times they tended to cut each
other’s throats in their eagerness to acquire higher appropriations for their
own special interests in the health field, especially during periods of tight
controls on the total number of dollars available, but on the whole they did
generate new public awareness and concern for health care which contributed
substantially to its emergence as national issue. If these groups were ever
able to form a common front by agreeing on a mutually acceptable set of
objectives for the health field, their force as a positive pressure group in
the politics of health would be unmatched. Whether or not they can find a more
effective forum or mechanism than has existed to date through which to
accomplish this remains a perplexing question.
No two lobbies are
completely similar in either their tactics or procedures. Not only are they
generally different from one another in this regard, but also any given lobby
may change its tactics from time to time. Each responds to the events that
focus on what it considers to be its constituency; it is molded by the
personalities of those who emerge as leaders within the constituency and by the
counter events in society that react to its positions. If an organized pressure
group takes a certain position through its lobbyist, and this creates a
generally unfavorable reaction with the public, then its tactics, procedures,
and even positions may well change. One of the difficult lessons to learn in
the conduct of our democracy is that often it is as beneficial to focus public
reaction on certain lobbying groups through their members in order to urge a
change in their position, as it is to focus on the public officials. We see
this occurring with greater frequency today and undoubtedly this tactic will
grow in importance insofar as the formulation of public policy is concerned.
The lobbies that occupy the health field are relatively recent phenomena when
compared to other traditional lobbies. Lobbies concerned with taxes, banking,
railroads, liquor, oil and gas, forests, transportation, guns and ammunition,
industry, tobacco, and shipping, to name but a few, are older, more consistent,
and perhaps more sophisticated. The health lobbies have received, until recent
years, relatively few funds in comparison with the total dollar magnitude of
the health industry, and have been low-key in operation. They have been highly
fragmented, often fighting with each other, almost with no ability to look
beyond their own special and specific interests of the total health field. This
fragmentation of the health lobby is due in large part to the way our health
care delivery system is organized, and it does make reasonable solutions to
some of the problems exceedingly
difficult. In fact, no other major industry in our economy presents so
fragmented an approach to the influencing of public policy. For virtually every
licensed level of performance, i.e. physicians, nurses, therapists and so on,
there is a separate position and thrust on the issues to be decided.
Professionally, medicine is organized on a craft basis, in place of an industry
wide basis, and as yet no unifying force has appeared which would cause the
individual levels involved to speak with one voice. Certainly the organized
physicians have received the greatest attention since, as a group, they have
poured the greatest resources over the longest the longest period of time into the
fray, but the per capita costs per physician to maintain this position of
dominance may in the long term be self-defeating. Not only are there several
different levels of lobbying input based upon the variety of health manpower
classifications and licensure, but also there is a major split between manpower
and facilities. Organizations representing facilities, and especially
hospitals, have a set of goals often at odds with the major manpower groups. To
be sure, many examples can be shown where the two forces have converged to
support a given position, but there are enough significant issues of increasing
importance to seem to indicate a widening of the breach, such as in the way
care should be organized or given, the degree to which services should be facility
based, the methods of paying for care. In fact, one of the fears is the
dwarfing of the health lobbies in existence by the large health care
co-operations and health maintenance organizations. Also another factor
provides a major cause for fragmentation of the health lobby. This is the
traditional pattern of approaching health problems categorically. Since people
usually become ill categorically- i.e. from cancer, respiratory or heart
disease, etc.- and not comprehensively, laymen have a tendency to support
efforts aimed at diseases with which they can easily identify. This has led to
numerous organizations built around a single disease. Each of these
organizations, directly or indirectly, constitutes a lobbying force. When they
are attempting to influence the government to spend funds for research and
services in their special disease areas they tend to compete with each other
and may from time to time nullify each other’s actions. There have been times
when the argument “my disease is more important than yours” has been used by
those interested in budget cutting as justification for cutting or not
providing new funds to anyone. In the fragmented field of the health lobby it
is exceedingly easy to play one group against the other if your goal is to do
nothing. That’s to say, not all lobbies
in other fields are unified, but many have found ways to reach agreements on
key issues. It might be argued that too much agreement can be as detrimental as
no agreement, but at least that would be a novelty in the health field. The
late Senator Everett Dirksen of Illinois, one of the Senate’s most eloquent
conservatives, used to comment, “nothing can stop an idea whose time has come.”
He made this comment about the passage of Medicare, a bill that he had opposed with
all of his unusual vigor and effectiveness. Medicare had been supported by
several lobbies, most of them from outside the health field. Chief among them
was the lobby of organized labor. The bill had been so strongly opposed by
organized medicine, with the notable exception of the National Medical
Association, the professional organization of black physicians. The fact is
that Medicare, which has to be described as one of the most important, if not
most important, health measures yet passed by Congress, was passed because of
forces outside health-related lobbies. This fact is not often recognized. The
lobbying efforts of the Committees for the Aged emphasizing the humane need for
care, letter campaigns of various groups demanding that the cost of care of aged
parents be lifted from the shoulders of their children who had their own
families to protect, church groups, and other civic groups that organized
support efforts were all instrumental in their own way in the final favorable
vote. But sometimes overlooked are the pressures brought to bear by the local
government on the federal government for relief from costs of care that fell on
the local property tax when the aged or their children were unable to pay.
Costs of care for those over 65 had escalated more rapidly than for any other
group and the local government was forced to bear a major portion of this cost.
The opportunity to shift a portion of these costs from the local property tax
base to a social security insurance base was a deciding factor to congressmen
who were increasingly badgered by city and county government lobbyists for such
relief. Although the lobbyists for local government maintain a low profile
operation, they have become an increasingly important force on the Washington
scene.
TECHNOLOGIC FRONTIERS.
Hopes and aspirations. Health care throughout
the industrialized world, and in the United States in particular, has made some
astonishing gains in effectiveness in recent decades through the employment of
new medical technologies. The sector has generally been far less progressive in
its use of computer and communications technologies, even for such basics as
improving traditionally paper intensive processes at the core of operations
(National Research Council, 1994). Now this is changing. Health care
information technology deployment is proceeding at a rapid pace, with spending
estimated at more than$10-15 billion per year (National Research Council, 1997)
Goals include: “electronic exchange" of claims information for billing and
insurance (for billions of reimbursement claims handled in the US system each
year); and transport of individual medical information in "paperless"
electronic records (for hundreds of millions of US patients; policy review,
outcomes research, population based health studies and public health
surveillance, and using data aggregated from computer-resident clinical and
administrative information; time computer based decision support tools,
replacing paper-based references and guidelines, complementing computerized clinical
records, consultations among continuing professional education of providers by
video and computer conferencing, and via computer based multimedia tools,
health education, home health care "self management" assistance and
remote monitoring via telephone, video and computer based tools; and to enhance
consumer choice, such as the internet-based data on providers, institutions,
and managed care networks.
Information and privacy. Information
technology (IT) proponents envision a more efficient, smooth running health
care system as a consequence, with better-coordinated care, reduced variation
in practice patterns, and lower administrative costs. Skeptics in the
"privacy community" have instead focused on the risks to
confidentiality posed by increased electronic record keeping. Though
disagreeing on how tradeoffs should be made- indeed on what trade offs are
possible- all sides concur that legal and policy framework controlling
information flows today is severely outdated and represents a 'legal, political
and practical mess"(Gellman, 1996). It is now commonplace that, in the
United States at least, the biggest information privacy issue in the 1990s will
involve healthcare information. Given the incentives inherent in our private,
risk-based system of health care finance, and the absence of adequate data
protection, legislation, no country presents as unsafe an environment for
health data as does the US today. It is well-studied policy territory. In this
decade alone, information privacy, confidentiality and security issues have
been considered in lengthy reports by among others, the Center for Disease
control and prevention (1996), the Department of Health and Human Services
(1993,1995), the Institute of Medicine (1991, 1994), the National Institute of
Standards and Technology (1994). Yet the weight of these reports has not been
sufficient to provide a path to the health care data protection legislation
that all agree is necessary. Our system of checks and balances and separate
powers requires consensus on the details to move the policy forward, and to
date none has emerged on the difficult political, economic and ethical
tradeoffs presented by health information issues. The National Information
Infrastructure (NII) initiative focuses on enhancing the basic infrastructure
for telecommunications and computer technology in all sectors of the US
economy. Conceptually, the NII is like a giant web that will allow each user’s
computer, telephone, and television to interconnect with others, regardless of
their location or the distance between them, and will enable each user to
communicate with everyone else who is connected to the web. Over this network,
public and private information sources and data processing utilities will be
able to transmit, store, process, and display information in many forms and
provide information retrieval and processing services on demand, as if
connected in the next room. This technology has the potential to revolutionize
the way Americans work, learn, shop, and live, by providing them with
information when they need it and where they need it, whether in the form of
text, data, images, sound, or video. At the outset, health has been identified
as one of the sectors that can benefit from NII technology. Thus far, however,
NII grants related to health have primarily supported applications of high
performance computing and telemedicine to the delivery of medical care to
individuals. Relatively little attention has been paid, by either the private
or the public sector, to applications that would support population health. As
the information infrastructure is built throughout the United States, it is
important to ensure that both medical care and public health requirements are
addressed. Information technology offers an opportunity to link the health of
populations and the medical treatment of individuals more closely, to the
benefit of both. The. Public Health Service (PHS) is committed to stimulating a
more vigorous participation of the public health community in the NII
initiative, and to bringing those involved in the NII and population health
together to articulate and realize a collective vision for harnessing the NII
in support of the health of the public. Four components of the PHS, the
National Library of Medicine (NLM), the Office of the Assistant Secretary for
Health (OASH), the Centers for Disease Control and Prevention (CDC), and the
Agency for Health Care Policy and Research (AHCPR), jointly sponsored an
invitational conference on this topic on April 19, 1995. The following outlines
what was discussed at the conference and incorporates the strategic plan
developed on April 20. It is for those seeking to learn more about the
potential of the NII to improve the health of the public, and to those who can
help make these applications a reality.
WHAT IS POPULATION
BASED HEALTH?
When most Americans
think about the health system, they tend to focus on the diagnosis of disease
and medical treatment. But the health of Americans is largely determined by
other factors, including genetics, personal risk behaviors, and hazards on the
job and in the environment. One important measure of health is the extent to
which early deaths are prevented. Various estimates suggest that only about 10%
of early deaths in this country can be prevented by medical treatment. By
contrast, population-wide public health approaches have the potential to help
prevent 70% of these deaths, through measures that target underlying risks,
such as tobacco, drug, and alcohol use; diet and secondary lifestyles; and
environmental factors.
WHAT IS THE ROLE OF
INFORMATION IN POPULATION-BASED HEALTH?
The extent to which
population-based public health can achieve its mission depends, in large part,
on the availability of accurate, comparable, timely, and complete information.
One could say that the collection, analysis, use, and communication of health
related information is the quintessential public health service, under girding
all others. The three types of information needs, data collection and analysis,
communication, support in decision-making, cut across all of the services of
public health. Meeting these needs depends not only on a supportive technical
infrastructure, but also on personnel with skills to use emerging technologies
(both to communicate and to translate complex data into meaningful
information), and on a willingness among professionals in different sectors to
work together toward common goals.
Data collection and analysis-effective
collection, analysis, use, and communication of health related information.
Since the client for public health is the community, data are needed not only
about people (including their health status, personal risk behaviors and
medical treatment), but also potential sources of disease and injury in the
environment (such as restaurants, wells, water or sewage treatment plants,
worksites, and insects), and available resources that can be mobilized for
effective action. These data need to be linked to each other and aggregated
geographically, so that it is possible to do such things as detect an incipient
epidemic from isolated cases seen by different care providers, relate clinical
events with proximate health hazards, and correlate the use and costs of
personal health care services with ambient behavioral and environmental risks
to health.
HOW IS NII TECHNOLOGY
CURRENTLY BEING APPLIED TO POPULATION-BASED PUBLIC HEALTH?
Because those with important roles to play in
population health are so diverse; encompassing public health agencies at
various levels, health professional and institutions, managed-care plans,
public and private organizations, policymakers, and consumers; information
systems technology is also needed to educate and empower different groups about
public health problems and link them together to take effective action. If the
expanding base of available information is to be more a blessing than a curse,
these groups will need the means to retrieve, manipulate, and display
information so that it can be efficiently put to use for specific health
related purposes. It is encouraging that are small number of public health
applications have been funded through broad-based NII grant programs in the
department of Commerce, (DOC) and the Department of Agriculture (USDA), public
health participation in these and other broad-based NII and HPCC grant and
contract programs has been modest at best. Thus far the bulk of federal support
for population-based applications has come from PHS programs specifically
targeted to the public health community.
WHAT BARRIERS NEED TO
BE OVERCOME TO MAKE THE VISION OF THE NII AND POPULATION HEALTH A REALITY?
The major barriers
that have emerged, above and beyond basic resource constraints and the limited
appreciation by both the public and policymakers of the importance of
population-based public health, include:
-A lack of nationally
uniform policies to protect privacy while permitting critical analytic uses of
health data;
-A lack of nationally
uniform, multipurpose data standards that meet the needs of diverse groups whom
record and use health information.
-Insufficient
awareness of the applicability of NII technologies in meeting the information
needs of population based public health.
- Organizational and
financing issues that make it difficult to integrate information systems or
bring potential partners together
Privacy; There is
little doubt that the information technology could improve the capacities of
communities to carry out the non clinical or population based functions of
public health (i.e., services that identify local health problems, prevent
epidemics and the spread of disease, protect against environmental hazards and
assure the quality and accessibility of health services). Attention to these
community wide health services is important because only about 10% of all early
deaths in this country can be prevented by medical treatment. Population-based
approaches, on the other hand, have the potential to prevent 70% of premature
deaths through measures that target underlying risks, the magnitude of social
benefits, it is not surprising to find that many advocates of a health
information infrastructure simply assume that collection of ever increasing
health information, in ever more efficient ways, is inherently a social good.
Given the magnitude of the personal costs that can attach to information
abuses, and the strong value the US citizens place on privacy, it is also not
surprising to find many privacy advocates who are deeply skeptical of health
care's information aspirations. Yet progress in medicine, for both personal and
public health, has always depended critically on information from and about
individuals. It is safe to assume that it will continue to be essential to the
evaluation of new technologies and treatments, and to identify and respond to
new health threats. Decisions about information policy are therefore critical
ones, for both the US population and populations around the world who use
leverage the contributions of our biomedical research.
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