Category: Public health

October 16, 2010

As I describe in the chapter, ‘What’s politics got to do with to do with it?’–more than we care to admit. Access to care is what we usually talk about.., but access to knowledge based on what research gets funded and access to treatment based on what drugs and products are approved relate to politics as well. And even access to information, as policy forms around labeling and package inserts and other ways to help us make informed decisions. All relate to politics… I was thinking about some of these issues while touring a Marcellus shale mining site and wondering about the health and welfare of workers and communities alike. 

A couple of days ago, I posted my thoughts about events leading to how we talk about the focus on politics and access to health care In the U.S. Here are a few other events worthy of note… The Great Depression led the government to identify access to health care as a political priority. Now it was unemployed workers who were unable to pay for their own health care that got the government involved. Because so many workers were unemployed, this led doctors’ incomes to fall. Middle class citizens began to rely on public hospitals and state and local health departments to receive health care. In turn, doctors began providing more services through these venues. Doctors charged the welfare departments, and State welfare departments in turn charged the federal government. This cost-shifting system was supported by political priorities established in debates at the federal level and then by passage of such policy as the Social Security Act in 1935.

President Truman expanded Social Security and recommended national health insurance in 1949. He continued to work toward it–unsuccessfully–until 1953. A role for government support of health care shifted from keeping workers working based on commerce to a role for government based on those in need or underserved–with the initial stimulus being the unemployed.  

A role for government and politics in access to health care shows great expansion in the realm of the underserved and needy during the era of the Great Society, when Presidents Kennedy and Johnson expanded the social welfare and services system. The government’s role now extended well beyond keeping a work force healthy. The effort to provide health care included powerless groups, such as children and the elderly. 

The government’s role in protecting workers’ health also grew during this era. But the focus shifted with new initiatives such as the Occupational Safety and Health Administration (OSHA), which was inaugurated in 1971, aligning with efforts to assure health and reduce the need for health care. In OSHA’s first three decades, fatalities in the workplace were cut in half, while injuries were cut 40%.

A role for government in health care as a strategy to promote the economy began to threaten the economy as health care costs mounted in efforts to bridge the gaps associated with underserved groups. President Nixon reflected this reality in his attempt to decentralize decision-making about health care, reducing the federal government’s obligations in this realm. This was part of his policy of New Federalism, a doctrine designed to draw lines between issues for national versus state or local governments. Largely, this era focused on wresting control from the federal government and revenue-sharing with states, returning a portion of taxes collected back to state and local decision-making, policy from 1972 to 1986. President Reagan also used the term New Federalism in his block grant approach, shifting monies to state and local initiatives related to providing health care.

President Clinton came into office with health care reform established as a priority. The six principles stated in a health care reform speech in 1993 reveal that the nation was not yet ready to accept limits associated with access: [1] Security: Guaranteed, comprehensive benefits; [2] Savings: Controlling health care costs; [3] Quality: Making the world’s best care better; [4] Choice: Preserving and increasing what you have today; [5] Simplicity: Reducing paperwork and cutting red tape; and [6] Responsibility: Making everyone responsible for health care. The first, third, and fourth principles reveal an emphasis on access, while the second, fifth, and sixth were the guides to be used in controlling cost. The conflict in pursuit of these two divergent paths contributed to the plan never passing, which leaves the government’s obligation in access to health care in a costly dilemma…and that is how we talk about health care in the U.S.–as a costly dilemma relating to assuring the health of workers who will contribute to the economic well-being of the country and assuring the health of groups unable to access care on their own…