Biomedical subjects
Publications and source records attributed to T R Marmor.
This paper reviews case studies of eighteen countries to identify similarities and differences in health planning problems and institutional arrangements for resolving them. On the basis of this review, it is argued that in order for cost-containment to be effective in the United States, planning agencies need to have control over resource allocation.
The health planning legislation of 1974, establishing HSAs, represented an important attempt to break recurring patterns of decision making in public choices. One widely heralded strategy for controlling contemporary medical care--consumer involvement through accountability, representation, and participation--is flawed by failure to recognize that political markets are always imbalanced because of unequal interests and disproportionate resources. How can we represent broad, diffuse interests when all the incentives point to domination by a minority of intensely interested producers? Solutions favored at the local level may not best serve the entire nation; they cannot mirror the full spectrum of constituencies. Adjustment of mechanisms both internal to HSAs and external to them are suggested--yet, even so, their mandate reaches beyond possibility of accomplishment.
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Marked by intense feeling, the NHI debate has produced a crisis rhetoric that clouds the issues and misrepresents the state of medical care. Generated in response to the rhetoric, current NHI proposals fail to combat the central problem of rising health care costs. A promising approach combines a comprehensive insurance plan for preschool children with protection against financial catostrophe.
National health insurance (NHI) is discussed as a redistributive issue (that is, conflict over it is characterized by stable coalitions with important ideological differences). Discussion of policy alternatives has been intensified, but obscured, by a rhetoric which insists that the medical care system is in crisis. Both rhetoric and discussion point to three problem areas: cost, quality, and distribution of care. Three kinds of NHI proposals exist--minimal intervention measurees (e.g., AMAs Medicredit proposal), major government action (e.g., Kennedy-Corman), and mixed strategies (e.g., CHIP). While these have different potentials for mitigating the problem areas discussed, none can provide complete solutions. Rather, the goal of NHI is to avert financial catastrophe for families and individuals. The emergence of Democratic majorities in Congress and a Democratic White House increases the chances that some NHI plan will be adopted. Political analysis suggests that, short of aggressive leadership committed to a comprehensive scheme, a "middle ground" solution will be outcome.
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This paper discusses the politics of anti-inflationary policy in the medical care sector. We first clarify the issue by distinguishing between four different conceptions commonly used when discussing medical inflation. We then present some of the standard solutions to these problems suggested by economists. In the main part of the paper, we analyze the response of the government. We show that the underlying causes for failure in the economic market are likely to exist in the political market as well. In particular, the public good aspect of anti-inflationary policy fails to provide a strong incentive for the consumers of medical care. In contrast, the providers have very powerful incentives in the political market because the benefits of governmental action in this sector greatly affect them. Providers exert great pressure to prevent government policies aimed at reducing medical care expenditures. We present evidence and theory to explicate which sets of circumstances are most conducive to governmental action. We show that the most effective anti-inflationary programs in medical financing are least likely to be implemented and that a dispersed, pluralistic financing structure reduces the government's incentive to curb inflation.
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