POLITICS, ECONOMY AND HEALTH
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.
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
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.
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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