Health reform for the 21st century? It may have to wait until the 21st century
P. P. Budetti
Institute for Health Services Research and Policy Studies, Northwestern University, Evanston, IL, USA.
OBJECTIVES: To assess the likelihood of health care legislation in the
forthcoming 105th Congress in 5 areas: health care coverage, tax and
Employee Retirement Income Security Act (ERISA) policy, Medicaid, Medicare,
and managed care. DESIGN: Informal, semistructured conversations that took
place in the months prior to the 1996 elections. POPULATION: Congressional
health staff and administration officials. OUTCOME MEASURES: Unofficial,
off-the-record personal opinions. RESULTS: Health care coverage initiatives
to benefit children and unemployed persons are likely to be proposed, but
have little chance of enactment; children are seen as well provided for
under current Medicaid law, the strong economy and high employment levels
lower concern for unemployed issues, and the effort required to pass the
Kassebaum-Kennedy legislation needs time to settle. Tax proposals, such as
medical savings accounts (MSAs), and ERISA amendments have no constituency;
also, the MSA demonstration in Kassebaum-Kennedy will forestall further
action. Medicaid is far less an issue than in the previous Congress,
because spending has fallen unexpectedly, the bitter fight over block
grants makes them unlikely to be revisited, and the administration is
likely to enhance state flexibility through waivers. Medicare will be the
subject of substantial action to defer impending insolvency temporarily,
but there is virtually no chance that definitive long-term solutions will
be enacted even though the underlying fiscal problems are thoroughly
understood and recognized. Managed care will be the venue for numerous
proposals designed to address specific consumer and quality issues.
CONCLUSIONS: Four bitter years of fighting over health care issues has
raised awareness of the problems, but has produced a political chemistry
that is too rancorous to permit passage of significant legislation in the
near future.
