Politics and Health Care Organization: HMOs as Federal PolicyBrookings Institution Press, 2010 M12 1 - 550 pages Among various health cost containment strategies proposed during the 1970s, none has held more sustained fascination than the health maintenance organization (HMO). For many years, policy analysts in search of market- and incentive-based alternatives to “command and control” regulation have argued that medical groups combining prepayment and group practice, and offering comprehensive medical services within a fixed budget, would hold down costs both by their own efficient operations and by the competitive pressures they would apply to the conventional systems. During the 1970s, three presidents and five Congresses worked to formulate and implement legislation to increase the HMO presence nationwide, with very modest results. Some observers concluded that but for the well-intended but counterproductive efforts of the federal government, HMOs might thrive. Indeed, the Reagan administration has called for an end to direct federal financial involvement in building HMOs—though it has also promised legislation to promote HMOs and a newly competitive health care system based on revamped financial incentives and reinvigorated markets. In this book, Lawrence D. Brown, a senior fellow in the Brookings Governmental Studies program, examines the interplay between politics and policy in the federal HMO development effort between 1970 and 1980. He argues that the basic explanation for the disappointments of the policy analysts and federal supporters of HMOs lies not in a political miscarriage but in the overambitious promises of the policy strategy itself. Tracing the poor fit between policy and politics revealed by federal efforts to translate the attractive HMO idea into a workable strategy, Brown concludes that the episode augurs poorly for the competitive reforms frequently offered as a nonregulatory solution to rising health care costs in the 1980s. |
Contents
Politics Organization and Health Care Policy | 3 |
The Political Evolution of Federal Health Care Policy | 11 |
The Federal Government and HMOs | 16 |
Organization Building The HMO as a System of Contributions | 31 |
Organizational Types | 32 |
The Roots of HMOs | 35 |
Sponsors | 36 |
Physicians | 51 |
Action in the Senate | 250 |
HEW OMB White House | 252 |
Reassembling the Fragments | 259 |
The Politics of Disappointment | 267 |
HMOs in HEW The Frustrations of Administrative Prudence | 276 |
Unsettling Cross Pressures | 278 |
An Uncomfortable Fit | 281 |
An Impossible Fit | 286 |
Subscribers | 59 |
Hospitals | 69 |
Contributions and Expectations | 73 |
The Political Economy of Management | 75 |
Organizational Costs of Comprehensiveness and Responsibility | 76 |
Economic Imperatives of Management | 79 |
The Political Economy of Management | 82 |
Organizational Growth and Bureaucratic Development | 89 |
Three HMO Prototypes | 102 |
Prototypes and Management | 124 |
Organizational Performance Quality Access and Cost in the HMO | 129 |
Quality of Care | 130 |
Access | 157 |
Cost of Care | 172 |
Contingencies of Performance | 189 |
Prepaid Group Practice Goes to Washington | 195 |
From Anathema to Initiative | 197 |
Initiative by Elimination | 201 |
HEW and OMB | 212 |
The President Delivers | 219 |
The Administrations Political Game | 221 |
The Gathering Storm | 224 |
Kennedy Takes Aim | 226 |
An Early Skirmish | 229 |
Roy Rogers et al | 235 |
Three Games Three Bills | 239 |
Congressional Liberals and PGP Purists | 246 |
Implementation Fragmentation | 315 |
Management and Politics | 333 |
The Continuing Quest for an HMO Policy Consensus and Its Limits | 345 |
Consensus and Amendment | 346 |
A Rising Political Priority | 357 |
Reorganization | 362 |
The Limits of Reorganization | 366 |
The Limits of Administration Support | 372 |
The Limits of Legislation | 392 |
The Limits of Consensus and of Politics? | 396 |
Politics and Policy The Federal Government and HMOs | 401 |
An Unworkable versus an Unacceptable Law | 404 |
Politicians versus PGPs | 417 |
Strategy versus Structure | 428 |
Policy Analysis and Disembodied Incentives HMOs as Idea and as Strategy | 442 |
Incentives versus Institutions | 443 |
Competition versus Complexity | 451 |
Policy Analysis versus Policymaking | 469 |
HMOs and the Future of Federal Health Care Policy | 489 |
Four Strategies of Intervention | 490 |
Decentralized Incentivebased Controls | 492 |
Decentralized Regulatory Controls | 507 |
Centralized Incentivebased Controls | 512 |
Centralized Regulatory Controls | 523 |
533 | |
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Common terms and phrases
administration administration's amendments approach areas argued bill Blue Cross Blue Cross-Blue Shield Brookings Institution bureaucratic committee community rating competition complex Congress consumer copayments cost-containment costs decentralized doctors dual choice economic effort Ellwood employees enrollees executive facilities federal government federal HMO fee-for-service funds generalists GHAA Group Health Group Health Cooperative growth Health Maintenance Organizations Health Plan health services HEW's HMO development HMO law HMO program HMO strategy HMO's hospital Ibid incentives increase independent practice associations inpatient institutions IPAs Kaiser plans Kennedy legislative loan major McLeod Medicaid medical director Medicare medicine moral hazard national health insurance Nixon offer open enrollment organization-building organizational patients percent physicians plan's policy analysis policymakers political premiums prepaid group practice problems professional providers qualified HMOs regulations Secretary sector Senate social staff subcommittee subscribers White House