Health care reform and policy factors

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World Medical & Health Policy www.psocommons.org/wmhp

Vol. 2: Iss. 1, Article 19 (2010)

The Ecology of Health Policymaking

and Reform in the United States of

AmericaSunday E. Ubokudom, PhD, The University of Toledo

Jagdish Khubchandani, MBBS, MPH, The University of Toledo

Abstract

This article demonstrates how constitutional, political, legal, economic,technological, social and cultural, physical, demographic, and global factors affecthealth policymaking in the United States of America. The ecological factors that

influence health policy in the United States are uniquely different from those of other countries. Therefore, even though a number of problems may be common tohealth systems worldwide, these problems may require different solutions indifferent countries, or in different sections of the same country. The articleconcludes that the above ecological factors, individually or collectively, cause U.S.health policies to be inconsistent. For example, policies were adopted in the past to promote the concentrated interests of health providers. Recently, the rise of opposing concentrated interests, a lingering economic recession, a weakenedresistance to change, and policy learning from the practices of other industrializedcountries and from scholarly publications give us hope that reform, although stilldifficult to achieve, may finally be in sight.

Keywords: health reform, health policymaking, ecological factors, United States of America

Author Notes: This paper grew out of a speech the lead author was invited to giveat a meeting of the Toledo Surgical Society on November 13, 2008. I am thankful tothe members of this group, especially Dr. Munier Nazzal, for their invitation.Sincere thanks also go to my wife, Mfon Ubokudom, a nursing provider, for her many useful suggestions. We also thank the journal editors and two anonymousreviewers whose suggestions significantly improved the manuscript. Finally, Linda

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Neuhausel deserves commendation for her excellent secretarial support. We are notadvocating for the journal, our employer, or for any of the two major political

parties in the United States. Rather, our opinions are based on our professionalconvictions of what we believe are in the best interest of U.S. healthcare consumers.Any errors in the manuscript are solely our own.

Recommended Citation:

Ubokudom, Sunday E. and Khubchandani, Jagdish (2010) "The Ecology of HealthPolicymaking and Reform in the United States of America," World Medical &

Health Policy: Vol. 2: Iss. 1, Article 19.DOI: 10.2202/1948-4682.1010Available at: http://www.psocommons.org/wmhp/vol2/iss1/art19

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Submission to World Medical & Health Policy

http://www.psocommons.org/wmhp



Introduction

Healthcare is a major issue facing policymakers in the United States.Increases in expenditures and in the population of the uninsured andunderinsured, declines in employer-sponsored insurance (ESI), avoidableillness and premature deaths, and health disparities based on race, ethnicity,and income have placed healthcare reform on the public and governmentalagendas (AMA 2008).

Efforts to enact major reforms of the healthcare system failednumerous times from 1920 to 1994 when President Clinton’s reform planwas defeated. Each time the reform was attempted, the reformers ran into a

well-organized opposition that expended immense resources to impedechange (Hacker 2009, 4).

Public opinion was very supportive of President Clinton’sSeptember 1993 reform proposal. But after powerful groups began to attack the proposal, public interest and support waned (Weissert and Weissert2002, 75; Patel and Rushefsky 2006, 392). Consequently, the Congress didnot vote on the Clinton plan or on any of the competing proposals that wereintroduced.

Health reform was one of the major issues of the 2008 presidentialelection campaign. Senators Barack Obama and John McCain offered

different reform proposals. About two months after President Obama took office, a healthcare reform summit was held in the White House. Another debate has begun about the merits of the healthcare system and the need for change (Pauly 2008, 482; Hacker 2009, 4).

The above discussion raises the following questions: Why is theU.S. healthcare system so resistant to change? Given the system’s resiliencyand resistance to change, will the Obama initiative succeed or fail like its

predecessors? What factors are likely to enhance or impede this newinitiative?

Some of the above questions are not new to the public, politicians,

and health policy experts. Book chapters and journal articles have beendevoted to analyzing the reasons for the failure of the 1993 Clinton plan. Insometimes biased, scattered, and incoherent ways, scholars have discussed avariety of environmental factors that affect U.S. healthcare policymakingand reforms. Consequently, not only are these discussions incomprehensive,

but the ideology and political inclinations of the analysts influence the issuesthey emphasize. As Anderson (2006, 45) observes, political scientistscontinue to spend most of their time studying the policy effects of politicalvariables, with which they are most comfortable.

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Ubokudom and Khubchandani: Ecological Factors and U.S. Health Policy



On the one hand, conservative thinkers illuminate government or political interference, a defective tort system, and the excesses of the welfare

state as the major factors impeding efficient healthcare delivery and reform.Liberal thinkers, by contrast, blame the existing constitutional arrangements,the medical–industrial complex, economic interest groups, the marketingtechniques used by private health insurers, and the lack of progressivefinancing of health benefits as significantly contributing to the problems of the healthcare system (Cutler 2004, 76). These contrasting causalexplanations help explain why Morone (2008, 49) writes that health scienceconstantly wrestles with self-interested politics, resulting in robust findingsthat are only as good as the policy coalition that assembles around them.

Because of the shortcomings of previous research identified above,

our paper takes a more balanced approach by analyzing all the ecologicalfactors, market based or politics oriented, that, in our opinion, influencehealthcare policymaking in the U.S. The paper is built on the premise thatthe U.S. health policy environment is uniquely different from those of other industrialized countries. Consequently, even though a number of problemsmay be common to health systems worldwide, these problems may requiredifferent solutions in different countries, or even in different sections of thesame country, because of dissimilar social, cultural, and political systems,stages of development, and geography (Payer 1996, 23; Kettl and Fesler 2005, 21; Ubokudom 2008a, 2). Therefore, the key to understanding the

problems of the U.S. health system is to study the ecology of the healthcaresystem.

Another unique strength of this investigation is that in addition tosocial, economic, and political factors, we place equal emphasis on globalfactors and on the likely beneficiaries of a reformed healthcare system. First,with regard to global influences, previous researchers included discussionsof other nations when foreign and defense policies were discussed(Anderson 2006, 39). However, recent events have made globalization animportant part of the discussion of American health policy. Second, withregard to those who are likely to benefit from healthcare reform, again,Morone’s (2008, 53) admonition that “the politics of social policy alwaysturns on the mental images we create of the beneficiaries” is very instructivein this respect. Public support for the present reform effort will depend, in

part, on how those who are expected to benefit from the reform are perceived.

Still on the merits of this study, it is equally important to note thateven well-designed programs cannot be left unattended. Rather, they must beadapted to changing environmental conditions. Therefore, whether thecurrent reform effort in the U.S. succeeds or fails, this analysis is expected to

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serve as one of the starting points for determining what went right, whatwent wrong, and what must be avoided or embraced in the future. Further,

the study is expected to serve as a guide for researchers doing ecologicalanalysis elsewhere in the world.

Theoretical Framework

Before proceeding, it is necessary to clarify our usage of the word“ecology.” Depending on the context, the words “ecology,” “surroundings,”and “environment” may be used interchangeably. But they are not used

interchangeably in this paper. The concepts “environment” and“surroundings” are too inclusive to be of any significant help in this study.Therefore, the paper focuses on a narrower concept, the ecology or that

portion of the general environment of the U.S. with which the health systemis closely intertwined (Dubnick and Romzek 1991, 93).

Writing in the 1940s, American scholar John Gaus introduced theconcept of ecology into the public policy and administration vocabulary(Gaus 1947). According to Gaus,

An ecological approach to public administration builds,

then, quite literally from the ground up, from the elementsof a place—soils, climate, location, for example—to the people who live there—their numbers and ages andknowledge, and the ways of physical and social technology

by which from the place and in relationships with oneanother, they get their living. It is within this setting thattheir instruments and practices of public housekeepingshould be studied so that they may better understand whatthey are doing, and appraise reasonably how they are doingit. (p. 1)

Gaus proposed a list of factors that he found useful in explaining“the ebb and flow of the functions of government in the United States.”These included people, place, physical technology, social technology, wishesand ideas, catastrophe, and personality. This theory is relevant for our studyof the U.S. health system. In any country, certain external factors determinethe characteristics of the health system (Shi and Singh 2008, 9). Theecological factors that we believe influence the health system in the U.S.,which are by no means exhaustive, involve constitutional, political, legal,

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economic, technological, social and cultural, physical, demographic, andglobal dimensions.

Even though we emphasize that the characteristics of the U.S. healthsystem are shaped by the ecological factors identified, the healthcare systemalso shapes the ecological factors. For example, the $2.24 trillion spent for healthcare in 2007 accounted for 16.2% of the nation’s gross domestic

product (GDP) (CMS 2009a), implying that healthcare is one of theimportant drivers of the American economy. The impacts of the healthcaresystem on the ecological factors qualify as another subject area for researchand analysis.

Relationship between Ecological Factors and the U.S.

Healthcare System

Having identified the nine ecological dimensions of the U.S. healthcaresystem, next we analyze how these factors help answer the questions we

posed in the introductory section of the paper—how do they cause thehealthcare system to be resistant to change and how are they likely toenhance or impede reform? We now turn to this task, beginning with theconstitutional ecology of the health system.

Constitutional Ecology

Health policymaking and reform are heavily constrained by the nation’sconstitutional ecology, a system of government comprised of three coequal

branches sharing power, and by federalism or the division of governmentalauthority between the national and state governments (Anderson 2006, 35).At the national level, power for making policies is divided between theexecutive, legislature, and judiciary. But since the judiciary is passive,

depending on citizens to bring cases before it, much of the formal policy-making process involves the executive and the legislature. In addition, asshown in Figure 1, both houses of the legislature must agree on a bill beforeit can be presented to the president for his signature or veto. ThisBicameralism checks on the emergence of radical policies, so to speak.

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FIGURE 1

Constitutional Ecology of the U.S.

Executive

1 3 4

Judiciary Legislative

House

5

6

Senate

1. Nomination of judges2. Judicial Review3. Vetoing Legislation4. Budget control, veto override, oversight functions, impeachment power,

confirmation of appointments.

5.

Impeachment of judges, confirmation of judicial appointments6. Judicial review

Federalism and Intergovernmental Relations

Federal government ↔ State government ↔ Local government

2

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The conflict described above becomes more pronounced whendifferent political parties control the White House and Congress. A president

facing at least one house controlled by the opposition party has to use adifferent strategy from one whose party controls both chambers. A presidentwho faces a Congress led by the opposition party must rely on the veto

power and public support. This is because members of the opposition,conscious of the next election, will try to frustrate the president (Weissertand Weissert 2002, 96).

The above discussion does not imply that a president who faces aunified Congress will always be successful in enacting his proposals. Thefailure of the Clinton healthcare reform proposal in 1994 is very instructivein this regard. At the time, President Clinton faced a unified Congress, but

this partisan majority did not guarantee him a policy majority. Therefore, theunified Congress that President Obama now enjoys does not guarantee

passage of his health reform proposal. As the rest of the article shows, thereare other ecological factors at work.

Added to the conflict caused by power sharing between the three branches of government and by divided government is the principle of federalism. Although the national government has elaborate powers, stategovernments are important policymakers in many areas, including health.Consequently, the national government shares many responsibilities withstate governments. For example, the national and state governmentscooperate to pay for medical services for poor Americans under theMedicaid program.

Whereas, the intent of the framers of the Constitution was to use the principles of the separation of powers to prevent abuse of power, these principles have had other positive and negative consequences. These includedecentralization of power; inefficiency in the operation of government; theneed for cooperation, deference, bargaining, and compromise among

policymakers; turf battles; gridlock; inability to formulate consistent andcomprehensive sets of policies; duplications of efforts; blaming others for

problems; and the dodging of responsibilities by different levels of government (Anderson 2006, 140; Weissert and Weissert 2002, 86). Theseconflicts generated by the constitutional ecology are dealt with in the

political and legal arenas.

Political Ecology

The political ecology consists of various stakeholders with different perspectives and interests. It includes, but is not limited to, interest groups,

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the electoral cycle or how near to an election a healthcare reform proposal is proposed, political parties, and the governmental-politics model of decision

making (Allison 1971, 144). We will briefly examine each of the elements of the political ecology, beginning with interest groups.

Interest Groups

Interest groups are organizations of people with similar policy goals enteringthe political process to try to achieve those goals. They seek to persuadeelected officials that their policy preferences serve the public interest andshould be enacted into law. But groups may not always act in the publicinterest. In several instances, they attempt to veto policy changes,

innovations, and reforms (Weissert and Weissert 2002, 119).The numbers and types of groups involved in healthcare politics are

very large (Feldstein 1991, 209). Some of them include the Health InsuranceAssociation of America (HIAA), American Medical Association (AMA),American Healthcare Association (AHCA), American Nurses Association(ANA), American Association of Health Plans (AAHP), and the AmericanAssociation of Retired Persons (AARP). These groups may lobby membersof Congress and the executive branch, or they may engage in grassrootslobbying.

Interest groups also influence policymaking by using their politicalaction committees (PACs) to contribute money to candidates for elections.For example, the Center for Responsive Politics reported in 2009 that duringthe 2008 election cycle, about 127 health PACs contributed a total of about$49.3 million to federal candidates.

Electoral Cycle

Patronage appointees in government agencies, including those responsiblefor managing the vast outlays for health services, may be changed after elections, at the discretion of a new administration (Hall 1987, 221;Ubokudom 2008a, 7). In the health arena, these changes may result in thereplacement of pro-reform political appointees with those who are anti-reform or indifferent. An example of this occurred in the environmentalarena in the early 1980s, when President Reagan selected Anne M. Gorsuchto head the Environmental Protection Agency and James G. Watt asSecretary of Interior. Both appointees were attorneys who had spent yearslitigating against environmental regulation (Vig 2000, 98).

Apart from the president appointing pro- or anti-reformers,legislative policymaking is also influenced by the quest for reelection.

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Therefore, legislative voting behavior takes into account the possible political costs or benefits of such decisions (Arnold 1990). A good example

in the health arena that illustrates how the electoral cycle influenceslegislative decisions is the public’s quest for a patients’ bill of rights in thelate 1990s. The public’s discontent with managed care practices during the

period led to efforts to enact a patients’ bill of rights to check thesequestionable practices (Mechanic and Schlesinger 1996, 1693). About onethousand bills were introduced in state legislatures in 1996 to regulatemanaged care practices (Bodenheimer 1996, 1601). Also, between 1999 and2000, the House of Representatives and the Senate passed different versionsof a patients’ bill of rights and set up a conference committee to reconcilethe bills (Ubokudom 2003, 68). A compromise was not reached by the

conference committee because legislators were more concerned aboutexploiting the issue for political advantage in the 2000 election than theywere on a compromise (Families USA 2001).

Political Parties

Political parties are defined as groups of people who seek political power sothat their policy preferences may become public policy. Some of their mostimportant functions involve organizing the competition in an election,unifying the electorate, helping to organize the government, translating

preferences into policy, and closely monitoring the actions of the party in power (Magleby, O’Brien, Light, Burns, Peltason and Cronin 2006, 162).

The two major American political parties differ on the role of government in virtually all policy arenas, including healthcare. Similarly,Americans’ views about the role of government in healthcare are heavilyinfluenced by their ideological orientations and party identification.Republicans are much more likely to share conservative views, to advocatefor a limited government, and to oppose more government intervention inhealthcare. Democrats, on the other hand, are more likely to share liberalviews, to advocate for an activist government, and to support moregovernment intervention in healthcare. Furthermore, Republicans are morelikely to hold individuals accountable for their health, while Democrats aremore likely to argue for a collective responsibility for health (Brodie andBlendon 2008, 259).

The differences in the health policy positions of the Democratic andRepublican platforms for the 2008 presidential election were along the linesdescribed above. Briefly, the Democrats advocated a collectiveresponsibility for health between employers, workers, insurers, providers,and government. Republicans, on the other hand, proposed to give control of

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the health system to patients and health providers, instead of bureaucrats ingovernment or business, and to generate more market competition (Woolley

and Peters 2008). These party platforms identify the two parties’ beliefsabout healthcare policy. They are said to be excellent predictors of a party’sactual performance in office (Pomper 1980, 161).

The Government-Politics Model of Decision Making

The government-politics model of decision making views decisions as the product of bargaining among many influential decision makers. The problems of the health system fit this model. Whether it is cost control or universal coverage, the participants include the federal and state

governments, employers, insurance companies, managed care plans, andvarious healthcare providers. The success of any policy proposal isinfluenced by the actions of the participants, who differ in their ability toshape the outcome (Allison 1971, 6), and by the political feasibility of thesolution proposed to solve the problem (Huitt 1970, 400). Incrementalismand consensus building are uniquely suited to this pluralistic environment of the government-politics model of decision making. According to Johnson(1996, 299), the “buck” may not stop anywhere in this model but may keeprevolving around the circle of the participants.

Another important dimension of the government-politics model of decision making is the degree of difficulty of the decisions to be reached.The problems afflicting the healthcare system are divergent—problems thathave many potential definitions and solutions, most of which are notcompatible with one another (Johnson 1996, 296). For example, rising costsin the U.S. may be blamed on consumers, providers, equipmentmanufacturers, government regulations, malpractice lawsuits, insurers, etc.Just as the problem may be defined in different ways, different solutionsmay also be proffered to solve it. The proposed solutions, as well as the

problem definition itself, do not meet with everyone’s approval. Therefore,there is need for consensus building, compromises, consideration of citizens’opinions, and considerations of the costs of implementing the solutionsagreed upon. This scenario complicates policymaking and may even result ininaction.

Legal Ecology

Statutory laws, legislative and administrative rules and regulations relatingto healthcare, are intended to subordinate the healthcare system to the rule of

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law. Even though the legislative and executive branches of government have primary responsibility for making policy, the judiciary also plays an

important role for several reasons.First, the legislative and executive branches delegate to the courts

the power to determine health providers’ liability for medical negligence(Rosenblatt 2008, 128). In particular, courts determine the substantive and

procedural rules to be followed in the course of deciding individual cases of fraud, negligence, and malpractice.

Second, because legislative and administrative rules and regulationsare often unclear or ambiguous, courts must determine the constitutionalityand meaning of the regulations. In other words, courts and the relevantadministrative agencies implement health laws and regulations.

Third, although the U.S. Constitution makes no specific mention of healthcare, the provisions protecting citizens from malicious, arbitrary, or capricious deprivation of life, liberty, or property, and guarantees of equal

protection of the laws, have been used by courts to rule on issues such asaccess to contraceptives, abortion rights, and the right to die (Rosenblatt2008, 128).

Another area of healthcare that is affected by public laws is healthinsurance. Insurance is regulated by the states. In some cases, state laws mayimpose premium taxes on insurance plans and health providers in order togenerate money to reimburse providers for uncompensated care(disproportionate share payments); state insurance laws may also imposecertain mandatory benefits and other consumer protection requirements.

Whereas the primary purpose of the federal Employee RetirementIncome Security Act (ERISA) of 1974 was to guarantee the security of workers’ retirement pension benefits, it also exempts self-insured employersfrom paying premium taxes, and to avoid other types of state insuranceregulations, such as financial reserves and consumer protectionrequirements. This federal law essentially undercuts states’ authority for health insurance regulation (Shi and Singh 2008, 203).

Economic Ecology

The economic ecology deals with concerns about the types of health servicesto produce, where they should be produced, production costs, and whoshould benefit from the produced services. In the health policy arena, currentand anticipated economic conditions influence the financing for services.Financing, in turn, influences the demand for services. Increased demand

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results in greater utilization of services, given adequate supply (Shi andSingh 2008, 199).

As was discussed earlier, healthcare financing influences productionlevels. Innovations and new services proliferate when there is adequatereimbursement for them. Therefore, financing gives rise to new technologiesand services. These services are likely to be used extensively when there isreimbursement for them.

Financing for health services also influences both the supply and thedistribution of health professionals. Greater reimbursement for specialty carehas been implicated for the increase in specialists and the decrease in thenumbers of generalists. Explicit government policies designed to influence

physician supply and distribution, such as the resource-based relative value

scales (RBRVS) used by Medicare to pay physicians, are designed to cut payments for specialty care and to attract younger physicians into general practice.

In addition to current and anticipated economic conditions, the levelof economic development influences government expenditures. The level of economic development affects both the capacity of a society to support the

public sector and the level of demand for services. Higher levels of economic development increase government’s ability to generate neededrevenues, provided that taxpayers are willing to shoulder the burden.

When taxpayers are reluctant to pay additional levies, governmentmay be forced to cut programs. Concerns about rising expenditures led toefforts to contract the healthcare system beginning around 1970 andcontinuing till today. Some of the efforts to cut costs, which have beenwidely documented, include President Nixon’s 1971 Economic StabilizationProgram (ESP); the establishment of Professional Standards ReviewOrganizations (PSROs); the Health Maintenance Organization (HMO) Actof 1973; the Health Planning and Resources Development Act of 1974,which required certificates-of-need (CON) for health facilities wanting toexpand; the institution of a prospective payment system for Medicare basedon diagnosis-related groups (DRGs) in 1984; and the utilization of novicedelivery and reimbursement regimes, such as contracts, managed care, andcapitation (Davis et al. 1989; Ubokudom 2003, 64).

Technological Ecology

We define medical technology broadly to include drugs, devices,sophisticated machines and ultramodern facilities, computer-supportedinformation systems, and medical and surgical procedures used in medical

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care, as well as organizational and supportive systems within which suchcare is provided (Riley and Brehm 1989, 21). This technology involves the

standardized physical and social means used to treat patients.Physical technologies include those standardized inanimate tools

that are relied upon to provide medical care. Some examples includemagnetic resonance imaging facilities and devices, computer axialtomography scanners, computerized electro-cardiograph machines, renaldialysis machines, etc. These technologies tend to change rapidly and tocreate high expectations from both consumers and providers.

Social technologies are those standardized social means andmethods used to solve certain problems (Dubnick and Romzek 1991, 127).Compared to physical technologies, social technologies are not inanimate

objects, but standardized human behavior patterns. They are lessstandardized than physical technologies. Social technologies can beclassified into two types: traditional and designed.

Some examples of traditional social technologies include families,schools, and churches. These institutions provide social support, informalcare, companionship, and economic security. An example in the health arenais the fact that most long-term care services in the U.S. are provided byfamily members of elderly or disabled persons (Wiener et al. 1994, 5).

Nurses also provide primary care services in schools.Industrialization and other changes in society have made people less

reliant on traditional social technologies to carry out basic economic, political, and social functions. To make up for the loss, designed socialtechnologies have been invented to accomplish these tasks. Some examplesof health-related designed social technologies include managed carecorporations, health interest groups, nursing homes, hospitals, counselingcenters, etc. These designed social technologies are important andunavoidable parts of the health system.

Physical and social technologies have had profound effects on boththe health of the people and the healthcare system. For example, whereasadvances in chemistry have allowed us to grow and store more food throughthe use of fertilizers, pesticides, and additives, some of these devices canhave adverse effects on people’s health. Similarly, whereas advances intelecommunications, electrical and mechanical engineering, and physicshave led to the development of telemedicine, radiology, cardiology, andmagnetic resonance imaging, some of the undesirable side effects of thesedevices include increased costs, depersonalization of care, ethical dilemmas,such as unnecessarily prolonging or shortening life, and the generation of radioactive byproducts that are difficult to dispose of.

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Physical and social technologies have also had significant effects onthe healthcare system itself. Specifically, the technologies have driven the

scope and content of medical training and the practice of medicine, governedthe organization and financing of medical services, influenced the statusaccorded to different medical workers, and raised consumer expectationsabout the types of treatment and outcomes that are possible (Shi and Singh2008, 177; Patel and Rushefsky 2006, 318). When these expectations are notmet, frustration sets in and lawsuits are filed.

Social and Cultural Ecology

Virtually all health policy matters are influenced by the nation’s culture andnumerous subcultures. Culture refers to the shared views that people haveformed about how their world works and about the methods for problemsolving that will be effective in that world (Schein 1985, 5). Added to thisworld view are the people’s values, which reflect what they think are theappropriate and desirable roles for government to perform. These values can

be divided into social and political dimensions.Social values determine whether Americans prefer immediate or

deferred gratification of individual needs or desires; whether there should be

favoritism in the application of rules; whether the society has an individualor a collective interest orientation; and whether people are evaluated basedon their personal achievements or on other factors over which they havelittle or no control, such as wealth, family ties, race, or gender (Dubnick andRomzek 1991, 141).

The American political culture rests on democratic values. Theseinclude liberty, equality of opportunity, individualism, democracy, justice,the rule of law, patriotism, optimism, and idealism. These widely shareddemocratic values overlap and sometimes conflict (Magleby et al. 2006, 82).

The above political values, or at least some of them, make up what

is called the American dream—the notion that the U.S. is a land of opportunity and that individual initiative and hard work can lead toeconomic success. These values account for why the people valuecapitalism, market justice, economic incentives, and a limited governmentrole in the economy (Magleby et al. 2006, 87).

The U.S. healthcare system is deeply rooted in the beliefs and valuesheld by the people (Payer 1996, 16). Some aspects of the health system thatare the result of the nation’s value system include more private influence andless government funding and involvement in the system; the lack of a centralagency to administer the numerous health insurance programs in the country;

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the diffusion of responsibility among numerous levels of government; thelack of comprehensive and universal coverage for all citizens; minimal

cross-subsidization of the uninsured or underinsured; the denunciation of national health insurance as a form of socialism; and the belief thathealthcare is a private good, as opposed to a public good.

Furthermore, Americans’ beliefs and values influence the trainingand general orientation of health providers, the organization of medical

practice, the association of high technology with high-quality care, and therecognition of physicians as private entrepreneurs who should practicemedicine as they were trained. These values also influence the wayAmericans conduct themselves within the political system, the standardsthey use to evaluate government activities, and how they feel about

government and politics. Perhaps, this explains why the people are generallyagreeable that the health system should be reformed, but are less supportiveof government-led reform efforts.

Physical Ecology

Some of the factors we count as being part of the physical ecology of health policymaking include air pollution, food and water contaminants, radioactive

substances, illicit drugs, disease vectors, safety hazards, habitat alterationsand outbreaks of communicable diseases (Shi and Singh 2008, 51).The relationship between physical ecology and health is well

documented. Medical care or those practices that are used for the care andrehabilitation of the sick (hospitals, nursing homes, prescription drugs, etc.)make only modest contributions to the health status of the population. On thecontrary, the health status of the population is largely determined by adifferent set of factors that involve important physical and economicdimensions. These factors are preventive medicine, environmental control,

behavior modification, and the totality of environmental, social, and cultural

interactions experienced by a population (Winkelstein 1993, 2504;Wilkinson 1997, 1504).As was noted previously, of the $2.24 trillion spent for healthcare in

2007, only $64.1 billion, or about 2.9% of the total expenditures wasaccounted for by those factors identified above as having the most effect on

population health (CMS 2009a, b). This finding is confirmation of thecontinued dominance of the medical model that has governed the healthcaresystem since its inception. Health policymaking and resource allocationcontinue to focus on clinical diagnosis and interventions to treat disease or symptoms of disease, to the neglect of physical ecological factors.

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In addition to the effects of physical factors on population health,spatial factors or the locations of health facilities and personnel are

important considerations. For example, physicians themselves decide wherethey will practice, without necessarily considering the needs of the

population (Long 1994, 31). Similarly, hospitals’ locations and operationsare influenced by financial considerations, without regard to duplications or shortages of services and technology (Shi and Singh 2008, 61). Theseconditions result in the maldistribution of healthcare providers and facilities.Physicians in the U.S. are more likely to locate in metropolitan and suburbanareas than in rural and inner city areas. Also, publicly run health institutionsare generally located in large inner cities and certain rural areas. Theseconditions create vast amounts of provider shortage localities. The publicly

operated facilities that are located in inner city and rural areas tend to treat adisproportionate population of the uninsured, thereby causing them seriousfinancial hardships (Ubokudom 1998, 68).

The environment or physical ecology is also known to significantlyinfluence developmental health. Research by Wynder and Orlandi (1984)and by Shellenbarger (1997, B1) shows that children who are isolated and donot associate much with their peers tend to be overrepresented amongdelinquents and adults with mental health issues.

Demographic Ecology

Demographic ecology refers to population characteristics; the agedistribution of the people; literacy rates; health needs; social morbidity, suchas acquired immune deficiency syndrome (AIDS), drugs, homicides, andinjuries; and the perceptions, attitudes, and values the people bring to thehealthcare system as consumers.

The population of the United States was about 302 million in 2007.Per capita expenditure for the year was $7,421, an increase of 5.1% from

2006. The number of people covered by private health insurance (202million) in 2007 was not statistically different from 2006, while the number of people covered by government health insurance increased slightly from80.3 million in 2006 to 83 million in 2007 (CMS 2009a, U.S. Census Bureau2007b).

In 2007, 37.3 million people were in poverty, up from 36.5 millionin 2006. The poverty rates in 2007 were statistically unchanged from 2006for non-Hispanic whites (8.2%), blacks (24.5%), and Asians (10.2%); itincreased slightly (about 1%) for Hispanics between 2006 and 2007.

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The poverty rate and the number in poverty increased for childrenless than 18 years of age in 2007. In both 2006 and 2007, the poverty rate for

children was higher than the rates for people 18–64 years old and those 65years and older. In 2007 alone, children under 18 years old represented35.7% of the people in poverty and 24.8% of the total U.S. population.

Even though the poverty rate and the number in poverty increasedfor children in 2007, the percentage and number of children under 18 yearsold without health insurance were lower that year than in 2006 (U.S. CensusBureau 2007b), most likely due to efforts by Medicaid and the StateChildren’s Health Insurance Program (SCHIP) to expand coverage for poor children. Even then, children in poverty were more likely to be uninsuredthan all children.

As has been the case since 2000, most Americans were covered byemployer-sponsored insurance (ESI) plans in 2007. At its peak in 2000, ESIcovered about 67% of the non-elderly population (Blumenthal 2006, 83). By2004, only about 61% of the non-elderly Americans under 65 years old werecovered by ESI (Clemans-Cope and Garrett 2006, 6). Continuing thedownward trend, only about 59.3% of the non-elderly Americans werecovered by ESI for some or all of 2007 (U.S. Census Bureau 2007b), adecline of about 7.7% since 2000. This is a strong indication of theweakening of the long-standing association between work and healthinsurance (Ubokudom 2008b, 19; Blumenthal 2006, 84). The currenteconomic recession is expected to lead to more steep declines in ESI for theforeseeable future.

In 2004, the year that complete information is available, lifeexpectancy at birth in the United States was 77.8 years (75.2 years for malesand 80.4 years for females) (Arias 2007, 4). The white–black difference inlife expectancy narrowed from 14.6 years in 1900 to 5.7 years in 1982, butincreased to 7.0 years in 1994. The increase in the gap from 1983 to 1993was said to be due to increases in mortality among the black male populationresulting from HIV infection and homicide (Anderson 1999; Kochanek et al.1994). However, homicides and HIV disease dropped from among the topfive causes of death among the black population during the 1990s to sixthand ninth, respectively, in 2004. Unfortunately, as deaths due to HIV diseasedecline among blacks, diabetes has become one of the top five causes of death for them.

In 2004, differences in the 10 leading causes of death in the UnitedStates were evident by age, gender, race, and Hispanic origin. Healthdisparities based on race, ethnicity, income, and gender continue to convergein some instances, and to fluctuate in other instances. For example, whereasthe proportions of deaths due to cancer and kidney disease were identical for

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both men and women in 2004, the relative burden of mortality fromunintentional injuries was higher for men than women. Similarly, the burden

of mortality from diabetes, relative to other causes, has typically been higher for women than men (Heron 2007, 8).

The last demographic factor that we want to examine is the agedistribution of the population. This is important because we expecthealthcare needs to differ based on people’s ages. In 2007, about 172 million

people were between 0 and 41 years of age, 85 million were between 42 and62 years old, and about 45 million were more than 62 years old (Schill2008). Federal health officials report that persons reaching age 65 have anaverage life expectancy of an additional 19.0 years (DHHS 2008).Consequently, the 85 years of age and above population is projected to

increase from 4.2 million in 2000 to 5.7 million in 2010, and then to 6.6million in 2020. The percentage of the elderly living in nursing homes or institutional settings increases dramatically with age, ranging from about1.3% for persons 65–74 years to 4.1% for persons 75–84 years and 15.1%for persons 85 years of age and older. These data are indicative of a pressingneed for long-term care services for the elderly in the near future.

Global Influences

The global ecology includes the effects of migration and populationmobility, trade and travel, terrorism, and the emerging and reemerginginfectious disease paradigms. These factors present new challenges for healthcare delivery and policymaking throughout the world.

Globalization refers to various forms of cross-country economicactivities. The process is driven by the current global exchange of cultureand information, the growth of migration and population mobility,international trade, outsourcing of the manufacturing business from thedeveloped countries to the developing countries where labor costs are lower,

and the increased interdependence of the world’s economic systems Thesechanges now shape global health, and raise an awareness that changes in theecology of human living, in relation to both the natural and socialenvironments, account for much of the ebb and flow of diseases over time(McMichael and Beaglehole 2000, 495).

The principal agents of a globalized market-based economic systemare international agencies such as the World Bank, the InternationalMonetary Fund (IMF), and the World Trade Organization (WTO). The

policies they promote have resulted in reduced expenditures for social programs, especially in developing economies. These policies have impaired

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population health, and slowed the advances in literacy for women, fertilityreduction, and improved reproductive health in the developing countries

(Kinnon 1998, 397; Gray 1998; Watts 1997).Globalization is also blamed for increased smoking and tobacco-

attributable mortality in the developing countries (Murray and Lopez 1997,1498). Also noteworthy is the escalation in the sale of weapons, much of itfacilitated by western governments. The wars that have raged on and off insub-Saharan Africa, Latin America, and Asia are tragic examples of the illeffects of aggressive weapon sales to these places (McMichael andBeaglehole 2000, 497).

Although the adverse consequences of globalization tend to affectdeveloping countries more than the U.S., there are significant adverse

consequences of globalization for the United States as well. Some of theseinclude the perpetuation and exacerbation of the gap between the rich andthe poor, job insecurity and reduced wages, the collapse of largemanufacturing businesses, increased availability and demand for illicitdrugs, and the emergence of new infectious diseases that spread more easily

because of increased migration and population mobility.The sudden appearance of the previously unknown acquired immune

deficiency syndrome (AIDS) in the U.S. in the early 1980s challenged thewidely held belief that infectious diseases were under control. Since then,new diseases and ailments have surfaced, such as the hantavirus, believed tohave originated in Korea; encephalitis cases in New York and California in2002; the spread of Severe Acute Respiratory Syndrome (SARS) from Chinain 2003; the polio virus that originated in India in 2005; and the 2009outbreak of the deadly H1N1—swine flu—influenza believed to haveoriginated in Mexico (CDC 2009; Shi and Singh 2008, 578).

The terrorist attacks in the United States on September 11, 2001,elevated public health to an important national instrument for anticipatingand dealing with terrorism. The 2001 experience has led to the developmentof large-scale plans to deal with the threat of bioterrorism. Consequently,expenditures for government public health activities, while still low relativeto expenditures for medical care, rose from $47 billion in 2001 to $64.1

billion in 2007, an increase of 36.4% from 2001 (CMS 2009a). The globalinfluences on health are introducing health issues into the U.S. foreign

policy discussions (MacPherson et al. 2007, 200).Other aspects of the U.S. health system that are affected by the

global ecology are medical technology and healthcare professionals andconsumers. Because the United States is widely believed to be the worldleader in the development and utilization of high-technology procedures,foreign dignitaries come here for specialty care. Also, nurses and foreign

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medical graduates (FMGs) move to the United States to acquire licenses to practice in the country. This so-called brain drain leads to shortages of

medical practitioners in the developing countries, and alleviates some of theshortages in the understaffed areas of the U.S.

Telemedicine allows physicians in the U.S. to transmit radiologicalimages to other countries where they are interpreted at lower costs. On theother hand, U.S. consulting pathologists and radiologists are able to providetheir services to other parts of the world. Furthermore, medical equipmentand supplies that are discarded here a few years after deployment areshipped to the developing and less technology-intensive developed countriesat low costs. The high costs paid by U.S. consumers are used to subsidize thelow costs paid by the developing countries.

We have just finished a detailed excursion into the ecology of health policymaking in the U.S. This exercise was intended to allow us identifysome of the constraints and opportunities for health reform presented by theecological factors. Therefore, this final section of the paper will discuss theopportunities and constraints, and the policy implications or types of reform

proposals that are likely to be embraced in this environment. First, weidentify the constraints posed by the ecological factors.

Constraints Posed by the Ecological Factors

The constitutional and political ecological factors discussed earlier causehealthcare policymaking to be in a constant state of fluidity, resulting ininconsistencies and conflicting programs and values. As was stated earlier,

power is decentralized among the different branches of government andamong individual policymakers. A person who is not very familiar with theU.S. system of government may conclude that there are 536 policy-makingagendas competing with each other (one agenda for each of the 435members of the House of Representatives, 100 Senators, and the president).

This assertion is wrong when one considers the various interest groups andother influences on the healthcare system. The challenge is how to aggregateall these different, and sometimes conflicting, values. The failures of

previous reform efforts point to the fact that value aggregation is no easytask.

The extensive reliance on ESI is another constraint on health policymaking and reform. At the outset, the nation delegated the provisionof health insurance for its citizens to private companies. Therefore, between1940 and 1950, the number of people with private health insurance increasedfrom 20.6 million to 142.3 million (Thomasson 2002, 233). By 2004, the

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number of non-elderly Americans with ESI was more than 159 million(Blumenthal 2006, 82). Even though ESI has been on the decline, the

continued reliance and investments in ESI seriously limit consideration of alternative financing mechanisms, a phenomenon economists call “sunk costs” (Anderson 2006, 124). This is probably why the reform proposalcurrently under consideration “builds on the current system in whichemployers, government, and individuals share responsibility for healthinsurance” (Alonso-Zaldivar and Werner 2009).

For the most part, healthcare reform involves concentrating the costsof the reforms on a few groups, while spreading the benefits in minutequantities to the general population. Under this scenario, those who areexpected to bear the costs of the reforms have more incentive to organize to

oppose the reform than the masses that would reap the benefits (Weissertand Weissert 2002, 252; Ubokudom 2003, 70). This explains why insurers,hospitals, and employers oppose a provision of the new proposal, whichcalls for a government-sponsored insurance plan to compete with privatecompanies (Alonso-Zaldivar and Werner 2009). Meanwhile, the masses donot seem to be paying attention to the debate.

Another important constraint that cannot be ignored at this time of high unemployment and budget deficits is cost inflation. The Kaiser FamilyFoundation’s annual survey of employer benefit plans for 2008 shows thathealthcare spending continues to rise at a rate that affects businessoperations and family expenses. In 2008, the average annual combinedemployer and employee premiums for ESI were $4,704 for single coverageand $12,680 for family coverage, up about 5% from 2007. In addition to

premium contributions, most covered workers face a general annualdeductible, physician office visit copayments, and a portion of the cost of

prescription drugs. Among employers that offer health insurance benefits,large numbers anticipate future increases in worker premium contributionsand co-payments (Claxton et al. 2008).

It follows, then, that healthcare cost increases are continuing at atime of declining employment. Declining employment and loss of ESIincrease citizens’ demands for government assistance. Similarly, the morethe number of unemployed citizens, the less revenues available for government to deal with the increased demand for public assistance. Thislimits government’s ability to provide health insurance for both thechronically and recently uninsured. Paradoxically, declines in employmentand insurance can provide government with the cover necessary to advocateuniversal coverage.

For a long time, the popular belief had been that the aging of theAmerican population would drive up both the demand and spending for

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healthcare. This line of thinking ignored the supply side of the healthcareequation. Research shows consistently that when supply-side variables are

controlled for, the aging of the population, by itself, tends to be only a minor determinant of the annual growth in aggregate healthcare use and spending.This is so because the rise in the age 65 and older population group isgradual (Reinhardt 2003, 27).

Even though recent studies have debunked the myth that the agingof the population is a major driver of the annual growth in the demand andspending for healthcare, the aging of the population still constrains health

policymaking and reform. This is so because the current fertility rate issignificantly below the “replacement rate” needed to maintain the present or desired age-dependency ratio (Graig 1999, 180; Reinhardt 2003, 27). For

example, in their 2009 report, the Trustees of the Hospital Insurance andSupplementary Medical Insurance Trust Funds predicted that in the future,Medicare trust fund income is expected to increase less rapidly thanexpenditures. This is because with past declines in birth rates, continuingimprovements in life expectancy, and prevailing rates of disability incidence,the number of workers is expected to grow more slowly while the number of

beneficiaries is expected to increase much more rapidly (CMS 2009b).The last constraint to policymaking and reform is the existing,

although narrowing, health disparities based on race, ethnicity, and income.Although the race-based gap in health status is narrowing, millions of Americans, many of them racial and ethnic minorities, lack access tohealthcare. Since other factors, in addition to healthcare, affect the healthstatus of the population, any effort to reduce health disparities must becomprehensive to be effective. Policies must address the disproportionatelylow level of access to healthcare for minorities, the relatively low levels of healthcare quality for minority groups, and the adverse social and economicconditions faced by minorities in their communities (Lavizzo-Mourey et al.2005, 313). This will be no easy task, especially since minorities usuallyhave the least amount of resources, political and economic.

The discussion of the constraints facing the health system does notimply that all hope for reform is gone. On the contrary, the ecology also

presents some real opportunities that, although fewer than the constraints,can be harnessed to achieve desired reforms. These opportunities areexamined below.

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Opportunities Presented by the Ecological Factors

From the beginning of the U.S. healthcare system till about 1980, health policy costs or the economic interests of consumers were diffused, whereasthe economic interests of health providers were concentrated. Consequently,there was a strong incentive for providers to organize and lobby for

beneficial legislation because the payoffs they expected to receive were largeand attractive (Feldstein 1991, 209). The fee-for-service reimbursementmethod, states’ restrictions on prepaid group practice, appropriations for health professional educational institutions, etc., were enacted based on theeconomic interests of providers, who had a concentrated interest in their

outcomes.Since the 1980s, much of the diminished political power andeconomic benefits enjoyed by the medical profession are the result of therise of opposing concentrated interests—costs for payers have increased tothe point where they become concentrated (Feldstein 1997, 220). These costincreases, continuing during a deep economic recession, have madehealthcare one of the leading issues among the public. At the moment, publicsupport for reform appears to be high. However, there are significantdifferences about the specific forms of reform the public will support.

Increased public and labor support for reform, a less vigorous

business and provider resistance to reform, policy learning from the practices of other industrialized countries, and policy learning from the publications of health policy scholars in the U.S. and around the world giveus hope that the coalition needed to push for universal coverage and costcontainment can be built in the Congress and among the general populationthis time around.

With regard to how the United States can learn from other industrialized countries, Theodore R. Marmor and Morris Barer (1997, 315)write that the rest of the developed world figured out some time ago that

providing universal coverage did not have to mean uncontrolled costs and

that controlling costs did not have to mean foregoing universal coverage.Some of the countries that have learned this lesson include England,Australia, Germany, The Netherlands, Canada, and Japan. Although thesystems in these countries are not devoid of quality or cost problems, theyhave been able to provide at least basic coverage to all their citizens at afraction of the costs incurred by the United States. Moreover, some of their health statistics are comparable to, or in some instances better than, those of the United States (Graig 1999, 176).

From within the U.S., the Institute of Medicine (IOM) reported in2002 that about 18,314 Americans die annually due to uninsurance. That

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death toll is expected to increase as the uninsurance rate increases duringthese hard economic times. These alarming statistics, if well communicated

to the population, may be the impetus for public support of heath carereform.

But, let there be no mistake. Success in building the coalition neededto push for universal coverage and cost containment also depends on theability of the president to use his popularity and speaking ability to convinceAmericans that the majority of them—the middle class, men and women, theyoung and the elderly, small and large businesses, the insured and uninsuredor underinsured, conservatives and liberals alike—would benefit from areformed healthcare system.

Poor health does not discriminate along party lines, gender, age,

social status, race, etc. Health is not a negotiable commodity—one either hasor does not have it. All Americans, regardless of political beliefs, would liketo be healthy, not unhealthy. The existing system is not conducive to

prevention and better longevity despite high expenditures. Some of the waysto remedy the current situation are to get rid of all the financial and legalintermediaries that stand between patients and their healthcare providers,strengthen the fiduciary responsibilities of healthcare providers, includingthe curtailment of defensive medicine, control costs, and pay better attentionto educating the public about making healthy choices. The Administrationmust not only educate the public on the above issues, it must also quicklyand vigorously dispel any misinformation or half-truths by those who arewilling to go to any length to preserve the status quo.

The above point reminds us of a debate Professor Morone (2008, 49)tells us he had in 1994 with a politician who opposed the Clinton reform

plan. Briefly, the politician’s claim that the proposed reform plan required“deserving” citizens “to go into the same health alliances as the crackheadsin the city of Chicago” effectively ended the positive reception the professor had received to that point. The rumors spread in the summer of 2009 that theObama Administration planned to insure illegal immigrants and to set up“death panels” to kill seniors as a way of cutting costs are indications thatantireformers will go to any length to block change. The Administrationmust anticipate these rumors and misinformation and must not allowantireformers to put it on the defensive. The plan that is presented to theAmerican people must be simple enough for the average citizen tounderstand, and must follow the neoconservative approach (Battistella andOstrick 1997, 75). It must seek balance and moderation between equity andefficiency, and must be able to adapt to changing local and globalcircumstances.

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Conclusion

The purpose of this paper was to examine the ecological factors that makethe U.S. health system resistant to change, and to explore the prospects of

passage of the reform agenda pursued by the Obama Administration. Weidentified and analyzed nine ecological factors that influence health

policymaking in the U.S. These ecological factors, individually andcollectively, cause the U.S. healthcare policymaking to be inconsistent. Inthe past, health policies and programs were enacted to support theconcentrated interests of providers. Recently, however, the rise of opposingconcentrated interests on the demand side of the healthcare equation, an

economic recession that is described as the worst since the Great Depression,a weakened business and provider resistance to reform, and policy learningfrom the practices of other industrialized countries and from the publicationsof health policy scholars in the U.S. and around the world give us hope thathealth reform may soon become a reality. However, given previousexperience, the constraints that reformers face are still very serious. Aneoconservative reform proposal that builds on existing structures stands a

better chance of being adopted than a proposal that involves sweepingchanges to the existing system.

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Health care reform and policy factors

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