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Health Affairs, 24, no. 6 (2005):
1396-1397
doi: 10.1377/hlthaff.24.6.1396 © 2005 by Project HOPE |
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From the Editor |
The Struggle That Never Ends: Reforming U.S. Health Care
More than a decade has passed since the ambitious effort of Bill and Hillary Clinton to reform health care went down to a humiliating defeat without so much as a House or Senate floor vote. Many of the same issues that bedeviled America’s troubled health care system in the 1990s and well before remain unaddressed: an uninsured population that numbers some forty-five million people and, by most accounts, is very likely to increase; high expenditures that continue to grow at two to three times the overall economy; and accumulating evidence that the quality of care delivered in many instances is well below optimal. Of course, there are two sides to these issues, given the reality that one man’s expense is another man’s income. In spite of these unresolved issues, societal interest in addressing them remains modest, given their magnitude in economic and human terms. Hurricane Katrina highlighted some of the shortcomings and will provide another test for the American appetite for reform.
In this thematic issue we offer a variety of papers that revisit the subject of reform from many angles and also take measure of the role of market-based competition in today’s medical economy. The issue was supported by grants from the Robert Wood Johnson Foundation (RWJF) and the Kaiser Permanente Medical Care Program. The RWJF is a private philanthropy that since 1972 has sought to expand coverage as an integral part of its mission to improve health and health care for all Americans. Kaiser Permanente is the nation’s leading model of how group medical practice and prepayment can combine to provide high-quality care to an enrolled population. Over the past three years, during the designated "Cover the Uninsured Week," the RWJF sponsored or collaborated in some 6,000 local events all fifty states and the District of Columbia in its ongoing efforts to expand coverage. The events generated extensive national and local media coverage and attracted more than one million visitors to www.CoverTheUninsuredWeek.org. This year the weeklong event brought together a wide array of organizations to organize activities that raised awareness about the need for affordable coverage for all Americans. The most tangible achievement of the RWJF and its partners has been to enroll some two million already eligible children and adults in existing public programs that offer coverage, particularly the State Children’s Health Insurance Program (SCHIP) and Medicaid. But that still leaves forty-five million people without insurance.
As a rigorously nonpartisan policy journal, Health Affairs cannot be a cheerleader for reform. Instead, the journal’s role is to foster and facilitate informed and thoughtful dialogue. In this issue, part of our strategy for doing that has been to invite papers that explore the foundations of various competing theories of how the health care system might be improved—rather than asking authors to repeat again the familiar arguments for why their vision is the best one. We are grateful to those who have put aside their rhetorical cudgels and answered this call, and we hope that the results will be helpful to readers as they face the challenge of improving the system’s performance in a tense and polarized environment.
Along the same lines, we present a group of papers on the subject of competition that do not center on the ideological debate over whether competition is or is not the key to reform. Most of these papers, too, seek to explore and explain, not to exhort. The illuminating result of this approach is that several of these papers focus on the way that consumerism—the linchpin of competitive theory in this decade—could combine and coalesce with traditional insurance and managed care instead of replacing them. The papers on competition include a retrospective look at market changes during the past ten years by Paul Ginsburg, whose services as editorial adviser enhanced this special issue above and beyond the paper he contributed.
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