The past few days I have been looking at gridlock (defined as non passage of bills introduced in Congress), and the role that confirmation bias plays in how we understand events (we see what we want and use reason to persuade, not to understand). This got me to thinking about a paper I published from my dissertation that argued that targeted programs to help the underserved–like the Community Health Center program and the National Health Service Corps–were often supported as a way to kill comprehensive health reform (Winter 1999, Journal of Rural Health).
My paper began by discussing the 1932 Final Report of the Committee on the Costs of Medical Care, the landmark report that basically argued that the entire nation was underserved when it came to health care, and called for rapid expansion of medical infrastructure and development of expanded insurance financing (though there were divergent views of how to achieve this on the Committee).
In general, the CCMC concluded that even among the highest income group, insufficient care is the rule (Falk et al., 1932), and the basic solution to this problem was to increase the proportion of national resources going to medicine.
This call was answered with laws such as the Hill-Burton Hospital and Construction Act of 1946, rapid post-War expansion of the NIH, and eventually the passage of Medicare and Medicaid. I was looking for an explanation for why our country had not gone the next steps and passed a universal health insurance scheme. My summary argument in 1999 was:
There has been a shift during the past 60 years from a broad notion of the entire nation as underserved to a more focused effort to identify particular areas (often rural) thought to be underserved. This approach was formalized with the advent of the war on poverty. This focused approach has been cemented during the past 30 years, in part by the success of various federal health center programs that have remained funded during this period in spite of opposition. This paper concludes that the consensus view that rural underserved areas represent an “exception” phenomenon that is properly addressed with special responses (organizations or physicians) has had two major effects: (1) the political survivability of focused programmatic responses (such as Community Health Centers) has been enhanced; and (2) the existence of an “elastic net” policy network to advocate for the expansion of such remedial efforts may play a contributory role in helping to defeat comprehensive health reform.
I was convinced that calling for expanded resources for the National Health Service Corps, or more money for Community Health Centers was ‘the cheap way out’ for opponents of the Clinton Plan, which in my graduate school mind of 1993-94 was already a sell-out. I wrote then:
In the House Energy and Commerce Committee, Rep. Dennis Hastert, R-Ill., and Rep. Billy Tauzin, D-La., developed a ”resolution designed to organize opposition to it” (“it” being an employer mandate and universal coverage). As part of this strategy, Republicans and Southern Democrats offered immediate approval of $100 million in additional funding for Community Health Centers and Rural Health Clinics to sway uncertain members to oppose “comprehensive reform legislation.” They were successful. House Appropriations Committee Chair David Obey, D-Wis., responded in this way: “We ought to be frank. What we have here is a political fig leaf. It’s being offered by people who don’t have any intention of supporting health reform” (American Health Line, The Daily Executive Briefing, 1994, p. 3).
Of course, this heuristic that I offered (targeted resources are used to block comprehensive reform) didn’t even work for the next major health reform attempt, the debate around the Affordable Care Act. If you recall the snowy December, 2009 Senate negotiations, you will remember that the last holdout to vote for the motion to proceed that wasn’t Ben Nelson was Bernie Sanders. Sen. Sanders wanted straight single payer, or at least a public option and got neither. However, he did manage to get a great deal more money (around $10 Billion over 10 years) for Community Health Centers, perhaps the centerpiece ‘special resources’ health policy response that represents an attempt to set up primary care in areas with absolute deprivation of health care infrastructure and/or inappropriate or inaccessible infrastructure for certain groups.
This provides an example of someone who wanted a more comprehensive reform than what passed, yet who also wanted more resources for community health centers because he believed that even with insurance expansions, special resources are needed to provide care to certain areas and populations. And in a further delicious piece of irony, in 2009-10 Mr. Tauzin was no longer in Congress, but instead was a chief force in negotiating the support of the pharmaceutical industry for the ACA that helped pave the way for passage of the law.
I was quite convinced when I wrote my dissertation in 1994-95 that targeted efforts such as those represented by Community Health Centers were a key part of killing the Clinton Plan. There is probably some evidence of this effect, but I likely overstated it, and correlation is not the same as causation. In any event, this heuristic did not prove useful for predicting the outcome of the ACA, as it was advocates for even more comprehensive reform that pushed hardest for increased targeted resources. 16 years removed from completing my dissertation, it seems obvious that such a simple predictive model would inevitably be wrong.