Health Care Reform and Health Services Research: What Once was Old is New Again, and Again

Congress, in passing the 2003 Health Care that Works for All Americans Act, created a 15 member Citizens' Health Care Working Group to try to improve our health care system and its financing, in order to better meet the needs of the entire population.1 Citing both high and growing health care costs and increasing numbers of uninsured Americans as major reasons, Congress charged this group to engage the public-at-large in an informed and informative dialogue and to bring back recommendations to Congress to redress these concerns. The dialogue will encompass what health care benefits and services should be provided and how they should be delivered; how health care coverage should be financed; and what trade-offs between benefits and financing the American public is willing to make to ensure more equitable access to affordable, high quality health care coverage and services.

Far-reaching attempts to develop and enact legislation to improve health care coverage and system efficiency are certainly not new. For example, there were nine national health plans under active consideration by the U.S. Congress in 1974 when the American Public Health Association's Medical Care Section held a symposium honoring Nathan Sinai for his scholarly contributions to our understanding of health insurance. The journal Medical Care published the prepared comments given at this symposium, all of which referred to the health care reforms being discussed at the time. One person remarked, “With the enactment of national health insurance perhaps only months away, highlighting the career and influence of Dr. Sinai seemed appropriate” (Breslow 1974, p. 1038). Sinai himself declared “a national health plan is in the making.” He prophesized, “Before us now are Medicare and Medicaid, as sources of controversy, managerial criticism, and uninhibited spiraling of costs,” feeding concerns about the costs and management of any new national health plan (Sinai 1974, p. 1044). In an accompanying commentary, Sy Axelrod added: “Other important social policy issues include population coverage—that is, whether we should rely on voluntarism with subsidy or insist on universality; methods of financing and sources of funds; the inclusion of incentives to achieve efficient and effective use of health care resources; and, of particular interest to public health workers, the benefits to be included” (Axelrod 1974, p. 1048).

Of course, many proposals to reform the U.S. health care system preceded and followed those in 1974. In fact, one of Sinai's earliest contributions to the field occurred over 70 years ago when he was a consultant to the Committee on the Costs of Medical Care, which was established in 1927 and funded by several foundations.2 The Committee spent 5 years conducting 17 research projects; it produced 26 reports and a book, Medical Care for the American People (1932), which summarized their research and made recommendations for system wide change. The book begins, “… today there is a vast amount of unnecessary sickness and many thousands of unnecessary deaths … yet medical science has made marvelous advances during the last 50 years. The people are not getting the services which they need—first, because in many cases its cost is beyond their reach, and second, because in many parts of the country it is not available. The costs of medical care have been the subject of much complaint” (Committee on the Costs of Medical Care 1932, p. v).

Medical science has continued to make great strides since this report was published. However, the problems that health services researchers focused on 70 years ago are the same as those focused on 30 years ago and still today—how to reduce costs, how to improve access and quality, and how to increase efficiency without sacrificing equity. For example, in 1974, an article published in the journal Inquiry asserted, “The rapid increase in hospital costs during the 1969s and early 1970s can be attributed in part to the methods by which hospitals are paid” and outlined the potential benefits of switching to a prospective payment system (Dowling 1974). That same year, the Milbank Memorial Fund Quarterly and Health Services Research each published articles that examined the factors contributing to the increase in overall hospital costs as well as to the variation in costs-per-case (Berry 1974; Jeffers and Siebert 1974). In the same volume of Health Services Research, reviewers of Odin Anderson's seminal book, Health Care: Can There Be Equity?, also noted that the ranking of international mortality rates, “with the United States highest and Sweden lowest, persists over a 50-year time span when medical technology, financing, and organization have changed so much” (Johnson and Neuhauser 1974, p. 245). This comment parallels that expressed 30 years later in the Health Care that Works for All Americans Act—“Despite increases in medical care spending that are greater than the rate of inflation, population growth, … there has not been a commensurate improvement in our health status as a nation.” Likewise, these same journals (and others) continue today to publish research and commentary that raise concern about unnecessary sickness and deaths.3 Evidence continues to find that many people are unable to get the services they need because of financial and other access limitations.4 And medical care costs continued to be the source of “much complaint” as noted in the 1932 report.

It may be tempting to conclude therefore that we as a community of health services researchers haven't made very much progress in either our understanding of these issues or in our ability to recommend appropriate policy. A more nuanced investigation reflects not only changes in the economic and political climate that led to changes in public and private health care policies, but also changes in the questions asked and methods used by health services researchers and in their contributions to the development of observed policy changes. The questions and goals may be the same, but the ability to provide answers to policymakers has improved.

For example, in 1974, Health Services Research published the seminal article “A Framework for the Study of Access to Medical Care” which developed a theoretical framework that would enable the evaluation of the effectiveness of policies aimed at improving or changing the access to medical care (Aday and Andersen 1974). That framework profoundly changed the way we thought about access and led to new programs and research efforts.

1974 was also the year Inquiry published an article by Newhouse describing the RAND Health Insurance Experiment (HIE), which estimated, among other things, the response of consumers to different financing mechanisms. The HIE not only informed policy makers about the likely impact of changes in private and public health insurance benefits design, it also dramatically changed the methods used by researchers to study health status, health care utilization, and consumer behavior.

Several articles published in the current issue of HSR illustrate the continuing contributions of the field in understanding the complexity of health care delivery and finance. Sloan, Rattliff, and Hall (2005) and Lantz et al. (2005) provide current examples of how much progress the field has made in understanding nonfinancial aspects of access and the effect on health care utilization and patient satisfaction. Similarly, the health status instrument used by Liu et al. (2005) is based in part on research conducted in the RAND HIE. Finally, the risk adjustment mechanisms used and the cost functions estimated by Maciejewski et al. (2005) reflect years of refinement since the articles by Berry (1974) and Jeffers and Siebert (1974).

And yet, advances in research may not always translate into advances in practice or policy. In making its recommendations for system-wide changes in 1932, the Committee on the Costs of Medical Care listed six essentials of a satisfactory medical program, which include the ability to “safeguard the quality of medical service,” the provision of services “on financial terms which the people can and will meet, without undue hardship,” and “provisions for assisting and guiding patients in the selection of competent practitioners and suitable facilities for medical care” (Committee on the Costs of Medical Care 1932, p. 38). Yet, as noted 70 years later in the Health Care that Works for All Americans Act, we still do not have a health care system that includes these essentials for all citizens. Hence, the two principal purposes of this Act are “(1) to provide for a nationwide public debate about improving the health care system to provide every American with the ability to obtain quality, affordable health care coverage and (2) to provide for a vote by Congress on the recommendations that result from the debate.” We sincerely hope that the outcome of this effort can make significant strides in translating our advances in clinical practice and health services research into a health care system that actualizes these essentials for U.S. citizens.