Healthy, Wealthy, or Wise? Issues in American Health Care Policy

By Charles T. Stewart Jr. | Go to book overview

dictable illness. That is why we are willing to help pay for others' misfortunes and consider ourselves fortunate if others do not have to pay for ours. When health insurance is extended to cover costs that are the likely or certain outcome of willful choices, not only are the costs of insurance raised for all of us, but its moral and psychological support is undermined. When insurance is used to pay for occasional checkups, for the normal, routine ailments that all of us can expect to experience from time to time, that are not expensive and that in many cases do not really require medical care, it is no longer insurance, but prepayment. But, unfortunately, insurance seems headed toward more coverage of behavioral illness and of normal and routine medical care.

What matters most is not the coverage of individuals--universal coverage eventually--but the coverage of procedures, especially surgery, and of tests and drugs. There are two issues here: which procedures and tests are covered, which are not; and to whom is the coverage extended, and for what purposes. Coronary bypasses, caesarean sections, and appendectomies are all covered, but it is clear that too many are performed. What criteria should be met if they are to be reimbursed? For example, blockage of three arteries justifies bypass surgery, but blockage of only one does not, unless it is the left main coronary artery. The condition of the patient must also be a consideration. Existing technologies--psychoactive or psychotherapeutic drugs, the area of addiction generally--are subject to almost indefinite expansion as concepts of unacceptable or undesired behavior and of addiction expand and are redefined as illness (see Chapter 7). Today, nicotine addiction is an officially recognized psychotherapeutic disorder; tomorrow? New and future technologies open up a Pandora's box in terms of who is covered: genetic testing, genetic therapy. Decisions on what procedures and which individuals will be covered by insurance could add hundreds of billions to our annual health care bill.


Notes
1.
Mark V. Pauly, "Taxation, Health Insurance, and Market Failure in the Medical Economy," Journal of Economic Literature 24 ( June 1986): 629-75.
2.
Elinor Langer, "AMA: Some Doctors Are in Revolt, but Revolution Is Not in Sight," Science 157 ( July 21, 1967): 285-88.
3.
Sally Burner, Daniel Waldo, and David McKusick, "National Health Care Expenditures Projections through 2020," Health Care Financing Review 14, no. 1 (Fall 1992): 1-29; see esp. 26-27.
4.
Richard Rosett and Lien-fu Huang, "The Effect of Health Insurance on the Demand for Medical Care," Journal of Political Economy 81 ( March/April 1973): 281-305.
5.
Martin Feldstein, "Hospital Cost Inflation: A Study of Nonprofit Price Dynamics," American Economic Review 61 ( December 1971): 853-72.

-49-

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Healthy, Wealthy, or Wise? Issues in American Health Care Policy
Table of contents

Table of contents

  • Title Page iii
  • Contents v
  • Preface vii
  • Notes viii
  • 1 - Determinants of Health 1
  • Notes 6
  • 2 - Why Are Costs Out of Control? 7
  • Notes 27
  • 3 - Must Living Standards Decline? 28
  • Notes 38
  • 4 - Health Insurance Raises Demand and Supply 40
  • Notes 49
  • 5 - The Excess of Physicians and Services 51
  • Notes 77
  • 6 - The Medicalization of Health 82
  • Notes 97
  • 7 - Mental Illness 99
  • Notes 119
  • 8 - The Excessive Demand for Medical Care 123
  • Notes 136
  • 9 - Research and Technology 138
  • Notes 161
  • 10 - The Physician as Agent 164
  • Notes 179
  • 11 - Prevention: Environmental and Behavioral Modification 181
  • Notes 210
  • 12 - The Demedicalization of Health Care 213
  • Notes 222
  • 13 - What to Do? 223
  • Notes 250
  • Index 253
  • About the Author 263
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