Editorial Column

Health Care Reform and HealthServices Research: What Once was Oldis 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 improveour health care system and its financing, in order to better meet the needs ofthe entire population.1 Citing both high and growing health care costs andincreasing numbers of uninsured Americans as major reasons, Congresscharged this group to engage the public-at-large in an informed andinformative dialogue and to bring back recommendations to Congress toredress these concerns. The dialogue will encompass what health care benefitsand services should be provided and how they should be delivered; howhealth care coverage should be financed; and what trade-offs between benefitsand financing the American public is willing to make to ensure more equitableaccess to affordable, high quality health care coverage and services.

Far-reaching attempts to develop and enact legislation to improve healthcare coverage and system efficiency are certainly not new. For example, therewere nine national health plans under active consideration by the U.S.Congress in 1974 when the American Public Health Association’s MedicalCare Section held a symposium honoring Nathan Sinai for his scholarlycontributions to our understanding of health insurance. The journal MedicalCare published the prepared comments given at this symposium, all of whichreferred to the health care reforms being discussed at the time. One personremarked, ‘‘With the enactment of national health insurance perhaps onlymonths away, highlighting the career and influence of Dr. Sinai seemedappropriate’’ (Breslow 1974, p. 1038). Sinai himself declared ‘‘a nationalhealth plan is in the making.’’ He prophesized, ‘‘Before us now are Medicareand Medicaid, as sources of controversy, managerial criticism, anduninhibited spiraling of costs,’’ feeding concerns about the costs andmanagement of any new national health plan (Sinai 1974, p. 1044). In anaccompanying commentary, Sy Axelrod added: ‘‘Other important socialpolicy issues include population coverage——that is, whether we should rely onvoluntarism with subsidy or insist on universality; methods of financing andsources of funds; the inclusion of incentives to achieve efficient and effective

599

use of health care resources; and, of particular interest to public healthworkers, the benefits to be included’’ (Axelrod 1974, p. 1048).

Of course, many proposals to reform the U.S. health care systempreceded and followed those in 1974. In fact, one of Sinai’s earliestcontributions to the field occurred over 70 years ago when he was a consultantto the Committee on the Costs of Medical Care, which was established in 1927and funded by several foundations.2 The Committee spent 5 years conducting17 research projects; it produced 26 reports and a book, Medical Care for theAmerican People (1932), which summarized their research and made recom-mendations for system wide change. The book begins, ‘‘. . . today there is a vastamount of unnecessary sickness and many thousands of unnecessary deaths . . .yet medical science has made marvelous advances during the last 50 years. Thepeople are not getting the services which they need——first, because in manycases its cost is beyond their reach, and second, because in many parts of thecountry it is not available. The costs of medical care have been the subject ofmuch complaint’’ (Committee on the Costs of Medical Care 1932, p. v).

Medical science has continued to make great strides since this report waspublished. However, the problems that health services researchers focused on70 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 increaseefficiency without sacrificing equity. For example, in 1974, an articlepublished in the journal Inquiry asserted, ‘‘The rapid increase in hospital costsduring the 1969s and early 1970s can be attributed in part to the methods bywhich hospitals are paid’’ and outlined the potential benefits of switching to aprospective payment system (Dowling 1974). That same year, the MilbankMemorial Fund Quarterly and Health Services Research each published articles thatexamined the factors contributing to the increase in overall hospital costs aswell 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’sseminal book, Health Care: Can There Be Equity?, also noted that the ranking ofinternational mortality rates, ‘‘with the United States highest and Swedenlowest, 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 HealthCare that Works for All Americans Act——‘‘Despite increases in medical carespending that are greater than the rate of inflation, population growth, . . . therehas not been a commensurate improvement in our health status as a nation.’’Likewise, these same journals (and others) continue today to publish researchand commentary that raise concern about unnecessary sickness and deaths.3

600 HSR: Health Services Research 40:3 ( June 2005)

Evidence continues to find that many people are unable to get the services theyneed because of financial and other access limitations.4 And medical care costscontinued 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 ofhealth services researchers haven’t made very much progress in either ourunderstanding of these issues or in our ability to recommend appropriatepolicy. A more nuanced investigation reflects not only changes in theeconomic and political climate that led to changes in public and private healthcare policies, but also changes in the questions asked and methods used byhealth services researchers and in their contributions to the development ofobserved policy changes. The questions and goals may be the same, but theability to provide answers to policymakers has improved.

For example, in 1974, Health Services Research published the seminalarticle ‘‘A Framework for the Study of Access to Medical Care’’ whichdeveloped a theoretical framework that would enable the evaluation of theeffectiveness of policies aimed at improving or changing the access to medicalcare (Aday and Andersen 1974). That framework profoundly changed theway we thought about access and led to new programs and research efforts.

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

Several articles published in the current issue of HSR illustrate thecontinuing contributions of the field in understanding the complexity of healthcare delivery and finance. Sloan, Rattliff, and Hall (2005) and Lantz et al.(2005) provide current examples of how much progress the field has made inunderstanding nonfinancial aspects of access and the effect on health careutilization and patient satisfaction. Similarly, the health status instrument usedby 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 estimatedby Maciejewski et al. (2005) reflect years of refinement since the articles byBerry (1974) and Jeffers and Siebert (1974).

And yet, advances in research may not always translate into advances inpractice or policy. In making its recommendations for system-wide changes in1932, the Committee on the Costs of Medical Care listed six essentials of asatisfactory medical program, which include the ability to ‘‘safeguard the

Health Care Reform and Health Services Research 601

quality of medical service,’’ the provision of services ‘‘on financial terms whichthe people can and will meet, without undue hardship,’’ and ‘‘provisions forassisting and guiding patients in the selection of competent practitioners andsuitable facilities for medical care’’ (Committee on the Costs of Medical Care1932, p. 38). Yet, as noted 70 years later in the Health Care that Works for AllAmericans Act, we still do not have a health care system that includes theseessentials for all citizens. Hence, the two principal purposes of this Act are ‘‘(1)to provide for a nationwide public debate about improving the health caresystem to provide every American with the ability to obtain quality, affordablehealth care coverage and (2) to provide for a vote by Congress on therecommendations that result from the debate.’’ We sincerely hope that theoutcome of this effort can make significant strides in translating our advancesin clinical practice and health services research into a health care system thatactualizes these essentials for U.S. citizens.

Catherine McLaughlin

NOTES

1. See http://www.gao.gov/pl108-173citizenshcwg.pdf for the full text of the legisla-tion.

2. The Carnegie Corporation, the Josiah Macy, Jr. Foundation, the MilbankMemorial Fund, the New York Foundation, the Rockefeller Foundation, theJulius Rosenwald Fund, the Russell Sage Foundation, and the Twentieth CenturyFund.

3. For more discussion of this topic, see the Institute of Medicine’s To Err is Human,Crossing the Quality Chasm, and other reports as part of the Health Care Qualityproject.

4. See the Institute of Medicine’s report Insuring America’s Health and the 5 relatedreports in the Consequences of Uninsurance project.

REFERENCES

Aday, L., and R. Andersen. 1974. ‘‘A Framework for the Study of Access to MedicalCare.’’ Health Services Research 9 (3): 208–20.

Axelrod, S. J. 1974. ‘‘National Health Insurance: A Commentary on Nathan Sinai’sContributions.’’ Medical Care XII (12): 1048–50.

Berry, R. Jr. 1974. ‘‘Cost and Efficiency in the Production of Hospital Services.’’ TheMilbank Memorial Fund Quarterly 52 (3): 291–314.

602 HSR: Health Services Research 40:3 ( June 2005)

Breslow, D. 1974. ‘‘Communications: ‘‘National Health Plans——The Challenge ofManagement: A SymposiumTribute to Nathan Sinai Dr. PH.’’ Medical Care XII(12): 1038–42.

Committee on the Costs of Medical Care. 1932. Medical Care for the American People; TheFinal Report of the Committee on the Costs of Medical Care. Chicago, IL: TheUniversity of Chicago Press.

Dowling, W. 1974. ‘‘Prospective Reimbursement of Hospitals.’’ Inquiry XI (1): 163–80.Jeffers, J., and C. Siebert. 1974. ‘‘Measurement of Hospital Cost Variation: Case Mix,

Service Intensity, and Input Productivity Factors.’’ Health Service Research 9 (4):293–307.

Johnson, E., and D. Neuhauser. 1974. ‘‘Review of Health Care: Can There by Equity?Odin W. Anderson. New York Wiley, 1972.’’ Health Services Research 9 (3): 244–6.

Lantz, P. M., N. K. Janz, A. Fagerlin, K. Schwartz, L. Liu, I. Lakhani, B. Salem, and S. J.Katz. 2005. ‘‘Satisfaction with Surgery Outcomes and the Decision Process in aPopulation-Based Sample of Women with Breast Cancer.’’ Health ServicesResearch 40 (3): 745–768.

Liu, H., R. Hays, J. Adams, W. P. Chen, D. Tisnado, C. M. Mangione, C. L. Damberg,and K. L. Kahn. 2005. ‘‘Imputation of SF-12 Health Scores for Respondents withPartially Missing Data.’’ Health Services Research 40 (3): 905–922.

Maciejewski, M. L., C. F. Lie, A. Derleth, M. McDonnell, S. Anderson, and S. D. Fihn.2005. ‘‘The Performance of Administrative and Self-Reported Measures for RiskAdjustment of Veterans Affairs Expenditures.’’ Health Services Research 40 (3):887–904.

Sinai, N. 1974. ‘‘Communications: ‘‘National Health Plans——The Challenge ofManagement.’’ Medical Care XII (12): 1043–7.

Sloan, F. A., J. R. Rattliff, and M. A. Hall. 2005. ‘‘Impacts of Managed Care PatientProtection Laws on Health Services Utilization and Patient Satisfaction withCare.’’ Health Services Research 40 (3): 647–668.

Health Care Reform and Health Services Research 603

604