American Journal of Law & Medicine

The Politics of Medicare.(Review)

For at least seven decades the issue of financing health care has been debated in this country. While the intensity of the battle has varied greatly, the underlying drive for reform has been well identified and remarkably consistent. Theodore Marmor's The Politics of Medicare(1) is an exceptional book which documents this period.

In its most general description the era has experienced persistent and growing support for financing reform that would have, at least, characteristics of universality, comprehensive coverage and delivery by a system capable of serving many diverse constituencies. Nothing in these attributes is novel, and each can be identified as present, to varying degrees, in health care financing systems operating throughout the industrial world. Broad goals always attract advocates of every stripe, but the scene changes rapidly when the process of definition commences. Even the most obvious component, universality, precipitates a conflict when the details of exactly who will be included in the covered population start to be hammered out. Endless examples of intense controversy exist over access to federal, state and local programs by the many different categories of individuals who live within this country.

The challenge of defining universality palls by comparison with the need not only to define what benefits will be included within the concept of "comprehensiveness" but, more importantly, who or what institutions will be paid to provide them. Hospitals and physicians are an easy "who or what" call, but they constitute only the most obvious of a determined and well organized array of other health care professionals, institutions, device manufacturers, drug companies, durable equipment providers and home care providers, to name just a few. …

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