Health care reform in the year 2000: the view from the front of the classroom.

I. INTRODUCTION: WHERE HAVE WE BEEN? My thoughts about the status of American health care as it enters the twenty-first century have less to do with any theory or model-or even my own politics-and more to do with my efforts as a teacher. For the past twenty-five years I have taught introductory health law courses in law and public health schools. While what I teach and how I do so have changed enormously during that time, my basic objective has changed very little: preparing my students for the political and legal issues that they will likely confront in their individual and professional lives. It is a task that I find endlessly challenging. I have to amass and continually update a tremendous amount of information concerning individual and institutional providers, various financing arrangements, state and federal programs, and all the other things that many Americans only partially understand or ignore altogether. But the real challenge is in delivering this information. It must be presented in some useful and retainable way. As in all other important things, the devils in American health care can only be found in the details; but the trick for a teacher ultimately, is figuring out which devilish details are important, which are not ands why, and how to pass all that along to tomorrow's decision makers-whether tomorrow is just tomorrow or whether it is the beginning of a new century. In the early years of my teaching career I was heavily influenced by my own mentors who insisted that American health care was fitfully, though inevitably, evolving towards some nationalized health care scheme and that I should organize my understanding of it accordingly. For example, I have always taught that the adoption of Medicare and Medicaid in the 1960s was one of the most significant changes in the structure of American health care during the twentieth century and I will continue to do so. Nonetheless, in the early years of my career I followed my own teachers' lead and emphasized what those programs left undone. Neither Medicaid nor Medicare resolved the problems of the working poor or of those for whom private insurance continued to be either unavailable or unaffordable.2 Moreover, while committing all that money to health care for the elderly and the poor, Congress and the states had not-yet, I frequently implied-done anything to control costs on those programs, nor had they interfered with the autonomy of private providers or the province of private third party payers. Again, steps yet to be taken, I taught. The health planning and other regulatory programs that followed in the 1970s fit nicely into that storyline. As health care costs continued to rise rapidly, government began to move again in that inevitable direction, first to control the costs of the publicly funded programs and then, hesitantly but increasingly, those of privately funded health care as well. Regional Medical Programs and Comprehensive Health Planning gave way to Health Systems Agencies and certificate-of-need requirements; there were even experiments with price controls and talk of empowering planners to decertify existing services.3 Each piece was oddly fashioned, but I thought the overall pattern was pretty clear, as was the future. There were times in the 1970s, when it appeared that we would take the next giant step, and at least I thought so, and I revised my teaching accordingly. As various national health insurance proposals moved on and off the political stage, I quickly reworked my class materials and built many of my classroom lessons around a comparison of the existing structural elements of American health care with what they might look like in the future under various nationalized schemes. I still have a faded chart in my notes contrasting Long-Ribicoff with Kennedy-Mills with the counteroffers forged by Nixon and Weinberger.4 In retrospect, I wish I had spent less time on the specifics of these proposals themselves-their details seeming all important at the time and now long forgotten-and presented the national health insurance debates of the 1970s more as I now see them: good illustrations of the conumbral nature of American health politics and the ambivalent values that underlie them. …