Solution Manual For American Public Policy An Introduction 11th Edition

Solution Manual for American Public Policy An
Introduction, 11th Edition
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Solution Manual for American Public Policy An Introduction, 11th Edition
CHAPTER 8
Health Care: Transformation or Continued
Crisis?
SUMMARY OVERVIEW
I. Health Care: Historic Change
Spring 2010 witnessed historic change in Washington. After nearly of
century of struggle, debate, false starts, and incremental change, major health care
reform legislation passed both houses of Congress and received President
Obama’s signature. What presidents Franklin Roosevelt, Harry Truman, Richard
Nixon, and Bill Clinton (and their respective congresses) failed to achieve,
President Obama and the Democratic House and Senate achieved – significant
movement toward universal health insurance coverage and the promise of
substantial change in the way health care is delivered and financed.
Yet the victory was by the narrowest of margins in an extraordinarily
rancorous political climate, following an ideological and political battle of epic
scale and complexity. That the passage of the Patient Protection and Affordable
Care Act (PPACA) was historic cannot be doubted.
II. Issue Background: The Changing Health Care System

The traditional American health care system combines public and private
institutions without central planning or coordination. At the highest level of the
health care profession—among physicians, dentists, psychiatrists, and
psychologists—solo, fee-for-service (FFS) practice was the rule until recent
decades.
Despite radical changes under way in American health care delivery, the same
fragmented and expensive care continues as a legacy of the system’s origins.
“Managed care” emerged as a force in American health care in the 1980s as a as a
method to hold down the increasing cost of health care. Through managed care
the federal government, employers, and private insurers attempt to hold down
costs by using selective contracting; that is, requiring patients to see only certain
providers, either through a health maintenance organization (HMO), a preferred
provider organization (PPO), or an independent practice association (IPA).
Incentives to control costs are built into HMOs.
III. Contemporary Policy: Medicare, Medicaid, and the Affordable Care Act
The federal government has long provided direct medical care to active
duty military personnel and veterans. Beginning with the establishment of the
National Institutes of Health (NIH) in 1937, the federal government has supported
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biomedical research. In the mid-1960s the volume and complexity of federal
health legislation increased dramatically, and expenditures exploded. Medicare
and Medicaid, the most important programs, were enacted in 1965 after years of
debate.
Congress designed Medicare as a supplement to Social Security for
elderly persons, who have more extensive medical needs and expenses than the
general population. Medicare aims to protect this population against the risks of
medical disaster.
Medicaid is a public assistance program funded out of general revenues.
Like TANF it is a federal-state program with benefits varying among the states.
Because of state variations in definitions of eligibility and difficulties in enrolling
eligible persons, the proportion of the poor actually enrolled varies by state.
IV. Policy Evaluation: Health Care at the Crossroads
When policy analysts evaluate health care policy in terms of its intended
goals, a mixed picture emerges. Federal programs have helped to train thousands
of health care providers and to fund path-breaking research. Quality of care is
good, but not as good as it should be.
V. Continuing Debates: Reshaping a Complex System?

In late March 2010, President Obama signed historic legislation that
will create major changes in response to the problems outlined above.
CHAPTER OUTLINE
I. Issue Background: The Changing Health Care System

1. The Structure of American Health Care
2. Quality: How Healthy Is America?
3. Inequities in Access to Health Care
a) The Uninsured
b) Disparities
4. High Cost
a) Third party payments
b) Technology
c) Prescription Drugs
d) Labor Costs
e) Age
f) Public Expectations
g) Other
5. Other Nations
II. Contemporary Policy: Medicare, Medicaid, and the Affordable Care Act
1. Medicare
a) Medicare Modernization Act of 2003
b) Medicare Costs
2. Medicaid
3. Patient Protection and Affordable Care Act
a) ACA and Access to Insurance
b) Access Expansion
c) Medicaid
d) Spending Reductions
e) Delivery System Reform and the Quality of Health Care
4. Other Federal Programs
III. Policy Evaluation: Health Care at the Crossroads

1. Patient Protection and Affordable Care Act
a) Politics and Public Opinion
b) Legal Challenges
c) Early Implementation
d) Promoting Prevention
e) Implementation of Health Insurance Marketplaces and Medicaid
f) Employment-based Insurance
2. Medicare and Medicaid
a) Successes
b) Problems
3. Ideology and the Health Care System
IV. Continuing Debates: Reshaping a Complex System

1. Medicare
a) Modest Changes in Medicare’s Current Structure
b) Fundamental Structural Changes
2. Medicaid and the States
3. Debating the Future of the ACA
a) Modifying the ACA
b) Conservative Alternatives to ACA
c) Progressive Alternative: Single-Payer
4. Controlling the Cost of Health Care
a) Administrative Costs
b) Prices and Labor Costs
c) Technology
5. Cost Control Measures
6. Beginning and End of Life
7. Reform and Long-Term Care
V. Summary
CRITICAL THINKING QUESTIONS
• Which state provides healthcare to the majority of its citizens? How does it
deliver and pay for the healthcare provided?
• Is there a “right to health care?” What ethical principles and what arguments
might you offer for or against such a right?
• The Affordable Care Act was designed based on Massachusetts healthcare

program. What are the similarities and the differences between the two
programs?
• Compare the United States health care system to that of one other OECD nation.
What are the strengths and weaknesses of that nation’s system? What could the
United States learn from that country?
• How should the United States long-term care system cope with the coming
retirement of the “baby boom” generation?
LECTURE LAUNCHERS
• Discuss the history of health care reform and why certain presidents were
more successful than others.
• Discuss why there continues to be disparity in health care due to socio-

economic factors.
• Discuss why there is political and social resistance to instituting

comprehensive healthcare in the United States.
IN-CLASS ACTIVITIES
• Break students up into groups and have them look up and compare the health
care statistics between “red” states and “blue” states.
• Have students participate in a debate on the pros and cons of Medicare

expansion under the Affordable Care Act.
• Break students up into groups, assign them a country and have them look up
health indicators, i.e., infant mortality rates, average life expectancy, etc.
Discuss whether the indicators are impacted by the level of health care
provided.
WEB LINKS
Centers for Medicare and Medicaid Services (CMS)
www.cms.gov
Hastings Center
www.thehastingscenter.org
Health Affairs
www.healthaffairs.org
Health Insurance Marketplace

www.healthcare.gov
Henry J. Kaiser Family Foundation

healthreform.kff.org
Modern Healthcare
www.modernhealthcare.com
U.S. Department of Health & Human Services

www.hhs.gov/healthcare/
TEST QUESTIONS
Multiple Choice
1. The healthcare “iron triangle” is composed of

A. patients, doctors and lawmakers
B. patients, clinicians and public health & government policymakers
C. patients, insurance companies and lawmakers
D. doctors, public health & government policymakers and insurance companies
ANS: B REF: 231
2. Which group is more likely to suffer illness and struggle to get access to health
care?
A. the homeless
B. the aged
C. the poor and aged
D. the poor
E. none of the above
ANS: C REF: 232
3. Under the fee-for-service model, medical care is fragmented, difficult to

coordinate for multiple medical conditions and expensive.
A. True
B. False
ANS: A REF: 232
4. Managed care emerged as a force in American health care in the 1980’s as

A. a means of centralized health care coordination
B. a method to have health care geographically distributed so as to be more
accessible
C. a means of insuring everyone
D. a method to hold down the increasing costs of health care
ANS: D REF: 232
5. Coordinated care systems are driven by

A. control of spending & improved quality
B. political demands
C. consolidation & integration
D. none of the above
E. A & C only
ANS: E REF: 232
6. IPA, PPO, and HMO are acronyms for

A. federal government health care agencies
B. federal health care programs
C. state health care bureaucracies
D. various types of managed care providers
ANS: D REF: 232
7. There are several reasons physicians are seeking employment by hospital and other
organizations except for
A. Working conditions
B. Income
C. Research capabilities
D. Quality of life
ANS: C REF: 233
8. _________, _______ & __________ has resulted in a disjointed and wasteful

delivery of medical care.
A. Advances in medicine, reduced admissions & length of stay
B. Hospital closings, mission redirection and competing incentives
C. Competing incentives, specialty hospitals & minor care clinics
D. Outpatient surgery, freestanding surgical units & minor care clinics
ANS: D REF: 233
9. A radical perspective on health care states that health care

A. is part of a corporate capitalist structure
B. is not monopolistic
C. doesn't go where the money is, but where the need is
D. is elastically structured
ANS: A REF: 233
10. The United States has made great gains in healthcare, surpassing Sweden, Japan,
England and Canada in life expectancy and infant mortality rates.
A. True
B. False
ANS: B REF: 234
11. Expensive curative care receives more attention in the American health care system
than
A. Primary care
B. Health education
C. Disease prevention
D. All of the above
E. None of the above
ANS: D REF: 234
12. Even though American medical technology is the most advanced in the world, the
United States still ranks behind ______________ in infant mortality.
A. Netherlands
B. Canada
C. Australia
D. United Kingdom
ANS: B REF: 234
13. United States health care problems do NOT include _________________.

A. quality
B. access
C. technology
D. cost
ANS: C REF: 234
14. The 1999 Institute of Medicine estimated that 100,000 hospital deaths occurred due to
_____________.
A. lack of testing equipment
B. paperwork errors
C. medical errors
D. patients being too sick to cure
ANS: C REF: 234
15. According to 2002 data, which of the countries below had highest health expenditures
as percentage of GDP?
A. USA
B. Germany
C. Sweden
D. France
ANS: A REF: 235
16. The largest share of American health care spending is paid by

A. the patient directly
B. private health insurance plans
C. government
D. none of the above
ANS: C REF: 235
17. Overspecialization by physicians is cited as one of the causes of

A. high cost of medical care
B. poor coordination of care
C. better performance on measures of health statistics
D. all of the above
E. A & B only
ANS: E REF: 236
18. Un-insurance is a dynamic process, but several groups are more likely to be uninsured
than the general population. These groups include all but
A. Persons living in the south and West
B. Those over sixty-five
C. Young adults
D. Low-income working adults
ANS: B REF: 236
19. The percentage of the population having health insurance coverage has
______________ since 1980.
A. remained the same
B. increased
C. doubled
D. declined
ANS: D REF: 236
20. Job lock is defined as

A. Being contractually bound to a job
B. Unable to change jobs due to the poor employment marketplace
C. Forced to remain in a job because of financial obligations
D. Forced to stay in a job because of the fear of not getting health care with new
employment
ANS: D REF: 237
21. Access to medical care, specialized institutions and personnel is proportionally

located in both urban and rural areas.
A. True
B. False
ANS: B REF: 237
22. Among the consequences of a high rate of uninsured Americans are which of the
following?
A. worse health outcomes
B. financial burdens on families
C. "job lock"
D. all of the above
ANS: D REF: 237
23. The areas and person with the greatest needs for health care are not the areas and
persons with the greatest access to care which means that medical care is
maldistributed.
A. True
B. False
ANS: A REF: 237
24. Poor children tend to suffer more form chronic and acute conditions, not
including
A. Upper respiratory ailments
B. Elevated blood lead levels
C. Vision problems
D. Low hemoglobin
E. All of the above
ANS: E REF: 238
25. A major problem in the American health care system is

A. too few doctors in suburban areas
B. too few doctors nation-wide
C. the financial burden of health care on many families
D. all of the above
ANS: C REF: 238
26. United States health care disparities means that

A. those in poor or rural communities have poor health and shorter life expectancy
B. African American infants mortality rates are neatly twice those of whites
C. One-third of Hispanics are uninsured
D. Ten percent of Hispanics rely on their primary care from emergency rooms
E. All of the above
ANS: E REF: 238
27. The largest share of American health care spending is paid by _______.
A. the patient directly
B. private health insurance plans
C. government
D. charitable foundations
ANS: C REF: 239
28. Which of these countries does NOT have mandated universal health insurance
coverage through employers or private policies?
A. France
B. Italy
C. Canada
D. Great Britain
ANS: D REF: 240
29. Which country actually provides Socialized Medicine for its citizens?
A. Germany
B. Canada
C. France
D. England
ANS: D REF: 240
30. Which of the following health care issue has broader coverage in other nations than
the United States?
A. dental service
B. nursery homecare
C. eye glasses
D. cosmetic surgery
ANS: D REF: 240
31. Americans when compared to other countries have higher rates of

A. Suicide
B. Smoking
C. Teen pregnancy
D. Health care satisfaction
ANS: C REF: 241
32. Medicare shifted responsibility for the health needs of elderly and disabled persons
from their family and charitable organizations to the federal government.
A. True
B. False
ANS: A REF: 242
33. Medicare is a program that was designed as

A. a program for the poor specifically
B. social insurance for elderly recipients
C. a protection to the young population against the risks of medical disaster
D. an anti-poverty program
ANS: B REF: 242
34. ____________ is a voluntary insurance program for persons age sixty-five and older.
A. Social Security
B. Welfare
C. Coinsurance
D. Supplementary Medical Insurance
ANS: D REF: 242
35. Which of the following health care coverage were added to Medicare in the Medicare
Modernization Act of 2003?
A. Prescription drug coverage
B. Coverage for renal kidney failure
C. Hospice care
D. Home health care
ANS: A REF: 243
36. Which of the following is NOT covered by Medical Insurance (Part B)?
A. outpatient hospital services
B. physician services
C. dental services
D. some home health and other medical services
ANS: C REF: 243
37. Which of the following is not a prime cause for the growth in Medicare costs?
A. higher hospital costs
B. increased death rate
C. higher physician’s fees
D. higher drug prices
E. advances in technology
ANS: B REF: 243
38. Chronic conditions such as diabetes, hypertension and arthritis accounted for more of
Medicare growth than hospital based treatment of acute illness such as
______________.
A. stroke
B. cancer
C. heart attacks
D. renal failure
E. (b) and (d)
ANS: C REF: 243
39. Medicaid is
A. a program for the young specifically
B. a supplement to social security for all recipients
C. a protection to the aged population against the risks of medical disaster
D. a public assistance program funded out of general revenues
ANS: D REF: 245
40. Medicare spending in the last couple of years

A. continued to rise rapidly
B. declined
C. stayed exactly the same
D. Medicare was abolished in 2002
ANS: A REF: 245
41. The main problems of U.S. health care can be grouped into which of the three
following categories:
A. access, cost, and quality
B. time, cost, education
C. education, age, quality
D. access, education, time
ANS: A REF: 246
42. Health care policy reform succeeded in 2010 because

A. Republicans pushed too hard for a national health plan
B. the president spent time, energy and political capital
C. Democratic and Republican leaders pushed moderate compromises
D. public opinion favored the single-payer plan
ANS: B REF: 246
43. The Affordable Care Act was designed to respond to which financial pressure?
A. The rising cost of health care pressure on federal and state government budgets
B. Increased premiums and co-pays
C. Reduced levels of benefits
D. All of the above
E. None of the above
ANS: E REF: 247
44. Which of the following features of the Single-Payer system of health care
administration do its supporters argue will reduce health care costs?
A. Reduction of administrative costs, such as billing and office staff.
B. Abolition of private, for-profit health insurers.
C. Centralization of administration.
D. All of the above
ANS: D REF: 249
45. Which of the following is NOT an argument in favor of the moral imperative of
universal insurance coverage?
A. all citizens should have equal access to health care regardless of income.
B. National Health Insurance would drive up the cost of health care.
C. all citizens should have access to a basic minimum of health care.
D. The government should take responsibility for the health of all citizens.
ANS: B REF: 249
46. Health care reform will expand access to 32 million people by
A. requiring most citizens and legal residents to purchase insurance
B. mandates some employers to provide insurance
C. insurance market reform
D. all of the above
ANS: D REF: 251
47. The State Children's Health Insurance Program (SCHIP) was

A. created by the Balanced Budget Act of 1997
B. abolished by the Balanced Budget Act of 1997
C. created by the Texas Legislature in 1995
D. part of the original Medicaid program
ANS: A REF: 252
48. The federal government does not support biomedical research.

A. True
B. False
ANS: B REF: 256
49. Which of the following is true?

A. Medicaid physician reimbursement rates are too high
B. Medicaid cannot fund nursing home care.
C. Many physicians refuse to accept Medicaid patients because payment rates are
too low.
D. all of the above
ANS: C REF: 262
50. Many physicians and dentists don’t accept Medicaid patients because
A. the patients can’t afford the co-pay
B. they must accept the Medicaid schedule as full payment
C. it takes too long to get reimbursed
D. they have to prescribe generic drugs
ANS: B REF: 262
51. Which of the following are the greatest determinants of premature death?
A. economic status
B. environmental conditions
C. behavioral
D. all of the above
E. (A) and (B) only
ANS: D REF: 266
52. The ___________ amendment bans federal Medicaid funding for most abortions.
A. Strong
B. Frist
C. Hyde
D. Howe
E. Johnson
ANS: C REF: 266
53. In 2001, the House of Representatives voted to ____________ human cloning.

A. encourage
B. permit
C. regulate
D. forbid
ANS: D REF: 266
54. Which of the following is NOT true of patients who use emergency room care as a
substitute for health insurance?
A. cost the same as basic care
B. patients remain ill longer
C. care received is often too little too late
D. patients have more disability
ANS: A REF: 271
55. Labor and technology is a primary contributor to the high cost of medicine.
A. true
B. false
ANS: A REF: 274
56. Service intensity may be the most important cause of higher health care costs because
A. new drugs can treat conditions formerly requiring surgery
B. the system of payment procedures is an incentive
C. doctor can perform more non-invasive procedures
D. B and C
E. all of the above
ANS: D REF: 275
57. The increasing number of persons 65 and over in the population has ___________
utilization of health care facilities.
A. increased
B. decreased
C. not affected
D. ceased
ANS: A REF: 275
58. Which is NOT a technique used by managed care to keep costs down?
A. utilization review which includes second opinion before surgery or
hospitalization
B. disease management programs
C. use of a gatekeeper or primary care physician who approves when patient can
see specialists
D. computerized patient files
ANS: D REF: 276
59. Which of the following are important bioethical issues?

A. regulating managed care
B. Funding AIDS research
C. Rationing new health care technologies
D. (a) and (c) only
E. (b) and (c) only
ANS: E REF: 277
Solution Manual for American Public Policy An Introduction, 11th Edition
60. The Supreme Court ruled that terminally ill people have no constitutional right to die
and, therefore, no right to physician-assisted suicide.
A. true
B. false
ANS: A REF: 282
Essay Questions
• Summarize the conservative and liberal/progressive analyses of the causes of

uninsurance. What are the strengths and the weaknesses of each analysis?
• Compare and contrast the politics of Medicare from the politics of Medicaid.
What accounts for the similarities and the differences?
• Compare and contrast the rollout of Medicare with the rollout of the Affordable
Care Act.
• Describe how a single payer healthcare system would work in the United States.
• Explain why rural areas have poor healthcare services than urban areas and what
solutions could help fix the problem
• What are some of the reasons that many working people do not have health
insurance? Will President Obama’s health care policy help them?
• How are other countries able to provide universal health care? Are their methods
transferable to the United States?
• Compare how the elderly fared in the United States prior to the passage of the
Medicare and Medicaid? Although they are expensive entitlement programs, are
they worth the cost?
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Introduction, 11th Edition

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II. Issue Background: The Changing Health Care System

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IV. Policy Evaluation: Health Care at the Crossroads

V. Continuing Debates: Reshaping a Complex System?

I. Issue Background: The Changing Health Care System

III. Policy Evaluation: Health Care at the Crossroads

IV. Continuing Debates: Reshaping a Complex System

CRITICAL THINKING QUESTIONS

• The Affordable Care Act was designed based on Massachusetts healthcare

• Discuss why there continues to be disparity in health care due to socio-

• Discuss why there is political and social resistance to instituting

• Have students participate in a debate on the pros and cons of Medicare

Health Insurance Marketplace

Henry J. Kaiser Family Foundation

U.S. Department of Health & Human Services

1. The healthcare “iron triangle” is composed of

ANS: B REF: 231

ANS: C REF: 232

3. Under the fee-for-service model, medical care is fragmented, difficult to

ANS: A REF: 232

4. Managed care emerged as a force in American health care in the 1980’s as

ANS: D REF: 232

5. Coordinated care systems are driven by

ANS: E REF: 232

6. IPA, PPO, and HMO are acronyms for

ANS: D REF: 232

ANS: C REF: 233

8. _________, _______ & __________ has resulted in a disjointed and wasteful

ANS: D REF: 233

9. A radical perspective on health care states that health care

ANS: A REF: 233

ANS: B REF: 234

ANS: D REF: 234

ANS: B REF: 234

13. United States health care problems do NOT include _________________.

ANS: C REF: 234

ANS: C REF: 234

ANS: A REF: 235

16. The largest share of American health care spending is paid by

ANS: C REF: 235

17. Overspecialization by physicians is cited as one of the causes of

ANS: E REF: 236

ANS: B REF: 236

ANS: D REF: 236

20. Job lock is defined as

ANS: D REF: 237

21. Access to medical care, specialized institutions and personnel is proportionally

ANS: B REF: 237

ANS: D REF: 237

ANS: A REF: 237

ANS: E REF: 238

25. A major problem in the American health care system is

ANS: C REF: 238

26. United States health care disparities means that

ANS: E REF: 238

ANS: C REF: 239

ANS: D REF: 240

ANS: D REF: 240

ANS: D REF: 240

31. Americans when compared to other countries have higher rates of

8. _____, _ & ________ has resulted in a disjointed and wasteful