History and Health Policy in the United States: Putting the Past Back In

Rosemary Stevens, Charles Rosenberg, and Lawton Burns have edited a series of essays by 17 scholars that provides a historical context for understanding today's health care system. The overarching theme is that our policy challenges are not new, and a historical understanding informs how we perceive and address the critical issues we currently face. Although this book was published in 2006, its central message is informative in thinking about the current debates concerning the future of the Patient Provider and Affordable Care Act and how to reform our health care system. Furthermore, several themes are especially pertinent in thinking about the mental health care system as we move forward with health care reform efforts.

In the introductory chapter, Rosemary Stevens highlights an important message that emerges from several essays when she writes, “The politics of deflection have become policies of convenience” (p. 3). In other words, the current state of our health care system is shaped by political inaction as well as the enactment of specific policies. The essay by David Mechanic and Gerald Grob illustrates how this particular issue applies to the mental health care system through the story of deinstitutionalization. During this process, individuals with severe and persistent mental illness were discharged from institutions to an inadequate community-based system that did not have sufficient resources to care for their complex needs. As a result, there was an increase in homelessness, substance abuse/dependence, and “criminalization” of the mentally ill. These problems persist today as a result of political inaction in developing comprehensive systems of care for this population.

Another theme that emerges from several essays is the tension between the expanding role of government in our health care system and the political ideology that says its role should be limited. An essay by Lawrence Brown discusses three reasons for this expansion: 1) the role of technological innovation and the bipartisan support for the expansion of the National Institutes of Health (NIH); 2) the importance of interest groups in protecting and advocating for incremental expansions of existing health care programs; and 3) the role of government in addressing market failures in our health care system, including the passage of Medicaid and Medicare in 1965 to fill “the gaps of an otherwise robust private system” (p. 45). In 2009, prior to the passage of the Patient Provider and Affordable Care Act, Medicare and Medicaid provided health insurance for 30% of the population (1), and the government financed 44% of national health spending (2). When considering mental health services, these numbers were even higher because of the government's prominent role in providing health insurance to those with severe and persistent mental illness through Medicaid and Medicare. The enactment of the Patient Provider and Affordable Care Act on March 23, 2010, increased this role by expanding eligibility criteria for Medicaid and providing government subsidies for the poor to purchase private health insurance.

Today, the debate concerning the role of government in our health care system is as contentious as ever because of the mounting federal deficit and political climate. In the time since this law has been enacted, Republicans regained control of the House of Representatives, and the House voted to repeal the Patient Provider and Affordable Care Act. House Republicans have advocated for policies that would make fundamental changes to Medicare and Medicaid and greatly reduce federal government expenditures in these programs. These changes would have enormous implications for the mental health care system given the fundamental role of these programs in financing mental health services. Yet, as we debate the future of our health care system in an austere fiscal climate, an essay by Robert Cook-Deegan and Michael McGeary examining the history and politics of the NIH highlights how we currently have a weak evidentiary base to guide the implementation of efficient and effective cost-containment mechanisms. Although NIH has been a successful engine of scientific innovation, it has historically placed much less emphasis on public health research and the evaluation of health services that could help guide these decisions.

As we move forward, it will be especially important to ensure that those with severe and persistent mental illness do not continue to fall victim to the “politics of deflection” and that any reforms to our health care system explicitly account for this population. Furthermore, we should also advocate for greater investment in public health and health services research to better inform how to improve the efficiency of our current system and mitigate the need for draconian cuts that could erode health care access and quality for our most vulnerable populations.