IDEOLOGY: THE SILENT PARTNER
5. CONCLUSION
solutions be determined by federal regulations or should such decisions be left to the free-market forces?
In general, an elaborate set of regulations is often perceived by business as unwelcome interference from the government. Federal regulations are viewed by some in the managed care industry as having too much of a limiting effect on resourcefulness in managing the medical loss ratio, thus making health care more expensive and concomitantly less affordable. At the same time, management that is less than optimal will have a negative effect on the organization’s financial performance. In other words, the organization will not be able to fully meet all of its fiduciary obligations. As a result, the company will be less profitable, and its earnings potential will be less attractive to investors. But the opposite holds true too.
Maintaining a tighter rein on medical expenses will enhance profitability, and having fewer restrictions on the management of the medical loss ratio will equate to more opportunities for creative problem solving.
Accepting the industry’s argument against substantial federal regulation at face value leads to some challenging implications. First, it implies an acceptance of the validity of the assumption that a higher level of regulation will indeed increase costs.
Second, it suggests that the managed care industry has substantive, generally agreed- upon rules in place to limit access to medical services in a fair and morally appropriate manner. Third, it puts forth the idea that employers rightfully consider the cost of health benefits as a deadweight loss, assuming that good health has little or no correlation with employee productivity. Fourth, it ignores the fact that, at the level of a national economy, increased health care spending also generates potentially advantageous effects. For example, it could create jobs, provide opportunities for the development of new technologies, reduce lost workdays, and improve employee productivity.
Affordability is but one example of a symbolic form in the discussion about health care that, next to its commonsense meaning and relevance, also carries an ideological load. It has become a supporting argument in the debate about whether to limit the regulations governing the managed care industry. However, without conclusive evidence for the position that more regulations would increase the cost of health care or that increased costs would not adequately offset expected benefits, affordability plays a primarily ideological role in that it assists the managed care industry in sustaining its asymmetric position of power.
Labeling health care as a deadweight expense is a matter of choice, a normative positioning with the potential to produce strong ideological symbols. However, failing to recognize the ideological contextual nuances in discussions about health care can limit the search for morally adequate alternative delivery systems.
IDEOLOGY: THE SILENT PARTNER 79 precipitated by, and then accompanied by, contextual changes that have resulted in ideologically important effects on the status of patients, medical professionals, and the business of health care. A proper understanding of all the idiosyncratic ideological components in the debates about health care rationing is quite relevant to a critical analysis of the restructuring process that has taken place during the past two to three decades.
By the same token, the role of ideology is not likely to diminish in future debates about health care. In fact, if the process of identifying “the good” with sufficient moral authority demands that moral agents engage in discourse, then the significance and potential impact of ideology are likely to increase. In other words, if morality and the establishment of moral authority have anything to do with reasoning, which implies the use of symbolic forms, it would be a mistake to ignore the power of ideology.
79
Table 1. Medicare Enrollees and Expenditures by Type of Service (1970-2002)
*
Type of service 1970 1980 1990 1995 1998 1999 2000 2001 2002
†
Enrollees, no. in millions Total
‡
20.4 28.4 34.3 37.6 38.9 39.2 39.7 40.1 40.5 Hospital insurance 20.1 28.0 33.7 37.2 38.5 38.8 39.3 39.7 40.1 Supplementary medical insurance 19.5 27.3 32.6 35.6 36.8 37.0 37.3 37.7 38.0 Expenditures, amount in billions Total $7.5 $36.8 $111.0 $184.2 $213.4 $213.0 $221.8 $244.8 $265.7 Total hospital insurance (HI) 5.3 25.6 67.0 117.6 135.8 130.6 131.1 143.4 152.5 HI payments to managed care organizations
§
… 0.0 2.7 6.7 19.0 20.9 21.4 20.8 19.2 HI payments for fee-for- service utilization
5.3 25.6 64.3 110.9 116.8 109.8 109.7 122.6 133.3 Total supplementary medical 2.2 11.2 44.0 66.6 77.6 82.3 90.7 101.4 113.2
insurance (SMI) SMI payments to organizations
§
0.0 0.2 2.8 6.6 15.3 17.7 18.4 17.6 17.5 SMI payments for fee- ║2.2 11.0 41.2 60.0 62.3 64.6 72.3 83.8 95.7
* Data compiled by the Centers for Medicare and Medicaid Services. † Preliminary figures. ‡ Average number enrolled in hospital insurance or supplementary medical insurance. § Managed care organizations approved by Medicare. ║Reporting categories for fee-for-service reimbursements by type of service differ before and after 1991. Modified from National Center for Health Statistics 2004.
IDEOLOGY: THE SILENT PARTNER 81
managed care for-service utilization
Table 2. Medicare Recipients by Basis of Eligibility (1970-2001)
*
Basis of eligibility 1972 1980 1990 1995 1997 1998
† 1999
‡ 2000
2001 All recipients, no. in millions Basis of eligibility
§
17.6 21.6 25.3 36.3 34.9 40.6 40.1 42.8 46.0 Age, 65 years or older 18.8 15.9 12.7 11.4 11.3 9.8 9.4 8.7 8.3 Blind and disabled 9.8 13.5 14.7 16.1 17.6 16.3 16.7 16.1 15.4 Adults in families with dependent children║17.8 22.6 23.8 21.0 19.5 19.5 18.7 20.5 21.1 Children under age 21
¶
44.5 43.2 44.4 47.3 45.3 46.7 46.9 46.1 45.7 Other Title XIX
#
9.0 6.9 3.9 1.7 6.3 7.8 8.4 8.6 9.5
* Data compiled by the Centers for Medicare and Medicaid Services. † Prior to 1999, recipient counts exclude persons who received coverage only under prepaid health care and for whom no direct ven
dor payments were made.
‡ The Medicaid data system was changed in 1999. § In 1980 and 1985, recipients are included in more than one category. In 1990–96, recipients with an unknown basis of eligibilit
y totaled 0.2–2.5 percent. From 1997 onward, unknowns are included in Other Title XIX.
Table 2 (continued) ║ for Needy Families (TANF) program. From 2001 onward includes women in the Breast and Cervical Cancer Prevention and Treatment Program.
¶ Includes
children in the Aid to Families with Dependent Childrenin the AFDCprogram. From 1997 onward includes children and foster care children in the TANF program. # onward excludes foster care children and includes unknown eligibility. Modified from National Center for Health Statistics 2004.
IDEOLOGY: THE SILENT PARTNER 83
Includes some participants in the Supplemental Security Income program and other medically needy people in participating states. From 1997
stance
Includes adults in the Aid to Families with Dependent Children (AFDC) program. From 1997 onward includes adults in the Temporary Assi-