Fact: As a nation, medical care expenditures represent 10.6% of the gross national product. The portion of the nation's medical care dollar coming from federal sources declined slightly (42.6% to 41.4%) between 1981 and 1984, but this share is more than 15 percentage points above the comparable figure from the years prior to 1965 (Anderson, 1985).

As these numbers illustrate, paying for health care is a very expensive proposition in the United States, consuming a higher proportion of our nation's resources than is true for most developed nations. While we have strongly resisted any move to a government-run system of health care delivery, the above numbers also show clearly that the federal government pays for a substantial share of all health care in this country.

Three major themes have dominated the health policy agenda during recent years: access to health care, cost containment, and quality of care. The fates of these issues have waxed and waned over the years as changes in health care delivery, federal budgetary politics, and shifting public opinion have altered the environment over time. In the 1960s, access was the key issue, as Democratic administrations used government programs to make health care more readily available to all Americans. As inflation levels soared in the 1970s, cost containment was forced onto the agenda, resulting in a series of attempts to reduce federal expenditures on hospital care. Finally, by the mid-1980s, cost containment pressures were modifying slightly; we have recently witnessed a return to access issues and the emergence of quality as a new political issue.

In 1965, when Medicare and Medicaid were enacted, concern about access to the health care system for the elderly and poor overrode concerns about cost. The legislation focused on removing financial barriers to health care for these groups, and implementation of the legislation was a matter of reaching agreements with hospitals and physicians over reimbursement and administrative procedures with the objective of insuring that health care resources would be available to the beneficiaries of these new federal health insurance programs (Wolkstein, 1984).

Ideological conflict and the alignment of interest groups are central to understanding the politics of Medicare. The intense disagreement over public versus private financing of medical care, and of universal coverage versus covering only the needy (i.e., social insurance versus charity), were key points of contention that established the context within which Medicare and Medicaid were developed, debated and enacted. Labor unions led the liberal organizations and those representing the elderly in advocating a universal, non-income tested federal health insurance system. The American Medical Association (AMA) led the health industry, business and conservative groups in opposing federal financing of personal health care. The intense opposition of the health providers and political conservatives to a universal federal insurance system led the national health insurance advocates to shift to an incremental strategy, the objective of which was to achieve a universal federal health insurance program in stages, beginning with a payroll-tax-financed Medicare program covering all (not just low income) elderly who were eligible for social security pension benefits.

As many political humorists remind us regularly, politics “inside the Beltway” is not always of interest or relevance to the rest of the world. Yet for political scientists interested in the ongoing evolution of America's health care system, what goes on inside the Beltway has great import. For any proposed reform, there are three basic steps: getting the issue on the political agenda, securing passage of pertinent legislation, and implementation (although we intend to narrow our discussion to the first two).

A common criticism of academic political science is the disparity between the textbook portrayal of policymaking and the reality of what happens in Washington. In this article, we use abbreviated case studies to inject a dose of “inside the Beltway” reality into the images of policymaking. Included in our discussion is an account of how one issue—catastrophic health insurance—reached the political agenda and then more general comments on how health legislation has been considered and passed in recent years, with particular emphasis on the use of the budget reconciliation process. While cursory, we think these reflections provide a thumbnail sketch of how Washington is attending to important issues of health policy.

“You could tell by their blank faces that most of them had no idea what the provisions really meant.” Using almost these identical words, two different congressional staff members described two separate groups: (a) the members of a congressional committee considering a Medicare reform provision at a committee mark-up and (b) the personal staff of these same members at a briefing on the provision prior to the mark-up. So what can we conclude about the level of information in Congress? Has the massive expansion of congressional information resources over the past two decades—including vast increases in the number of personal and committee staff and support agency personnel—been for naught?

During the past three years, I have been conducting a study of the approach taken by members and staff of Congress in learning about policy issues and the implications of that approach for congressional decisionmaking. In the fall of 1984, I selected several discrete health and transportation issues which seemed likely to receive significant attention over the entire two years of the 99th Congress. My strategy was to study, for each issue, a sample of congressional “enterprises”—each made up of a member of Congress and his or her staff—as they followed and became involved in the development of the issue. My interest was in communication about these issues both within each enterprise and among all the various enterprises. At this point, nearing the conclusion of the fieldwork, I have conducted over 300 interviews, including meeting with certain key staff members as often as six times in order to monitor their evolving understanding of the issues.

The high cost and inefficiency of the United States' health care system has been widely documented. These problems, augmented by increased government financing of the health cost spiral, have led policymakers to search frantically for programs and strategies which can interject a modicum of rationality back into the health care field. There has been general agreement among health care analysts about the need to control costs and even the principal causes of these rapid increases. However, there has been less agreement on appropriate and effective solutions. The following analysis will provide an overview of current problems and proposed solutions.

Nursing home care has been described as the most troubled and troublesome segment of the American health care system. Despite the annual expenditure of billions of dollars, extensive regulation, and the emergence of an increasingly sophisticated and concentrated industry, significant problems persist. Inadequate quality of care continues to be a serious and pervasive problem. Discrimination against patients whose care is paid for by Medicaid and Medicare, as well as against those with “heavy care” or extensive needs, is rampant. Costs have escalated at a phenomenal rate and continue to represent a substantial fiscal burden, causing one state Medicaid director to refer to nursing home payments as “the black hole of state budgets.”

These circumstances are neither new nor surprising. They are, in fact, the result of rather startling failures in the public sector that are rooted in the special nature of the politics of long-term care. This article discusses the history of public policy toward nursing homes and the politics of long-term care, emphasizing problems in assuring acceptable quality of care. It also addresses the possibilities for reform during the next two years, particularly in light of new patient advocate and nursing home reform coalitions that promise to change the face of long-term care politics.