Riddle: Why is political reform like a clear mountain lake? Answer: When we look into both we see ourselves.

The Means and Ends of Reforms

What should be the ends of presidential reform? Obviously, such a question assumes that something is wrong and can be remedied through reform, which I define here as an intentional act (or acts) of institutional engineering to restructure incentives in the political system. Naturally, any effort to engage in reform, therefore, raises numerous issues. What are the purposes of reform? What are the problems a reform proposal or package of proposals presumes to address and to remedy? What are the feasibilities for implementation? What are the consequences and implications of reform? Will its purported benefits be larger than the costs incurred? To what extent does thinking about reform help lead to or clarify a theory of the presidency and, more generally, a theory of government? To what extent, above all, when thinking about reform can we escape the time warp in which our present preferences or momentary dissatisfactions lie? A would-be reformer must struggle to disassociate short-term preferences and judgments about an incumbent from longer-term conceptions as to how institutions should operate. In this regard, a would-be reformer must think like a constitution-maker. Is this the system one would prefer under worst case conditions?

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.