Passage Of Medicare Research Articles

The Origins, Development, and Passage of Medicare's Revolutionary Prospective Payment System

This article explains the origins, development, and passage of the single most influential postwar innovation in medical financing: Medicare's prospective payment system (PPS). Inexorably rising medical inflation and deep economic deterioration forced policymakers in the late 1970s to pursue radical reform of Medicare to keep the program from insolvency. Congress and the Reagan administration eventually turned to the one alternative reimbursement system that analysts and academics had studied more than any other and had even tested with apparent success in New Jersey: prospective payment with diagnosis-related groups (DRGs). Rather than simply reimbursing hospitals whatever costs they charged to treat Medicare patients, the new model paid hospitals a predetermined, set rate based on the patient's diagnosis. The most significant change in health policy since Medicare and Medicaid's passage in 1965 went virtually unnoticed by the general public. Nevertheless, the change was nothing short of revolutionary. For the first time, the federal government gained the upper hand in its financial relationship with the hospital industry. Medicare's new prospective payment system with DRGs triggered a shift in the balance of political and economic power between the providers of medical care (hospitals and physicians) and those who paid for it--power that providers had successfully accumulated for more than half a century.

Health Care and Public Opinion

Health Care and Public Opinion

Robert Ball and the Politics of Social Security (review)

Reviewed by: Robert Ball and the Politics of Social Security Rosemary A. Stevens Edward D. Berkowitz . Robert Ball and the Politics of Social Security. Madison: University of Wisconsin Press, 2003. xx + 455 pp. Ill. $45.00 (0-299-18950-3). Robert Ball, a smart, idealistic English major with a master's thesis in applied economics, entered government service in 1939, four years after the Social Security legislation; by the late 1940s, he was influential in the growing ranks of social security experts. Able, canny, politically attuned, inspiring, and urbane, Ball was the chief administrator of the U.S. Social Security program from 1953 through 1972, years that included the Medicare legislation. Ball continued to influence social security policy as a Washington-based consultant, organizer, national committee member, and political broker. In one of the last activities described in this book, Ball tapes a commercial for presidential candidate Al Gore, backing his views on social security and criticizing those of George W. Bush. Congressman Wilbur Mills, who orchestrated the initial design and passage of Medicare, described Ball as a "near-genius" (p. 217). Equally, one could see him as a brilliant politician in his own right. Edward Berkowitz portrays him as the consummate bureaucrat: an unobtrusive problem-solver, marshaling critical facts to sway debate, wringing consensus across conflicting groups, and making Medicare work. His general approach was "relentlessly reasonable" (p. 363). The Social Security program was, of course, much more than Medicare. Cash payments were initially designed as an extension of labor benefits, with payroll taxes imposed in 1937 and the first pensions scheduled for 1942. Much of the debate about Social Security, and thus most of the action of this book, is about cash benefits and eligibility policies. In 1948, for example, discussions at the Advisory Council on Social Security included, among many other topics, the extension of coverage beyond industrial and commercial workers, for whom the act was designed, to workers in nonprofit institutions, including hospitals. Health insurance was off the agenda. Robert Ball was staff director, and wrote much of the report that led, in turn, to major expansions in the program through passage of the Social Security Amendments of 1950. Medicare was the major task of the Social Security Administration between 1961 and 1967. As with other aspects of Social Security, Ball worked with Congress, individually and at hearings, and negotiated with stakeholders, including Blue Cross and the American Hospital Association, about the form the proposals would take. Important decisions about Medicare were made during regulation writing and implementation. Part A, the hospital part of Medicare, was compulsory, but Part B (medical services) was voluntary. The bureaucrats launched a major promotional campaign to sell Part B, achieving a 90 percent acceptance rate among Medicare beneficiaries by May 1966; launched civil rights policies; and negotiated contracts with private insurance carriers. The machinery of bureaucracy was remarkably efficient (as well described here), a model of what a civil service can do. Berkowitz makes full use of Ball's extensive papers and of numerous interviews. Here is the thick context of legislative development in the United States. [End Page 160] This is a book about hundreds of people who know each other, shift jobs but remain in touch, develop expertise (and Social Security expertise is arcane), and work within and beyond the various bureaucracies in which they are placed. Ball's networks include invaluable contacts and allies in Congress, highly placed congressional staff, foundation executives, and at least one president. This is also a book about change. Berkowitz marks the early 1970s as the end of an era of liberal legislation on Social Security that began in 1950. In 1977 Medicare was shifted to a specialized health agency, weakening its bonds to Social Security. Technical expertise largely replaced the practical idealism of individuals such as Robert Ball. It is useful to be reminded that government can be effective, and that a brilliant bureaucrat can play a noble role. Rosemary A. Stevens University of Pennsylvania Copyright © 2005 The Johns Hopkins University Press

Medicare and rural kidney medicine

Medicare and rural kidney medicine

A Cultural and Economic History of Old Age in America

The lives of today's elderly population have deep historical precedents by which we can better understand current social policies, health care, and retirement. The history of old age in America is more complex and varied than most people realize. This history has been shaped largely by the search for economic security. In the agricultural economy of preindustrial America, few individuals saved sufficient resources for their declining years, and most elderly people either continued to work or lived in dependent poverty. More than any other factor, the lack of family members willing or able to provide for an elderly relative resulted in the relative moving to the dreaded poorhouse. Passage of Medicare and Medicaid legislation resulted in the rapid development of commercial nursing homes, accelerating the trend away from nonprofit and government facilities. However, serious deficiencies in care have continued to occur, prompting additional federal legislation. Knowledge of the history of aging in America can provide a useful touchstone: it can expose past problems that could happen again, identify what is worth preserving from the past, and help us avoid relearning painful lessons.

MSJAMA: A historical survey of national health movements and public opinion in the United States.

THE UNITED STATES IS THE ONLY INDUSTRIALIZED NATION THAT does not have national health insurance. It has, however, witnessed 5 attempts to achieve it. In the early 1900s, patients paid physicians directly for their services. Concerned that more than a quarter of the population could not afford basic care, the American Association for Labor Legislation (AALL) in 1915 proposed a national insurance system that would cover medical care, sick pay, maternity benefits, and funeral expenses for low-paid workers and their dependents. It would be financed by mandatory employer and employee contributions and additional state funds. Later expanded to cover large segments of the population, the AALL proposal was called a social insurance plan because it would cover only those who paid into it. Opposition from the American Medical Association (AMA), business, and labor, compounded by shifting attitudes and priorities as the United States entered World War I, defeated the proposal. The next movement toward national health insurance came in the 1940s, when senators Robert Wagner and James Murray and Rep John Dingell proposed a plan to expand Social Security, enacted in 1935, to cover physician and hospital care for workers and retirees. Employers and employees would pay into a federal trust fund that would in turn reimburse providers. The unemployed would rely on government assistance or charity care. At the time, 74% of the public favored national health insurance, and 68% liked the idea of Social Security coverage of medical fees. In 1945, President Truman embraced a similar proposal, making him the first president to support national health insurance. Public opinion on the Truman proposal was initially evenly split—38% for and 38% against—but its support by a wide range of legislators and organizations led analysts to predict that it would be passed. The AMA opposed the plan, however, and defeated it with a massive campaign. The first successful push toward national health insurance came in 1965 with the passage of Medicare and Medicaid under President Johnson. At that time, 85% of the elderly were uninsured, and political pressure to cover them was great. Medicare narrowed the Wagner-Murray-Dingle plan to cover only those over 65 with funding from Social Security payments, federal income taxes, and individual premiums. Although Medicare was initially opposed by the AMA, it was supported by 61% of the public. At the same time, Medicaid became the first public assistance program in the national health insurance movement. Public assistance programs are need-based and, unlike social insurance programs, do not require that recipients have paid into them. Medicare and Medicaid are not true national health insurance programs because, unlike similar programs covering the elderly and poor in other nations, they were never expanded to cover all Americans. The 1970s brought a wave of public debate and over a dozen health reform bills, most espousing national health insurance. Two competing proposals, each the first of its kind, stood out. In 1970, Sen Edward Kennedy and Rep Martha Griffiths proposed the first single, universal health insurance program to cover all Americans. The KennedyGriffiths Health Security Program would be funded by employer and employee contributions and federal income taxes. Medicare and Medicaid would be folded into the program. Organized labor supported the bill but the AMA, the insurance industry, and President Nixon opposed it. Like earlier proposals, the Kennedy-Griffiths bill would have replaced the private insurance industry with government-based health insurance. Nixon countered with the first national health insurance plan to maintain the private insurance industry and tie health insurance to employment. Nixon’s plan mandated that employers purchase private insurance policies for their employees. The government would contribute funds to cover the unemployed. With two thirds of the public in support and both Nixon and Kennedy willing to compromise, many thought the passage of national health insurance was imminent. However, congressional delays and the distraction of the Watergate scandal reduced political pressure for national health insurance, and no plan was passed. National health insurance entered public discourse again in the early 1990s, as the number of uninsured in the United States rose from 25 million to 40 million. Voters ranked health care among the top three issues of the 1992 presidential campaign, and two thirds of Americans favored tax-financed national health insurance. President Clinton’s proposal, like Nixon’s, combined mandated employer-based private insurance with governmentfunded public assistance. Clinton’s plan organized payers into a government-regulated system called “managed competition.” Groups of insured would be consolidated into large purchasing cooperatives that would buy insurance for their members, decreasing but not eliminating the number of private insurance companies. Clinton’s plan initially had 59% of the public’s support, but opposition campaigns cut support to 40% in 10 months and reduced momentum for reform. At about the same time, supporters of governmentfinanced national health insurance began calling their pro-

Health Policy, Health Insurance, and the Social Contract

Ever major western democracy is currently engaged in renegotiation of the social contract, which serves as the foundation for the social welfare state. This between the State and society represents a negotiated agreement between the government and citizens over respective responsibilities and duties. The agreement specifies what benefits government agrees to provide to citizens in return for tax-based financing of these benefits; it also recognizes the role of government in designing and administering the programs, which ultimately provide the desired benefits. This essay examines the development of the social contract as it relates to the development of the structure of the health care system in the United States and the performance of that system in terms of providing health services. It argues that the social-political debates in Europe had a very limited influence on the development of the American health care system and that the transatlantic connection may have greater applicability in the health care debates of the early 21st century than it did in the 18th, 19th, and 20th centuries. The current system of managed care in the United States is being adapted in Germany and other European countries as opposed to the adaptation of the European health care model in the United States. In other words, many political leaders and academics foresee a great similarity in the future between the U.S. and European health care systems. Others would argue that the traditions and practices of these countries differ sufficiently that a narrowing of the gap is neither desirable nor feasible. Until the 20th century, the American health care system was essentially a non-system. At the same time, there was very little support in the United States for government financing of health care programs similar to those being developed and adopted in Europe. The defeat of national health insurance proposals in the early 1900's through 1946 helped to bolster the position of private insurance companies and organized medicine. With the passage of Medicare and Medicaid, the role of the federal government was fundamentally changed. These programs represented a major change in the government's approach to the design, financing, and delivery of health care. Subsequent to Medicare and Medicaid, Congress enacted the Health Maintenance Organizaation Act of 1973. Federal involvement in health care was augmented in 1986 with the enactment of the Emergency Medical Treatment and Active Labor Act of 1986, the Health Insurance Portability and Accountability Act of 1996, and the Children's Health Insurance Program of 1997. During the period between 1865 and 1995, the influence of the transatlantic connection was very limited. Social policy makers in the United States were aware of the innovations and programs being adopted in Europe. Some of these policy proposals were introduced in the United States and rejected. In contrast, concepts of employer mandates and compulsory insurance were commonplace and fully accepted by most segments of society in Europe. Over the last fifteen years, with the growing economic pressure on the European social welfare state, there is growing pressure to reform the health care system and adopt some of the U.S. concepts of managed care. The managed care experience of the United States and the employment crisis of Europe may be leading to a convergence in the organization and financing of our respective health care systems.

Three decades of health care use by the elderly, 1965-1998.

Over the past three decades health spending and hospital use increased more for the elderly than for persons under age sixty-five. Medicare spending for the oldest old (age eighty-five and older) increased faster than for persons ages sixty-five to seventy-four, but that increase was due entirely to greater postacute care use. Health care trends are consistent with the idea that Medicare has improved the health of the elderly. Greater spending increases for the elderly may reflect legislative developments such as the passage of Medicare and its continued fee-for-service nature and the failure to pass universal coverage, as well as changes in the health care delivery system such as the rapid growth in managed care enrollment among persons under age sixty-five.

American health care: government, market processes, and the public interest

President Clinton's health care reform proposals of 1993 represented the most far-reaching program of social engineering attempted in the United States since the passage of Medicare and Medicaid in 1965. Under the guise of reforming the health care system, the Clinton plan would have herded almost all Americans under age sixty-five into large, government-sponsored health insurance purchasing alliances that would have contracted with insurers to offer a standard set of benefits at regulated prices. The plan came under fire from both Republicans and Democrats, including moderates from both parties, but it soon became apparent that what doomed it was a public unwilling to trust government to manage their health care. The critical literature has failed to offer a cogent analysis of why government control of health care does not work. American Health Care delivers that analysis. This volume examines why untoward consequences usually follow when government sets out to do good things. The contributors demonstrate how hospital rate regulation raises hospital prices, that no-fault medical malpractice increases the occurrence of faulty medicine, and that FDA regulation is a major cause for the escalating cost of new drugs. Part 1, trace the genesis of Medicare and its later developments and argue the consumer advantages of medical savings accounts and written health contracts. Part 2, explore the fallacies of antitrust policies that serve the interests of competitors, attack community rating for making health insurance unaffordable to large numbers of young workers. Part 3, contains a powerful critique of the FDA for withholding vital information on the health benefits of aspirin and shows how HMOs and other plans have caused pharmaceutical marketing to shift its focus from medical effectiveness to cost effectiveness. The final section explores how the private sector is improving in the areas of regulating physician and other health professional fees and the supply and quality of health professionals. American Health Care proposes reasonable balances between government and market options for in supply of health services. Without denying the need for some governmental action, the contributors show how far the market can go farther in performing critical functions in the health care industry. This volume will be important reading for health policymakers, economists, and health care professionals.

The Health Care Market

The preeminent view among the American public, its elected federal and state officials, and the health policy community is that competition and the market will accomplish many of the critical reforms proposed by President Clinton, in particular moderating costs and improving quality, even if this approach falls short of providing universal health insurance coverage. Further, that the American public will be much better off for avoiding added microincursions of government into the management of its health care system with consumers, rather than bureaucrats, determining future decisions. How well do these assumptions about the superiority of the market to allocate revenues in health care and expand consumer choice square with the trends of the past 3 decades, the situation today, and the likely developments tomorrow? <h3>A Backward Look</h3> To preview my conclusions: almost everything that has happened since the passage of Medicare and Medicaid in 1965 has indicated a pronounced shift

Mr. Social Security: the life of Wilbur J. Cohen

Book Review by Larry DeWitt* President John F. Kennedy referred to Wilbur J. Cohen as Social This was Kennedy's way of indicating his respect for Cohen's vast expertise and authoritative voice on all matters related to Social Security. And that respect was welldeserved. Wilbur Cohen was present at birth of Social Security and watched over it with parental concern for more than 50 years, until his death at age 73 in 1987. This splendid biography by Professor Edward D. Berkowitz, Chairman of History Department at George Washington University, does an outstanding job of telling story of one of Social Security's most engaging figures. The book's foreword is by Joseph A. Califano, former Department of Health, Education, and Welfare (HEW) Secretary. Wilbur Cohen was a staffer of Committee on Economic Security (CES) that drafted President Roosevelt's social security proposal. Immediately after passage of Social Security Act in 1935, Cohen became first employee of Social Security Board, where he worked with energetic enthusiasm on behalf of new program. Quickly making himself indispensable, Cohen became Agency's chief liaison to Capitol Hill, where he worked with tenacity and effectiveness for 20 years. He would go on to become Secretary of HEW during Johnson Administration and would become a key player in development of disability program and, especially, in creation of Medicare. Berkowitz's assessment of this latter accomplishment is that ...with possible exceptions of President Lyndon Johnson and Congressman Wilbur Mills (D-AR), Cohen played leading role in passage of Medicare in 1965. Mr. Cohen was a former student of Edwin Witte at University of Wisconsin and when Witte was appointed Executive Director of CES he asked Cohen to become his assistant. Cohen's intelligence and hard work were valued by Witte, who would later write a memorandum to Arthur J. Altmeyer describing Cohen as our best research worker. Edwin Witte also supported a job recommendation for Cohen as Altmeyer's executive assistant, a recommendation which contained this glowing assessment: To say that we have been highly pleased with his work is to put it very mildly. He has a keen mind and turns out an enormous quantity of work. These traits, intelligence and prodigious hard work, would characterize Wilbur Cohen's entire career. Cohen, like Altmeyer and Witte, was a product of Wisconsin progressive tradition in public policy. Berkowitz describes him as a post-Progressive Era reformer whose approach to social reform was shaped by his studies at Wisconsin. The portrait of Cohen that emerges in Berkowitz's book is of consummate Washington insider. Patient but determined, brilliant but not self-promoting, Wilbur Cohen was content to work behind scenes and was willing to settle for incremental progress, so long as progress was being made. His knowledge of Social Security would lead Senator Paul Douglas (D-IL) to quip: ...an expert on Social Security is a person who knows Wilbur Cohen's telephone number. Witte and then Altmeyer would become young Wilbur Cohen's mentors, and others would eventually join with Cohen in a kind of informal network that Berkowitz calls the apparatus. This group, which included Arthur Altmeyer, Bob Ball, Elizabeth Wickenden, and Nelson Cruikshank, among others, would work together in an ad hoc way to influence every piece of Social Security legislation from 1940's to 1980's. Wilbur Cohen provided important staff support in passage of 1939 amendments that dramatically changed character of Social Security program by adding survivors' benefits. He provided input to President Truman's famous message in 1945, calling for creation of a national health insurance program. As an aid to Altmeyer, Cohen played an important role in passage of 1950 amendments that increased Social Security benefits for first time and which Altmeyer judged to be crucial for program's survival. …

Primary care at a crossroads: progress, problems, and future projections.

The tension between generalist and specialist roles in medical education and practice has been marked by recurrent perceived crises for many years in the United States. Primary care was at a crossroads during the 1960s. There was much turmoil within the health care system, and many in the population were unable to gain access to and afford health care. As a result of this turbulence, a major effort was mounted at state and federal levels to increase the proportion and number of primary care physicians. New initiatives included efforts to increase the total number of physicians, passage of Medicare and Medicaid legislation, new emphasis on education programs in primary care, recognition of family practice as a specialty, and emergence of the National Health Service Corps. Today, 25 years later, the health care system as a whole is unraveling and in crisis as a result of soaring costs, the difficulty of providing access to all citizens, and health care outcomes that have fallen short of those achieved in many other industrialized countries. It is ironic how many of the failings of today's health care system mirror those of the 1960s, and how parallel the approaches to address these problems are to those taken a generation ago. Primary care finds itself again at a crossroads as intense pressures mount for fundamental reform of a health care system that has an inadequate primary care base. It is timely to take stock of the progress achieved by the initiatives to expand primary care during the last 25 years. Accordingly, this report addresses the following four objectives: (1) to

The vanishing health care safety net: new data on uninsured Americans.

New data obtained from the Census Bureau shows that the number of Americans without any health insurance increased by 1.3 million between 1989 and 1990, bringing the total number of uninsured to 34.7 million, more than at any time since the passage of Medicare and Medicaid 25 years ago. This increase coincided with a 10.5 percent increase in health spending, the second largest in the past three decades. The number of people covered by Medicaid grew by 3.1 million, due to a one-time expansion of eligibility mandated by Congress, but this was more than counter-balanced by a population growth of 3 million and a decrease of 1.3 million in people covered by private insurance. Had Medicaid not been expanded, the number of uninsured would have increased by 4.4 million. The increase in the uninsured affected virtually all parts of the nation. Seven states had increases of more than 100,000 persons each. Only Texas experienced a decrease of that magnitude, but still had the second highest rate of uninsurance of any state. Of the 1.3 million additional uninsured in 1990, 77 percent were male, 32 percent had family incomes in excess of $50,000 per year, and 74 percent had annual family incomes above $25,000. Fewer than 9 percent had incomes below the poverty line. The numbers of uninsured children and senior citizens fell slightly (but not significantly), while the number of uninsured working-age adults rose by 1.4 million. The number of uninsured workers in each of four of 20 major industry groups increased by more than 100,000 in 1990. None of the industry groups showed a significant decline in the number of uninsured. Among professionals, there were substantial numbers of uninsured doctors, engineers, teachers, college professors, clergy, and others, but all legislators and judges were insured. The data presented here largely predate the recession and understate current problems. In 1991 the number of uninsured will likely reach nearly 40 million. Also, these estimates are based on the number of people uninsured at a single time during 1990; a far higher number were temporarily uninsured at some point during the year. Moreover the Census Bureau survey ignores the problem of the underinsurance of at least 50 million insured Americans. Patchwork public programs are grossly inadequate to plug the holes. A national health program covering all Americans could assure access to care and contain costs.

From Cottages to Condos

The home health care industry has undergone a dramatic period of growth since the passage of Medicare (Title XVIII of the Social Security Act) in 1965. This growth has occurred in both the expansion of the total number of Medicare-certified agencies providing care, as well as the number of clients served and hours of care provided. It has been suggested that the single most important factor in this market expansion was the inclusion of a home care benefit in the original Medicare legislation, thus making it possible for nonprofit home care agencies to rely on a predictable source of government reimbursement. This paper explores the influence that amendments to the Medicare legislation since 1980 have had on market expansion, as well as other federal, state and private policy initiatives that have also influenced this growth. The authors suggest that overall growth does not equate with improved access or availability of needed services in the home for the frail and functionally-impaired elderly. Research findings from the first year of a three year study designed to document the impact of cost containment policies on community-based care for the elderly are reported in summary form to illustrate the authors position.

Medical Care for the Poor: No Magic Bullets

LESS than a quarter of a century ago, at the time of the Great Society programs of President Lyndon Johnson, many believed that with the passage of Medicare and Medicaid a single standard of superior medical care for all Americans was at hand. Governmentally funded entitlement for the elderly and the poor, the two major groups that lacked private health insurance, promised that the problem of access would soon be history. Clearly, that expectation has not been fulfilled. Rather, developments in the 1980s suggest that the numbers at risk because of lack of insurance coverage for health care are increasing. It should be noted that the United States is unique among the developed economies in having based its general health insurance system on employer benefits, while providing coverage for the elderly and the poor as extensions of the Social Security system. What lies back of the serious miscalculation, what can

Long-Term Care and Public Policy in an Era of Austerity

N the past twenty years, considerable progress has been made in the control and treatment of disease. There has been a dramatic improvement in life expectancy and a decline in mortality, particularly infant mortality. Ime n proved standards of living and medical advances in the cDsA prevention and control of formerly fatal infectious diseases have made it possible for an increasing number of persons to live a longer life. In addition, the passage of Medicare (Title XVIII) and Medicaid (Title XIX) in 1965 has made a substantial contribution to these improvements by making health services available to millions of older persons. An aging population raises many important socioeconomic issues relevant to an adequate and equitable health and long-term care policy. Intergenerational issues are raised at the community, state, and national levels in the course of developing a long-term care policy which meets the multiple needs of the elderly and encourages healthy aging, independence and autonomy in old age (1). The concept of healthy aging in our society involves a movement upstream against the tide of prevailing values wlich regard older people as an economic burden. It involves movemenit upstream against the tide of national politics of austerity and retrenclhmclnt in domestic social programs illustrated most recently by the attacks oIn Social Security and Medicare-two major sources of well--ei,g for older A mericans (2). It also involves movement upstream againct the vcry iiifluciitial medical-industrial complex whose emphasis is on acute, cpisodic care within a biomedical paradigm resulting in rising costs and a divcrsioii of resources to institutions. The development of a comprehensive long-term care policy is a formidable task, given the complex interaction between the public and private

Procompetition in Health Care: Policy or Fantasy?

century social reformers sought to persuade the American people that national health insurance (NHI) was the only practical answer to providing universal access to health care. Around the time of World War I, even the American Medical Association favored the enactment of NHI, but within a few years it retreated and assumed leadership of the opposition. After a long journey in the wilderness, the reformers scored their first success in 1965 with the passage of Medicare and looked forward to final victory in a two-stage advance: the proximate passage of insurance for mothers and children to be followed by coverage for other adults.

The Evaluation of a Hospital as a Long-Term Borrower

THERE is no area of private financing in the United States which will in the next five years undergo as much change and development as will the financing of voluntary non-profit hospitals. represent the last major established industry in the country for which traditional methods of evaluation, bond quality rating and financing have not been thoroughly established. Until the past two years, major Wall Street investment banking firms showed only passing interest in financing hospitals. For example, in 1969, four of Wall Street's most respected large investment banking firms formed a consortium to arrange long-term financing for hospitals. Two other major underwriters, that professed skepticism about the credit worthiness of hospitals early in 1970, had by September 1970 underwritten a major hospital tax-exempt bond issue. Standard and Poor's Corporation, a well established bond rating agency, began in 1969 to rate hospital bonds. There is good reason for these developments. desperately need massive amounts of private financing to modernize their facilities in order to meet the nation's goal of making health care the right of all citizens, rather than the privilege of a few. At the present time, health care ranks third largest as an employment industry behind agriculture and construction.1 According to an article in Hospitals Journal of the American Hospital Association, the total investment in hospitals required by 1975 will be $48 billion-an increase of $14 billion over estimated 1970 assets of $34 billion.2 Another source, the Department of Health, Education and Welfare, estimates that the industry will require a further investment of $20 billion over the next three to five years.3 At their present rate of growth, hospitals. will account for 7 per cent of the nation's gross national product by 1975. It is not the apparent intention of the federal government to m-eet the hospital's capital needs directly. Rather, the government has encouraged hospitals to borrow privately. The government has, at the s.ame time, increased the feasibility of private financing by paying patients' bills via Medicare and Medicaid. The result has been to make the. federal government, rather than the patient, responsible for hospital receivables, with dramatic effect on hospital credit. The passage of Medicare and Medicaid began a new era in American hospitals. These two programs created demands for medical care well beyond the expectations and capacity of hospitals by making treatment available to large segments of the population which had never before in the history of the country had access to good medical treatment in such quantity. were not prepared for the demand. In the late 1960's, the Department of Health, Education and Welfare estimated that over half of the GORDON H. BERG is Chairman of Sprague Medical Systems Corporation in Boston. He was formerly an officer of the New England Merchants National Bank of Boston. 1. Footnotes appear at end of article.

The Medical Admissibility Provision vis-à-vis the Charter of Rights and Freedoms

Since the initial formulation of a national immigration policy for the country in 1869, Canada has included a provision of inadmissibility on the grounds of mental and/or physical disabilities. Whereas the provision was created with the intention of excluding from Canada those subjects who were considered a risk to the genetic integrity of the nation or ‘unemployable’ because of their disability, with time the emphasis has shifted to focus on the excessive costs that the disease or disability would likely place on Canadian medical and social services, particularly after the passage of Medicare in 1968. The focus of this article will be on the provision as included in the Immigration Act of 1976 since only after the passage of the Charter of Rights and Freedoms in 1982 has the provision been questioned as discriminatory towards persons with mental or physical disabilities.

Nursing homes: a review.

Recent developments, such as the passage of Medicare, have drawn attention to the need for evaluating existing posthospital extended care services, of which nursing homes are presently a major part. The author traces the evolution of the nursing home and reviews the literature describing nursing home services in the areas of general medical care, rehabilitation, psychiatric therapy, and psychiatric evaluation. The future of nursing homes, he concludes, depends in large part upon their ability to broaden and professionalize their functions beyond the provision of basic custodial care.