Health care and the homeless: a political parable for our time

The growth in the number of homeless persons is perhaps the most visible indicator of social disintegration in the 1980s, although health and health care are not the central issues of homelessness. This paper, which draws on the author's experience as chairman of the Committee on Health Care for Homeless People of the Institute of Medicine (IOM), describes what is known about the characteristics of homeless persons and the causes of homelessness, and about the health status of homeless persons, which is often not very good (but not significantly worse, it would appear, than that of other low-income persons). The contemporary history of health services targeted to homeless persons begins with the joint initiative of the Robert Wood Johnson Foundation and the Pew Charitable Trusts in 1985, which became the model for federal support through the Stewart B. McKinney Act of 1987. The McKinney Act, like the IOM report, demonstrates how, in contemporary American politics, there can be widespread political consensus not only about a problem but about solutions, while the resulting policy actions are largely symbolic.     

Reforming Medicare provider payment

The basic thesis of this paper is that, in the short to medium term (that is to say, the politically relevant term), fee-for-service payment will be the dominant form of Medicare transaction--and that is not such a bad thing. Capitated arrangements will grow, and should be encouraged, especially for long-term-care services, but for reasons to be discussed, it would be a mistake to put too many policy eggs into that basket. As the nascent Prospective Payment System (PPS) for hospital care reveals, fee-for-service payment can take almost an infinite variety of forms, and the connection between the choice of form and the cost impact is highly variable and somewhat uncertain. PPS needs considerable improvement; so, unquestionably, does the current nonsystem of physician payment. An analysis of potential improvements in both arenas will constitute the bulk of this discussion. That emphasis reflects not only the personal predilections of the author, but also the contention that those are the most sensible things to talk about.