Publication year: 2017

In his 1949 State of the Union speech President Harry S. Truman promised that the federal government would work towards developing a comprehensive health care system that would make high quality medical care affordable to every American citizen.  Almost sixty years later, however, the United States is no closer to accomplishing that goal than it was during the post-World War II era.  Although the U.S. spends more per capita on health care than any other developed nation, it remains the only major industrialized country that does not provide universal health care coverage for all of its citizens.  Notwithstanding the need for improved health care systems in the U.S., Congress has failed to approve a compressive health care system that is consistent with the needs of the majority of American citizens.  Moreover, bipartisan politics, combined with excessive oversight, has prevented Congress from passing an acceptable health care policy on virtually all issues with the exception of HIV/AIDS, thereby indicating that members of Congress are unfamiliar with their constituencies.  In short, Congressional health care policies have failed to evolve with American society.  This paper argues that excessive oversight, combined with increasing partisan politics, has prevented Congress from adopting a comprehensive health care policy, albeit the efforts of several former Presidents, and the desires of the American people.  As a means of demonstrating Congresses failure to evolve with American society, this essay will compare congressional activity on two primary twentieth century health-related issues: Medicare and HIV/AIDS.  Doing so will reveal that Congress places more value on budgetary politics than it does on the health of the US citizens.

According to the World Health Organization (WHO), the United States spends $5,711 per capita on health care (15.2% of total GDP, 2003); more than twice the amount of other established market economies, such as Canada, France, Germany, or the UK.[1]  Nevertheless, the US is the only fully industrialized nation that views health care as a commodity rather than a social right.  Consequently, over 39 million Americans are without health care coverage each year.  Article I, Section 8 of the U.S. Constitution empowers Congress to, “promote the progress of science…make all laws which shall be necessary and proper…and all other powers vested by [the] Constitution…or in any department or officer thereof.”  (US Constitution, 1787)  Accordingly, in 2005, Congress authorized the Institute of Medicine of the National Academies (IMNA), a non-profit organization created by the federal government to advise on scientific and technological matters, to study the effects of access to health care on working-age adults.  The IMNA concluded that approximately 58% of working adults (age 21-58) were lacking access to vital areas of health care, thereby indicating that Congressional health care policies have fallen short of expectations.[2]

The notion of Congressional oversight vis-à-vis health care policy is one of debate and controversy.  President Woodrow Wilson believed that vigilant oversight of administration was, “[q]uite as important as legislation.”[3]  Although oversight may have been, “Congress’s neglected function,” (Bibby, 1968) during the Wilson administration, by the 1990’s, it dominated much of the Congressional activity.  For example, in 1993, the House Subcommittee on Heath and the Environment conducted 103 hours of investigative and oversight hearings, compared with only 35 hours of legislative hearings and markups, thereby indicating that Congress spent much more time on oversight.  [4] Oversight has become a larger component of Congress partly because divided government has changed the nature of oversight, and partly because as the federal government grew, and citizens became burdened by its size and complexity, there was a, “shift in the relative payoffs of endeavors such as creating new programs compared with overseeing those already established.”  (Aberbach, 1990)  Additionally, both spending and federal budget deficits have created more need for subcommittees whose primary responsibility is to identify fraud, and oversee appropriations.  Combined with increasing partisan politics over the last few decades, and legislators who attempt to exercise as much influence as possible over the administration of programs, oversight has moved from a method of monitoring the operation of federal programs and exposing fraud, abuse, and mismanagement, to a policymaking tool.[5]  Consequently, oversight has become a vehicle through which Congress retains power over numerous federal programs, including health care.

As a rule, oversight is best defined as the legislative (lawmaking) branch’s formal and informal review of the executive (decision making) branch’s implementation and operation of programs and policy.[6]  Ever since its inception, Congress has always exercised oversight in some manner; however, it was not formalized until The Legislative Reorganization Act of 1946 was passed, which required both the House and the Senate committees to watch over legislative matters.[7]  Since then, several agencies have been created to aid Congress in its work.  For instance, the Congressional Research Service (CRS), the public policy research arm of the United States Congress, conducts research that ensures administrative adherence to congressional intent; improves the efficiency, effectiveness, and economy of governmental operations; evaluates program performance; and prevents executive encroachment on legislative authority.[8]  Together with numerous subcommittees that focus on all aspects of American Government, including health care policy, Congress’ role in shaping American society has been greatly enhanced since the end of World War II.

According to a recent poll, 74% of Americans believe that Congress is out of touch with what Americans want.[9]  Indeed, more often than not Congress has adopted policies that are inconsistent with what Americans, particularly senior citizens, desire vis-à-vis health care.  For example, in 1994, around the same time of President Clinton’s inauguration, polls indicated that 66% of senior citizens preferred Canada’s health care system to their own.[10]  In addition, the polls indicated that the majority of US citizens were dissatisfied with the quality of the US health care system, which they ranked tenth out of the top ten industrialized countries.[11]  Notably, the US ranked behind Italy, who spends 25% of what the US spends per capita on health care each year.[12]  The years subsequent to World War II saw a dramatic change in health care in every industrialized nation except the United States, who unlike Europe, views health care as a commodity rather than a social right.  Moreover, even though, “presidents Wilson through Roosevelt, Truman, Kennedy, Johnson, Nixon, and Clinton” (Mann, 1995) advocated national health reform, political opposition and new organizations have hindered progress.[13]  For instance, in the 1940’s, about the same time that much of post-World War II Europe was implementing comprehensive health care policies, the American Medical Association (AMA) claimed that national health care was a Communist plot that was consistent with the ideals of Socialism.[14]  The AMA was instrumental in defeating many national health insurance proposals, including the policies advocated by Truman in 1949.  By 1971, the AMA connected with conservative Republicans who pushed tax credit plans as an alternative to Ted Kennedy’s national health insurance bill, and President Nixon’s employer mandate proposal, both of which would have been more in line with what the American citizens desired from health care.  Instead, the US adopted an employment-based, private health insurance system that benefited Prudential, Aetna, Metropolitan Life, and other major insurance companies by allowing them to raise their rates whenever health-care bills increased.  Simply put, the US system failed to provide a cost-controlling mechanism for health care, thereby allowing health-care providers to control both supply (their medical skills) and demand (services, procedures, and tests that they recommend).[15]

Based on the above-mentioned facts, it is not surprising that Gallup polls in both 1938 and 1991 indicated that 80 % or more of Americans believed that the government ought to provide medical care for those who are unable to pay, particularly senior citizens.[16]  However, government-sponsored health care requires Congressional appropriations, and as such, there are numerous obstacles.  Both the House and the Senate expect its Appropriations Committees to, “engage in oversight of administration…to keep itself and the rest of the House informed on the way in which executive agencies use the money granted to them and…to influence the use of public funds in ways prescribed by law.”  (Fenno, 1966)  Oversight requires that the appropriations committees examine, and pass (or not pass) administrative budget requests as based on past performance of the agency, however, mandatory spending for legal entitlements and federal obligations has reduced its authority.[17]  Notwithstanding the fact that most governmental health care programs have powerful constituencies, Congress had unrestricted authority for only $24 billion, or less than 10%, of the $256 billion spent on federal health care programs in 1994.[18]  Consequently, appropriations committees often have little influence over such organization as the Food and Drug Administration (FDA) or the Centers for Disease Control (CDC).  Nevertheless, Congressional committees still possess considerable authority over other important programs such as Medicare and Medicaid.

The legislative role of appropriation committees are derived from a combination of, “formal rules, unpublished precedent, and informal agreements” (Tiefer, 1989) between committees.  Jurisdiction is described in chamber rules (Rule 10 in the House and Rule 25 in the Senate), and was first codified fifty years ago as part of the Legislative Reorganization Act of 1946.[19]  The committees agenda has changed significantly since jurisdictions were designed, and as such, they often conflict with key issues, such as health care policy, partly because it is, “highly technical, touching on matters as diverse as child nutrition, medical malpractice, hazardous wastes, and alcoholism on Indian reservations.”[20]  Consequently, if Congress were to adopt a single health care committee, for example, rather than the current multi-committee arrangement that is currently in place, it would require, “that almost all domestic policy items be given to that panel,”  (Tiefer, 1994) thereby suggesting that the justification for multiple health care committees is based on the assumption that one committee is intellectually and managerially incapable of handling US health care policy.[21]

Notwithstanding the partition between Democrats and Republicans, however, they do manage to legislate.  Approximately 66% of the significant laws that were enacted between 1949 and 1994 passed the House with bipartisan majorities.[22]  Moreover, b­­­­­­­­­­­­­­­­­ipartisanship was widespread in the Senate, with 69% of the bills passing.[23]  In fact, “during periods of divided government there has been more bipartisan support for significant legislation” (Mann, 1995) than when a single party controlled the White House and Capitol Hill.  Nevertheless, Congress and the White House rarely agree on health care policy.  Instead, health care has been subject to partisan conflict, partly due to increased spending within Congress.  For example, from the mid-1960’s to the late 1980’s, Congress added large numbers of staff to its payroll, four of which had jurisdiction over heath care reform in the House and the Senate.[24]  In the House, the Energy and Commerce Committee grew from 45 to 162, and the Ways and Means Committee from 22 to 99.[25]  In the Senate, the Labor and Human Resources Committee staff rose from 28 to 127, and the Finance Committee staff increased from 6 to 54.[26]  During the same period, and despite the increase in staff, there was no call to implement a strategy that would control the spiraling costs of Medicare and Medicaid, even though, “less than 56% of elderly people had hospital insurance.”[27]  As a result, Congress struggled for over ten years with rising Medicare costs, yet continued to add staff to its payroll.  Arguably, Congressional oversight was successful when a new prospective system for paying hospitals based on patients’ illnesses was developed in 1982.  Although Medicare costs continue to escalate, one recent study indicates that the prospective payment system (PPS), a system that Congress implemented to control Medicare costs and expenditures, has in fact limited the growth of spending without seriously affecting health care quality or accessibility.[28]  On the other hand, however, other studies indicate that Medicare’s new prescription drug program will cost taxpayers over $720 billion over the first ten years, with estimates as high as $100 billion a year by the middle of the next decade.[29]  In either case, the increased payroll expenses, combined with the fact that less than 56% of elderly people had hospital insurance in the 1990’s, makes it difficult to argue that Congress has implemented a truly comprehensive plan merely because the PPS controls costs.

Although budget concerns are both legitimate and necessary reasons for changing policy, there are inherent dangers when budget policy drives important legislation, as demonstrated by the aforementioned facts vis-à-vis Medicare.  Timetables are often discordant with needs, (as was the case when Congressional staff was added at the same time that senior citizens needed hospital insurance), and the need to cut budgets.  Consequently, the authority of the Ways and Means Committee vis-à-vis health care policy, which originated from its jurisdiction over the Social Security Act and the Internal Revenue Code, became obvious as Medicare and Medicaid grew.[30]  In the short time between its implementation in 1965, and the early 1970’s, the House Ways and Means committee gained overwhelming power as the dominant health care committee.  Consequently, in the mid-1970’s, House reformers who were concerned about the Ways and Means Committees broad jurisdiction over health care were able to pass legislation that reduced its authority over the health care titles of the Social Security Act that were not directly financed by payroll deductions.  Nevertheless, the Ways and Means Committee remains a key actor in national health care policy, primarily because of its jurisdiction over Medicare.  That the House reformers lobbied for legislative change to reduce the Ways and Means authority is consistent with the characteristics of a divided government.[31]

In addition to the previously mentioned new staff members, and the creation of the CRS, one of the most significant developments to health care policy was the creation of the Congressional Budget Office (CBO), which was authorized via the Budget and Impoundment Control Act of 1974.[32]  The CBO operates as a non-partisan organization that conducts advanced methods of data collection and analysis; it was designed to provide support to

the new budget committees in the House and Senate, and the existing appropriations committees.[33]  In addition to providing raw data, the CBO determines how certain policy options should be handled.  For instance, during the 103rd Congress, the CBO’s twenty health analysts, led by its director Robert Reischauer, highlighted, “inconvenient facts” (Samuelson, 1994) that spoke, “truth to power.”  (Samuelson, 1994)  Simply put, the CBO tells it like it is, and leaves the final decisions to Congress.  As evidenced by the spiraling costs of Medicaid, which increased from 9 to 14% of average state budgets between 1980 and 1990, Congress has been unable to separate bipartisan politics from the raw data that the CBO provided, thereby indicating further division between not only the members of Congress, but also between Congress and its constituencies.[34]

In 1981, Ronald Reagan increased the division between Democrats and Republicans when he proposed social security cuts.  Doing so upset many senior citizens, and provided the Democrats with an opportunity to increase the divide between the Democratic and Republican parties, and subsequently, both chambers of Congress.  By 1985, administration officials attempted to repair some of the hard feelings between the two parties while simultaneously seeking new domestic programs.  However, in 1986, Reagan’s State of the Union message fell short when it urged the youth of America to resist the temptations of illegal drugs, noting the associated health care dangers, but failed to advocate real health care reform.  In absence of structural reform, special interest group’s feared that Congress would, out of frustration, adopt cost controls, as it had for hospitals in 1982 before adopting the prospective payment system (PPS) in 1983.  As a result, by 1989, a majority of medical professionals contemplated health care reform after Congress created payment restrictions for physicians.[35]  Consequently, heath care policy moved further from what the majority of American’s desired, and supports the notion that bipartisan politics had interfered with the health care policy reform.

As demonstrated above, health policy oversight, combined with political division, and budgetary politics, has prevented Congress from passing a comprehensive health care policy.  Although Congress has made many alterations to the existing health care system, it has merely moved policy sideways; not forward, as all other major industrialized nations have done since the end of World War II.  Although serious financial implications made it difficult for Congress and the President(s) to agree on Medicare and health care policy, in the early 1990’s, HIV/AIDS had become a major worldwide concern.  It was at that point when Congress was able to put aside its differences and agree on a health care strategy that included approval of appropriations for HIV prevention and research.  Although it was initially a relatively small program, Congress overwhelmingly supported HIV/AIDS funding and support, which included appropriations for scientific research that even the most conservative Republicans were unable to oppose.[36]  As the HIV epidemic worsened, policy and politics evolved to a point where epidemiological research made up only a fraction of Congresses agenda.  Advanced congressional debates vis-à-vis HIV/AIDS testing, broad-based public education on HIV infection prevention, and conflicts over cultural values that stemmed from preventative techniques, such as condom use, were on Congresses agenda.  Consequently, the politics of HIV/AIDS evolved, “from a new emergency to an established problem,” (Mann, 1995) and unlike the Congress in 1987, which according to the Congressional Quarterly Almanac, was, “[s]talemated Over [the] AIDS Epidemic,” the Congress of the early 1990’s displayed a rare showing of unity. Unlike the need for Medicare, HIV/AIDS had affectively moved Congress far beyond the issue of appropriations, and into debates that stemmed around the needs of health, cultural differences over HIV treatment, and the potential devastating affects on American society if they were unable to come to an agreement.  Moreover, Congress did not stalemate over the budgetary needs for HIV research as it had for Medicare.  In fact, it appropriated over $900 million in FY  1988, and it provided an additional $50 million for AZT treatment (define) for individuals who tested HIV positive.[37]  The above-mentioned facts indicate that Congress is capable of agreeing on health care policy, and leaves open the question (that is far beyond the scope of this paper) why did Congress value HIV spending more than it values the health of senior citizens.  Based on the Congressional voting record and appropriations vis-à-vis both HIV research and Medicare, it is reasonable to suggest that Congress favored the former over the latter.

Notwithstanding the fact, however, by the mid-1990’s the appropriations committees began to view HIV/AIDS as a high priority that was also subject to tradeoffs.[38]  By 1995, budgetary politics resurfaced, and combined with the low priority of comprehensive health care reform, the 104th Congress shifted its focus from HIV funding to the Contract with America, a document released by the Republican Party during the 1994 Congressional election that proposed a constitutional amendment to balance the budget, and a promise to reduce the deficit to zero over seven years.[39]  As a result, both Medicare and HIV appropriations suffered as the newly elected Republican Congress moved money away from health care issues and into other areas, such as defense.  Considering Congresses inability to fix Medicare in the late 1980’s, it was unexpected that policymakers would approach the HIV/AIDS crisis with such ambition and optimism.  Doing so suggested, even for a brief period, that members of Congress could indeed work together during times of crisis.  However, what Congress defines as a crisis is questionable.  Clearly, a senior citizen who lives on a limited income would consider any additional cuts to his or her Medicare a crisis, thereby leaving open the question: why does Congress fail to view Medicare and health care reform as a crisis in need of a cure.  Instead of addressing that issue, typical Congressional budget-minded behavior emerged in the mid 1990’s, and even in the face of a devastating infectious disease such as HIV/AIDS, Congress was unable to puts it philosophical differences aside and agree on a health care policy that is consistent with what American citizens desire.

According to the Universal Declaration of Human Rights, and the International Covenant of Economic, Social, and Cultural Rights, all citizens deserve government subsidized health care coverage.[40]  Perhaps the closest that America has come to a comprehensive health care system that is consistent with universal human rights was during the Clinton administration.  Clinton’s health care reform proposal, which was largely based on the concept of managed competition, an unproven theory which presumes that the market will work to regulate health-care costs, if health care can be made to function as a market.  The Managed Competition Act of 1992 demonstrates the fundamental problems that all market-based proposals face; it combines, “the worst of bureaucratic regulation with the voraciousness of the market system.”  (Mann, 1995)  In other words, its chance of success is both unproven and doubtful within a Congressional environment that is characterized by bipartisan and budgetary politics, and excessive oversight.  Nonetheless, the previously mentioned polls suggest that the majority of Americans wanted the Clinton plan, (or something similar) and even though a minority of Democrats proposed several competing plans, and the far left preferred the Canadian, single payer system, Clinton’s plan was defeated by Congress on September 26, 1994.  In late 1994, Republicans seized control of Congress, and since then, a comprehensive health care system in the US had not been seriously considered.

Indeed, comprehensive health care is consistent with universal human rights.  Although international treaty ratification has no connection per se with domestic health care, America’s failure to ratify international treaties on other key issues, such as the International Criminal Court (on military tribunals), the Kyoto Protocol (on greenhouse gas emissions), or the torture treaties of the Universal Declaration of Human Rights, suggests a pattern of what is otherwise known as Exceptionalism.[41]  On one hand, the US insists that other nations accept human rights treaties that are consistent with social and economic equality.  On the other hand, however, the US chooses to exclude itself from the same requirements, arguing that it prefers to handle domestic issues without foreign interference.  Hence, it is not surprising that Congress has failed to adopt a comprehensive health care strategy, or that it waivers between appropriations on important issues such as HIV/AIDS.  From a behavioral aspect, doing so is no different than failing to ratify international treaties that all other industrialized nations have embraced.  By contrast, the Clinton administration indicated its commitment to, “ratify of all remaining international human rights instruments, including the International Covenant on Economic, Social and Cultural Rights with its recognition of a right to health.”  (Chapman, 1994)  Although Clinton’s plan was defeated by Congress, it represents a new era in health care issues in the sense that health rights, as determined by the UDHR, has entered the American political arena as a right to healthcare.[42]

Despite the efforts of several former US Presidents and the desires of American citizens, Congress has been unable to pass an acceptable health care policy that is consistent with both international human rights, and of the same quality as other top industrialized nations.  Excessive oversight has done nothing more than create division, while excessive spending and increased budgetary politics to a level where appropriations are rarely done in accordance with the health care needs of American society.  The current administration is largely against health care reform, however, the Clinton administration helped to redefine health care not as a Constitutional right, (the Constitution makes no mention of social, economic, or health care rights) but rather, one that all citizens are entitled too based on universal human rights.  Congresses failure to evolve with American society is evident in how it handled both the Medicare crisis and the HIV/AIDS epidemic, and it is doubtful that a comprehensive health care policy will be forthcoming until members of Congress are able to put aside their personal difference and political career goals, and pass legislation that is good for society.

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Aberbach, J.D. Keeping a Watchful Eye: The Politics of Congressional Oversight ( Brookings, 1990), p. 191.

 

Bibby, J.F. “Congress’ Neglected Function,” in Melvin R. Laird, ed., Republican Papers ( Garden City, N.Y.:

 

Anchor, 1968), pp. 477-88.

 

Chapman, A. R. (Ed.). (1994). Health Care Reform: A Human Rights Approach. Washington, DC: Georgetown

 

University Press.

 

Congressional Quarterly Almanac, 1990 ( Washington: CQ Press, 1990), p. 572.

 

Fenno, R. The Power of the Purse: Appropriations Politics in Congress ( Boston: Little, Brown,

 

1966), p. 17.

 

Ignatieff, M.(2005) American Exceptionalism and Human Rights. Princeton University Press.

 

Letters and Statements from Members, Groups, and Individuals Regarding the Work of the Select Committee on

 

Committees, Committee Print, House Select Committee on Committees, 93 Cong. 2 sess. ( GPO, 1974)

 

Mann, T. E. & Ornstein, N. J. (Eds.). (1995). Intensive Care: How Congress Shapes Health

 

Policy. Washington, DC: American Enterprise Institute; Brookings Institute.

 

Ornstein, N.J., Thomas E. Mann, and Michael J. Malbin, Vital Statistics on Congress, 1987-88 ( American

 

Enterprise Institute, 1987), pp. 147-48.

 

Samuelson, R.J. “CBO’s Wishful Thinking,” Washington Post, February 16, 1994, p. A19; Editorial,

 

“Accounting for Health Care,” Washington Post, February 9, 1994, p. A22.

 

Schick, A. Congress and Money: Budgeting, Spending and Taxing ( Washington: Urban Institute, 1980).

 

Tiefer, C. Congressional Practice and Procedure: A Reference, Research, and Legislative Guide ( New York:

 

Greenwood Press, 1989), pp. 68-87

 

Tiefer, Congressional Practice and Procedure; Oleszek, Congressional Procedures and the Policy Process. See also

 

David King, “The Nature of Congressional Committee Jurisdictions,” American Political Science Review,

 

vol. 88 ( March 1994), pp. 48-62.

 

U.S. Constitution, (1787)

 

www3.who.int/whosis/country/compare.cfm?country=USA&indicator=PcTotEOHinIntD&language=English

www.cnn.com/2006/POLITICS/10/18/congress.poll/index.html?section=cnn_topstories

www.whitehouse.gov

[1] http://www3.who.int/whosis/country/compare.cfm?country=USA&indicator=PcTotEOHinIntD&language=english

[2] http://www.iom.edu/

[3] Study on Federal Regulation: Congressional Oversight of Regulatory Agencies, Volume II, S. Doc. 95-26, 95

Cong. 1 sess. (Government Printing Office, 1977), p. xi.

[4] Mann, T.E. & Ornstein, N.J. (Eds). (1995). Intensive Care: How Congress Shapes Health Policy. Washington

DC: American Enterprise Institute; Brookings Institute

[5] Ibid.

[6] Mann, T.E. & Ornstein, N.J. (Eds). (1995). Intensive Care: How Congress Shapes Health Policy. Washington

DC: American Enterprise Institute; Brookings Institute

[7] Ibid.

[8]  http://www.loc.gov/crsinfo

[9]  http://www.cnn.com/2006/POLITICS/10/18/congress.poll/index.html?section=cnn_topstories

[10] http://www.who.int/inf-pr-2000/en/pr2000-44.html

[11] Ibid.

[12] http://www.who.int/inf-pr-2000/en/pr2000-44.html

[13] Ibid.

[14] http://www.pnhp.org/facts/

[15] http://www.pnhp.org/facts/

[16] Mann, T.E. & Ornstein, N.J. (Eds). (1995). Intensive Care: How Congress Shapes Health Policy. Washington

DC: American Enterprise Institute; Brookings Institute

[17] Ibid.

[18] President Clinton’s Fiscal Year 1995 Budget: A Summary and Analysis Prepared by the Staff of the House Budget

Committee, Committee Print, House Committee on the Budget ( GPO, 1994), pp. 3,171-73.

[19] see Charles Tiefer, Congressional Practice and Procedure: A Reference, Research, and Legislative Guide ( New

York: Greenwood Press, 1989), pp. 68-87

[20] Tiefer, Congressional Practice and Procedure; Oleszek, Congressional Procedures and the Policy Process. See

also David King, “The Nature of Congressional Committee Jurisdictions,” American Political Science

Review, vol. 88 (March 1994), pp. 48-62.

[21] Ibid.

[22] Mann, T.E. & Ornstein, N.J. (Eds). (1995). Intensive Care: How Congress Shapes Health Policy. Washington

DC: American Enterprise Institute; Brookings Institute

[23] Ibid.

[24] Ibid.

[25] Norman J. Ornstein, Thomas E. Mann, and Michael J. Malbin, Vital Statistics on Congress, 1987-88 (American

Enterprise Institute, 1987), pp. 147-48.

[26] Ibid.

[27] John K. Iglehart, “Health Policy Report: The American Health Care System–Medicare,” New England Journal of

Medicine, vol. 327, no. 20 (November 12, 1992), p. 1467.

[28] Marsha Gold and others, “Effects of Selected Cost-Containment Efforts: 197:1-1993,” Health Care Financing

Review, vol. 14, no. 3 (Spring 1993), pp. 195-98.

[29] Estimates according to the Bush administration www.whitehouse.gov

[30] Letters and Statements from Members, Groups, and Individuals Regarding the Work of the Select Committee on

Committees, Committee Print, House Select Committee on Committees, 93 Cong. 2 sess. ( GPO, 1974), pp.

40-42.

[31] Ibid.

[32] Allen Schick, Congress and Money: Budgeting, Spending and Taxing ( Washington: Urban Institute, 1980).

[33] Ibid.

[34] see Julie Rovner, “Governors Ask for Relief . . . From Burdensome Medicaid Mandates,” Congressional

Quarterly Weekly Report, February 16, 1991, pp. 414,41

[35] Mann, T.E. & Ornstein, N.J. (Eds). (1995). Intensive Care: How Congress Shapes Health Policy. Washington

DC: American Enterprise Institute; Brookings Institute

[36] Mann, T.E. & Ornstein, N.J. (Eds). (1995). Intensive Care: How Congress Shapes Health Policy. Washington

DC: American Enterprise Institute; Brookings Institute

[37] Ibid.

[38] Ibid.

[39] Mann, T.E. & Ornstein, N.J. (Eds). (1995). Intensive Care: How Congress Shapes Health Policy. Washington

DC: American Enterprise Institute; Brookings Institute

[40] http://www.unhchr.ch/udhr/

[41] Ignatieff, M.(2005) American Exceptionalism and Human Rights. Princeton University Press

[42] Chapman, A.R. (Ed). (1994). Health Care Reform: A Human Rights Approach. Washington, DC.: Georgetown

University Press