Health care is an essential aspect in the contemporary world. As asserted by Levett-Jones (2012), a family that does not have a proper medical plan can easily find itself in financial constraints in the event of a medical emergency. It is due to this fact that many nations around the world have developed policies and passed laws that aim at improving the overall quality, accessibility and cost of health care.
The access to quality, affordable, and equitable health services has been the main goal of the federal and state governments in the USA. Medicare and Medicaid, the Health Saving Act (HSA), the Patient Protection and Affordable Health Care Act, well known as the Obama Care Act (ACA) were all moves to ensure that the health care within the United States is equitable, affordable, and accessible to all citizens irrespective of their social and economic backgrounds (Schoonhoven, 2013).
These proposals and legislations aim at achieving their goals through tax subsidies, consumer protection, and insurance exchanges in the provision of both public and private insurance policies. Additionally, campaigns, such as the Million Heart, aim at reducing heart attacks by around 50% in the United States, mainly within the minority population (Sobo, 2013). Finally, the United States has been diversifying the qualification and expertise of its medical staff to ensure that they are competent enough to provide the nation with high quality health care services.
In the United States, a high proportion of individuals: the elderly, those who come from minority racial and ethnic backgrounds, earn a limited income, or possess low education qualifications, or are disabled tend to receive low standards of health care (Fairman, 2011). These individuals are usually under insured or uninsured. As asserted earlier, such individuals usually face serious financial difficulties in the event of a medical emergency.
When an individual is in such a situation, they tend not to have any form of economic security. Additionally, such individuals find it difficult to progress at work or education. Therefore, reformations with regard to access, affordability, and improvement in the quality of health care plays a significant role in not only ensuring that the uninsured and under insured individuals enjoy healthy lifestyles but also guarantees social and economic growth in the long run.
It is as a result of the health challenges that the American public has been facing that has made both the federal and state governments be actively involved in coming up with reforms within the health sector (Lohr, 2005). Commencing in the 1950s and having an early implementation during the 1960s, the American government had been actively funding health programs aiming at improving the provision of equitable health services to the elderly population as well as the poor within the United States through the Medicare and Medicaid programs respectively.
During the 1990s and early 2000s, the US government tried to come up with an effective program that would provide health insurance to its citizens. However, after several failed attempts the Patient Protection and Affordable Care Act was passed by the congress and passed into law by the former US president, Barrack Obama (Cohn, 2010).
This further increased the role played by the US government in the provision of health insurance to its citizens. With this background, this paper will critically analyze the process of health reforms in the United States. To achieve its goals, the paper will first assess whether the legislative process has changed over time by comparing the different legislative efforts related to the development of Medicare in the 1960s, HSA in the 1990s and ACA. Furthermore, this paper will also critically analyze whether the long standing dedicated attention is present with regards to the development of contemporary health policies as compared to the era when Medicare was developed and implemented.
Evolution of Health Policy Reforms
The United States of America has a very unique and different health policy as compared to the developed nations around the world. Unlike other developed nations that have incorporated a national health insurance scheme covering most or all citizens, the United States has opted for a different approach whereby insurance cover is mainly offered by private institutions and employers, while the government only covers specific groups such as the poor or elderly within the population (Lowery, 2007).
This approach has received mixed reactions with one group of thought criticizing the role played by the US government in the provision of health insurance, while another group of thought supporting the efforts by the government and actually viewing them as innovative means of meeting the health needs of the nation.
According to Lowery (2007), there is a high proportion of individuals who believe that the US contemporary health policies that are in place need to be reformed. This is due to the mere fact that over 46 million people in the US do not have any form of health insurance (Lowery, 2007).
Furthermore, there is a high proportion of individuals who are under insured. The fact that the cost of health has been rising with time and the realization of the fact that the US is not among the leading nations in the provision of health insurance to its citizens further affect the overall quality of health care that Americans are currently enjoying. Therefore, to determine whether the policy process has changed over time, this paper will discuss the Medicare and Medicaid, HSA and ACA policies in detail to determine the influence of the above factor in their enactment process and the reasons behind why they were enacted or failed to be enacted into law.
During the 1950s, the prospects of developing a health insurance policy for the general American public were low under President Eisenhower’s regime (Marmor, 1994). During this time, controversial bills that aimed at improving the health of the elderly and the poor lacked the congressional support that would have seen them being signed into law. Furthermore, these bills lacked presidential support due to the fact that the President Eisenhower was against the concept of ‘Socialized Medicine’ (Marmor, 1994).
In this respect, the proposed Truman’s health plan as well as the bills that had been developed to cater for the health needs of the elderly were not considered as a national priority at the time. Despite these setbacks and challenges, the promoters of these bills, who later played a significant role in drafting the Medicare policy, did not lose their enthusiasm. Examples of these promoters included:
- Wilbur Cohen, who was the director of Social Security Administration.
- Nelson Cruikshank, who was the ALF’s-CIO head of the Department of Security.
- Robert Ball, who worked in the Department of Social Security Administration.
These promoters introduced various aspects of health policy bills annually since 1953 with the knowledge that they would not be enacted into law, but with the agenda of keeping the idea of health insurance under social security alive and going. At the same time, they worked hard to develop strong relationships with congressmen who would present these bills to the Congress annually. Consequently, they developed a campaign aimed at creating public awareness on the need of health reforms in the United States, using the ALF-CIO platform (Marmor, 1994). An example is the Forand Bill that was largely rejected by the Ways and Means Committee in 1959, but its debate played a critical role in renewing the idea of social security health insurance in the United States (Marmor, 1994).
During the 1960s, the American economy grew, resulting in the growth of the middle class population that was highly educated and fully understood their rights. This fact explains the increase in the intensity of civil rights and labor union movements. Key on the agenda during this era was the question of health reforms. The Presidency at this time was also in favor of change in a bid of building a better economy and a great community through an increase of government spending and a reduction in the overall taxes charged to the public. One of the areas that Presidents Kennedy and Johnson looked at increasing on expenditure was in social health insurance (Panicola, 2007).
During the 1950s, the health insurance cover that most citizens had were from their employers. As such, when these individuals got out of employment and became older, they ended up either being underinsured or uninsured. It is due to this population group that health became the subject of attention for health reformers during the 1950s and early 1960s. The first response was through the Kerr-Mills Act that was enacted in 1960 and which enabled the federal government to fund states to provide health coverage for elderly individuals who were poor (Panicola, 2007). This policy soon proved to be ineffective since 3 years after its implementation, only 28 states around the nation had implemented it and from a critical standpoint, they had not adequately planned and budgeted for it.
In 1965, the House Ways and Means Committee started working on the Medicare plan. This bill also comprised elements of the improved Kerr-Mills Act and a proposal that required the government to provide subsidies in the purchase of private medical insurance for the elderly (Panicola, 2007). In the end, the Medicare bill comprised three layers. The first layer included coverage for medical care in hospitals and at home as well as nursing care. The second layer consisted of coverage for the payment of physicians, Medicaid, and federal funds directed towards the health insurance coverage of poor and disabled individuals. The third layer left the burden of payment of prescription medicine, long-term medical care, as well as insurance for eyeglasses to the elderly and as such, they had to get private medical insurance to cover for these services.
The Congress had mixed reaction all through the development to the enactment of this bill into law. As asserted earlier, President Kennedy was in support of this bill. Most Democrats were also in support of this bill other than the Southern Democrats who present it from being signed into law during Kennedy’s regime (Marmor, 1994). However, the Congress experienced changes after the election of Johnson into office. This election also saw an increase in the number of liberal Democrats in the Congress, a situation that Johnson rapidly took advantage of in spearheading the passage of the Medicare bill into law.
Outside congress, the Medicare bill gained support from labor unions who were incurring high medical expenditure on retirees. Consequently, civil rights organizations such as the ALF-CIO supported the bill as a means of achieving health equality for the elderly and in the process encouraging the elderly to form groups and organize rallies as a means of enlightening and creating awareness about the Medicare bill and its importance in improving social health insurance in the United States. However, the American Medical Association (AMA) was against the bill due to its stand against socialized medicine.
The Health Security Act (HSA)
The performance of the American economy in the 1980s and President Reagan’s administration was at the record low since the great recession of the 1930s (Sanderson, 2006). During this regime, the government policies were characterized by substantial tax reductions, increased expenditure on defense and military operations, and mild reduction in public expenditure. As a result, the federal debt greatly increased to a record high in American economic history, unemployment rates increased, and ultimately, the cost of health care kept escalating all through the 1980s.
The scenario was dire. It affected even the individuals who were working in the business sector to advocate for health reforms in the nation, especially with the ever increasing gap between the lower and upper middle class and the 1990-91 recessions (Sanderson, 2006). It is these factors that made campaign topics between the 1992-94 election campaigns.
During the early 1990s, most Americans were in fear of losing their health benefits (Sanderson, 2006). Furthermore, Americans were also uncertain as to whether they would be able to meet their medical costs given the trending economic situation. To gain support, politicians focused their campaign approaches on health reforms. Running for the senatorial post in the state of Pennsylvania in 1991, Harris Wofford was among the early politicians to base their campaign focus on health reforms (Sutton, 2011). As a result, numerous proposals on health reforms started surfacing. They included:
- Market focused reforms that mainly expounded on the role played by the private sector in the provision of health insurance.
- Public payment plans
- Employer mandates
- Health care tax credits (proposed by President Bush, but never materialized since Clinton won the elections).
President Clinton proposed the HSA policy that aimed at achieving universal health insurance coverage whereby every American will have a health security card (Schulenburg, 2010). This policy also advocated for employer and individual mandates and also encouraged competition among private insurance companies under the health-purchasing alliances where the government played an integral role of keeping down the cost for various insurance covers (Sanderson, 2006).
This bill was developed by the Health Care Task Force that was led by the then First Lady, Hillary Clinton supported by a team of approximately 600 professionals and aides (Schulenburg, 2010). President Clinton presented the sophisticated bill before the Congress in September 1993. Despite the fact that the Democrats hold the majority seats in Congress, they did not have a unanimous front due to the differences that they had on various issues presented by the HSA bill.
Most of the Democrats supported clauses such as the single-payer bill and the competition among various insurance companies, since this would ultimately reduce the cost of health insurance cover. However, the universal health insurance clause did not get unanimous support from all Democrats lawmakers. This split decision also extended to interest groups within and outside the congress and the American public in general.
Unlike in the case of Medicare where various institutions and organizations openly supported the bill, support for HSA was on a conditional basis, especially with regards to specific organizations and unions. For instance, there were labor unions that were not in 100% support of the HSA bill, but did not want to oppose it publicly (Starr, 2015). Other organizations such as public health organizations wanted to fight change to various segments of the bill from the inside and not publicly.
On the other hand, there are organizations such as the Health Insurance Association of America (HIAA) and the National Federation of Independent Business (NFIB) that publicly opposed the bill. HIAA, for instance, was against the bill due to the fact that larger insurance companies would outcompete small firms; hence the latter would have no choice but to close down their business because of unfair competition. NFIB, on the other hand, argued that the implementation of the bill would be unfair to small business entities to provide cover to their employees on the same level as large and well established business entities (Starr, 2015).
To clearly air out their opposition of the bill, the HIAA produced an advertisement that was aired on TV across the United States, portraying a middle class couple who felt threatened by the proposed health reforms. This advertisement got a lot of response and support from the American public, mainly low and middle income earners (Starr, 2015).
Just like during Truman’s and Kennedy’s regimes, it is evident that the fact that Clinton was elected power without gathering majority votes highly affected the manner in which he would be able to pass bills into laws in the Congress, the HSA being an example. Furthermore, the tactics and approach used by his administration to present the bill to the Congress. For instance, in addition to its complexity, the proposed bill was approximately 1400 pages long. This greatly slowed down the rate at which the bill passed through the congress and greatly reduced its chances of gaining popular activism (Marmor, 1994).
This resulted in a divided Democratic support in the Congress. At the same time, the opposition was well organized to oppose the passage of the bill and as such, the HSA did not stand a high chance of being enacted into law. However, it is through its proposals that Medicaid got its foundations from and was enacted in 1997 as a program aimed at providing children from low income families with health coverage (Devettere, 2009).
The Affordable Care Act (ACA)
Just like the recession that the United States was facing in the 1930s, and the 1980s, the nation once again faced another recession between 2007 and 2010 (Edwards, 2011). This created a huge challenge to the policy makers of the ACA in 2010, especially with regards to the fear that expanding the health insurance policy at the time coupled with the new health insurance coverage requirements that employers had to meet, the nation would find it rather difficult to recover from economically since the proposed bill would greatly affect the availability of jobs in the nation.
This meant that there was a possibility that the rate of unemployment would increase further after the enactment of the bill into law (Starr, 2015). On the other hand, however, there were those who believed that this new law would curb the rise in the cost of health care resulting in the availability of capital to be invested in other ventures, hence creating more employment opportunities and leading to economic growth (Flook, 2005).
Like Medicare and HSA, the ACA bill had presidential support. Proposals for the bill commenced earlier in the decade, but in 2009 President Obama outlined eight principles of proposed reforms in the social health insurance policy of the United States during the financial year budgetary speech. In accordance with the 2009 budget, $634 were allocated to fund the proposed health insurance reforms (Gurbutt, 2011).
In February 2010, the updated version of the ACA comprising the consensus reached by the House and the Congress. Despite this, the Democrats and the Republicans found it difficult to come to a consensus on ratifying the bill even after its presentation by President Obama during the second Health Care Summit held in February 2010. Despite the stiff opposition from the Republicans, the House of Representatives passed the bill and presented it for presidential ascent in March 2010.
This new law aimed at covering the poorest individuals in America under the Medicaid umbrella. The American Health Benefit Exchanges was also introduced as a subsidy to the individuals who did not enjoy health insurance benefits from employers and still could not adequately afford to purchase health premiums for themselves. At the same time, the act made it not mandatory for employers to pay health insurance benefits and at the same time, small entities were given subsidies to meet the health insurance needs of their employees.
Dedication of Passing Health Reform Policies into Law
So far, this paper has critically analyzed the similarities and differences that are present between the Medicare, HSA, and ACA health policies and their legislation processes. This next segment with thus critically analyzes whether the long standing dedication to implement long lasting health policies can be achieved in the contemporary world as it was during the era when Medicaid was implemented.
From the discussions presented so far, it is evident that the proposed bills that have recently been presented to the Congress, to be particular, the HSA and the ACA, have been developed, drafted, and presented in a professional manner with a lot of care and effort put in place through this process. From a personal perspective, I do believe that the effort and the long standing dedication put in developing social health policies in the 1950s and 1960s can be achieved in contemporary times despite the change in the socio-political environment in the USA between these two eras. This conclusion can be explained using the following models:
- The rational actor model.
- The organization process model.
- The bureaucratic model.
Rational Actor Model
In accordance to this model, the government is considered as a rational actor whose main aim is to make strategic sociopolitical decisions. As such, the policies that the government implements play a significant role in achieving specific goals and objectives within the overall society. In this respect, the government needs to make the right choice by selecting and implementing specific goals and objectives through purposive action and implementing the selected policies strategically through rational calculation (Marmor, 1994).
With this in mind, it is evident that during the 1950s, social health reforms were not considered as the main challenge that the American government was facing, hence explaining the reason why the proposed social health reforms were not passed into law by the Congress at the time. However, the constant presentation of health reform proposals and bills kept the idea going by the 1960s, social health reforms became the main agenda in the policy implementation plans of the American government that resulted in the enactment of the Medicare policy.
Similarly, in the 1990s, the United States was on a brink of health policy reform, but the sociopolitical environment did not consider the HSA policy as the immediate solution to the social health policy problems that the nation was facing at the time. However, it is the provisions of this bill that laid foundations to the ACA that were later enacted into law under the Obama regime in 2010 (Hunink, 2011). Acting rationally, the government enacted the ACA due to the fact that the United States currently requires a social health policy that is not only affordable, but also focuses on the health needs of all individuals in America and not specific population groups (Jensen, 2011).
Organization Process Model
This model is mainly concerned with the behavior of organization that play a significant role in the development and implementation of specific decisions and policies in a given setting. A key assumption of this model is the fact that organizations change gradually over time, not drastically (Marmor, 1994). Therefore, the future behavior of a certain organization can be predicted by considering its structure, the programs that it is running, and its past and present behavior.
The US government does not solely make the decisions in relation to matters of policy, but highly relies on other organizations, groups, and institutions to present their ideas and views on contemporary issues. For instance, the ALF-CIO, labor unions and other organizations were actively involved in the 1950s and 60s in spearheading the need for social health reforms in the United States through campaigns and public awareness movements (Gold, 2009).
The AMA on the other side ran a parallel campaign against socialized medicine. As President Clinton was presenting the HSA policy to the Congress, there was a mixed reaction in most labor unions, some of whom chose not to publicly oppose the policy, but fight it from inside while others. However, there were organizations such as the HIAA and the NFIB that openly criticized the bill, a move that gathered public support, hence playing a significant role in making the HSA not to be passed into law.
The Bureaucratic Model
The outcome of a domestic policy in the United States is determined by the influence of various groups such as the presidency, the executive, legislature, congress, lobbying groups, and the like (Marmor, 1994). Given this interaction, consensus can only be achieved through a bargaining process following the laid down hierarchy or the national government that involves bargaining strategies, presentation of stakes, and trade-offs.
It is through these bargaining processes that the final versions of the Medicare and ACA policies were arrived at after negotiations among the independent players. Despite the fact that these policies had presidential backing, the bargaining process still had to take place, especially in Congress that resulted in various amendments that resulted in the final policies that were finally enacted into law. It is critical to note that the final versions of these policies were not what were actually proposed, but were an outcome of a bargaining process (Marmor, 1994).
Application of the Models
USA has a long history of health reforms, especially during the 20th century. Theodore Roosevelt’s regime called for the development of a national health industry in 1912 that resulted in proposals by several states of developing a state-based health insurance system. In the 1920s, progressive reformers campaigned for group medicine and voluntary insurance, which resulted in the development of the phrase ‘socialized medicine’ (Gray 2007).
However, prior to the 1960s, no significant development had been made towards the development of an effective, efficient, and sustainable health policy. As asserted by Gray (2007), this could be attributed to ideological differences, the complex nature of the proposed national health policies at the time, the lack of lobbying strength by special interest groups that were campaigning for health reforms, weakened Presidency, and the fact that the power of the Congress at the time was decentralized. These factors are consistent with the rational action model, since during this era, social health insurance was not considered as a top priority government issue during the Eisenhower regime.
However, by 1965, Medicare had been signed into law by President Johnson. This legislation was conducted in the presence of Harry Truman, former President of the United States. This success can be attributed to strong influence from the President (Kennedy, Johnson, and Truman), the exceptional political skills that Johnson possessed while dealing with the Congress, a majority of whom were democrats, as well as overwhelming support from the public and the medical industry (Starr, 2015).
During this time, the federal agencies that are involved in determining the legislation costs of proposed policies were not in existence. Consequently, cost projections of economic policies at the time were not central to Congress debate as they are at the moment. These two factors were influential in the development and implementation of the Medicare health policies. Here, a combination of the rational actor and organization process models can be seen in play through the combined effort by the government and other agencies to ensure that the Medicare policy is successfully implemented to meet the needs of the American people.
The HSA was developed during Clinton’s Era as the President of the United States in the 1990s. This bill was spearheaded and got a lot of support from the then Hillary Clinton. This policy aimed at developing a universal mandate that made it mandatory for all employers to contribute to a specific fund trust for employees to carter for their health insurance premiums (Kaufman, 2006). In this respect, established institutions would have had a cap limit that they had to contribute, while small business entities would have been given subsidies. Additionally, competition from private insurance firms would have been curbed by caps on the increase in growth of insurance costs. At the same time, subsidies from the government were expected to come from the reduction in Medicare costs as well as an increase in the taxation of tobacco in the United States (c Kaufman, 2006).
However, despite the careful organization of this policy and the fact that it received huge support from the Presidency and from the American public in theory, it was never passed into law by the Congress. This was as a result of a stiff opposition from medical and private insurance entities. Anti-tax rhetoric were also against the policy. It is as a result of this failure the Republicans gained an upper hand in the House of Representatives as well as the Senate during the 1994 elections (Lohr, 2005). From a critical standpoint, it is evident that despite there being a need for health policy reforms, there are players who are against various aspects of this bill and through the bargaining process, they end up coming up with a national solution of not passing it into law, since it would be detrimental to the overall operation of the US government.
The ACA, popularly known as the Obama Care was developed by the Obama administration during President Obama’s first term in office. Despite the tough economic situation at the time and opposition of the draft policy, it was enacted into law in 2010 (Cohn, 2010). The hallmarks of this policy were:
- Reforming the private health insurance industry.
- Increasing health insurance coverage for uninsured citizens.
- Improving the health insurance covers for individuals who have pre-existing health conditions.
- Enhancing the efficiency of prescribed medical coverage under the Medicare policy.
Just like under the HSA, ACA funding is expected to be generated from taxes. 40% of taxes from Cadillac insurance policies are used to fund this program as these are products used by the rich and wealthy within the community (Starr, 2015). Furthermore, taxes from pharmaceutical products as well as medical devices are also used to fund the program. From a critical point of view, it is clear that the political environment during the Obama administration in 2009 was similar to that of Clinton in the 1990s due to the mere fact that both Presidents were from the Democratic Party which enjoyed majority support in both chambers of the Congress.
From the discussions presented, it is evident that there are similarities and differences in the manner in which the Medicaid, HSA, and ACA policies were developed and implemented. One of the major similarities is the fact that for high profile bills like these, it is essential to have support from influential individuals, organizations, and authorities for proposals to even be presented before the Congress. For instance, Eisenhower’s regime did not support the proposed social health reforms at the time, hence the reason why the failed. Consequently, the lack of support by the Congress saw the HSA failing to pass Congress. However, strong support of Medicare and ACA by the President, the Congress, organization, and the American public saw these bills legislated into laws that are still in existence to the present moment.
It is thus evident that before a policy is passed into law, a number of factors need to be put into consideration. These include special interests, committee structures, the justice department, the Presidential influence and legislative power, the public opinion and overall voting power, and most importantly, the media. Using the rational actor, organization process, and bureaucratic politics models, it is evident that the players involved in the formulation and implementation of health policies still have the same level of long-standing determination to ensure that the policies that are enacted meet the current and future needs of the American society. This is a critical consideration as it ensures that the implemented policies are effective, efficient, and sustainable over time.
Cohn, J. (2010). How did they do it? Web.
Devettere, R. J. (2009). Practical decision making in health care ethics: Cases and concepts. Washington, D.C. : Georgetown University Press.
Edwards, A. (2011). Shared decision-making in health care: Achieving evidence-based patient choice. Oxford, England: Oxford University Press.
Fairman, J. A. (2011). Broadening the scope of nursing practice. The New England Journal of Medicine, 364(3), 193-214.
Flook, E. (2005). Health services research and R&D in perspective. Ann Arbor, MI: Health Administration Press.
Gold, M. (2009). Pathways to the use of health services research in policy: Health services research. New York, NY: SAGE.
Gray, J. (2007). Evidence-based health care. Edinburgh, UK: Churchill Livingstone.
Gurbutt, R. (2011). Decision making and health care management for frontline staff. London, England: Radcliffe Pub.
Hunink, M. (2011). Decision making in health and medicine. Cambridge, England: Cambridge University Press.
Jensen, U. J. (2011). Changing values in medical and health care decision making. Chichester, England: Wiley.
Kaufman, H. (2006). The political ingredient of public health services: A neglected area of research. The Milbank Memorial Fund Quarterly, 44(4), 13–34.
Levett-Jones, T. (2012). Clinical reasoning: Learning to think like a nurse. Frenchs Forest, N.S.W.: Pearson Australia.
Lohr, K. (2005). Health services research: An evolving definition of the field. Health Services Research, 31(1), 15–17.
Lowery, D. (2007). The political management of managed care: Explaining variations in state health maintenance organization regulations. Journal of Health Politics, Policy and Law, 32(3), 457–96.
Marmor, T. (1994). Understanding health care reform. New Haven, CT: Yale University Press.
Panicola, M. R. (2007). An introduction to health care ethics: Theological foundations, contemporary issues, and controversial cases. Winona, MN: Saint Mary’s Press.
Sanderson, C. J. (2006). Analytical models for decision making. Maidenhead, England: Open University Press.
Schoonhoven, L. (2013). Nursing implementation science: How evidence-based nursing requires evidence-based implementation. Journal of Nursing Scholarship, 40(4), 302-310.
Schulenburg, J. M. (2010). The influence of economic evaluation studies on health care decision-making: A European survey. Amsterdam, Netherlands: IOS Press.
Sobo, E. (2013). Behind the scenes in health care improvement: The complex structures and emergent strategies of implementation science. Social Science and Medicine, 67(10), 1530-1540.
Starr, P. (2015). The social transformation of medicine. New York, NY: Basic Books.
Sutton, A. J. (2011). Evidence synthesis for decision making in health care. New York, NY: Blackwell.