Fact and fiction: The medicare "crisis" seen from the United States.

There are at present two conflicting images of medicare available to the visitor from the United States. One is the conventional media portrait of crisis--from both U.S. and Canadian sources--an image of a program in deep trouble, overcome by problems of access, cost and quality. The other image is far more favourable: medicare as a structurally sound program of universal health insurance that largely satisfies those who use it, but, like all programs, requires managerial adjustment and attention to the fearfulness of medicare's future that has marked the last decade. This is the conclusion of the recent report of the Canadian Institute for Health Information (CIHI). Both portraits cannot be accurate, just as being green and white all over is logically impossible. What is the American interpreter to make of this dispute?

Medical care and public policy: the benefits and burdens of asking fundamental questions.

This article questions two assumptions that regularly appear in discussions of what a fundamental discussion of medical care policy choices should include. First, we review skeptically the presumption that explicit specification of the scope of publicly financed medical services is a crucial step in improving policy-making in the health and medical care arenas. Second, we question the appropriateness, in many if not most contexts, of explicit rationing, the belief that being clear about who gets what (and who does not) constitutes proper public policy. The article proceeds by looking back on the grounds for universal access to medical care, discusses the disputes about how to set limits on care, and illustrates its argument with references to Dutch debates about explicit choice, the Oregon experiment with priority setting, and the appeals to 'healthy public policy' as a standard for sensible policy reform. The article closes with a brief discussion of the spread of assumptions about health reform as they move across national borders.

Forecasting American health care: how we got here and where we might be going.

This article is a form of thinking about the future properly regarded as conditional forecasting. It begins by reminding readers of the enormous changes in American medicine since World War II. The second part revisits critically an earlier effort at conditional forecasting for 1995 that Paul Starr and I published in the early 1980s. Besides reviewing the prescience of our forecasts, the second part outlines the earlier trends in progress we identified and the four combinations of political and economic settings we explored. On that basis, the final part takes up the challenge of anticipating sensibly some possible medical futures in the America of the early twenty-first century, a task which excludes simple extrapolation.

Hope and hyperbole: the rhetoric and reality of managerial reform in health care.

The scope of this essay is broad--the dangers that much conventional management commentary represents for health care institutions and those who work in them. It emphasizes two themes in the hype and hyperbole of management talk about health care. The first is the character of the language used to describe health care arrangements--the 'rhetoric of medical managerialism'--a rhetoric that powerfully and misleadingly combines the jargon of modern management schools with the marketing hype of advertising. Second, it includes some observations about what this cautionary tale might mean for the daily work of those in health care.

Medicare: challenges and future directions in a changing health care environment.

In this GSA-sponsored Congressional Briefing Seminar, authorities from several disciplines summarize the history, rationale, strengths, weaknesses, and future challenges of the Medicare program. In the current arena of health care reform, the role of Medicare is far from certain, and it is crucial to understand and confront a multitude of issues, many of which are raised in this briefing.

Commentary on Canadian health insurance: lessons for the United States.

The Government Accounting Office's comparatively favorable report on Canada's National Health Insurance program (Medicare) prompted a firestorm of reaction: criticism from the health insurance industry primarily and praise from advocates of single-payer models of American reform particularly. Congressional hearings aired this controversy, and this article is a revised version of the author's testimony to the Government Operations Committee, June 18, 1991. The author examines the legitimacy of cross-national comparison as a general analytic tool and the lessons to be learned from North American health care comparisons in particular. In the final section he critically discusses two sets of myths about Canada's experience with universal health insurance: those regarding the desirability of the Canadian system itself and those questioning the transplantability (adaptability) of the model to the United States.