Government control and the sustainability of democratic institutions

Sustainability of Democracy

The objective of this study is to examine the sustainability of democracy including the Health Care Reform of Medicare and Medicaid that is burdening physicians and Durable Medical Equipment Providers to compete for contracts through competitive bidding and the patients not having the option to choose their providers. As well, the government control of the issues of health insurance will be examined and the question answered as to whether the sustainability of democracy will remain given the evidence of government control.

Sustainable democracy is addressed in a report of the Government Commission on Swedish Democracy which states that democracy "is not immutable. The institutions of democracy are fragile in the sense that they take a long time to build up but can collapse significantly more quickly, not least through violence. However, de-democratization can also creep forward, by small but conscious adjustments of important details of the structures." (Ministry of Justice, Stockholm, Sweden, 2000, p.1) This may result from "critical development being neglected or by political representatives consciously or recklessly misusing the confidence of citizens." (Ministry of Justice, Stockholm, Sweden, 2000, p.1)

Representative Democracy

Representative democracy is reported to constitute "the interaction of representative democracy with citizens' experiences and desires that the development of government by the people is determined. In the many meetings between citizens the virtues and norms that a democracy both requires and aims are formed." (Smith 2008, p. 2) Sustainable democracy is comprised by "self-organization, decentralization, and self-administration. Scope is therefore given for diversity in participation and a large measure of pluralism and autonomy." (Smith 2008, p. 2) It is reported in the work of Most people engaged in sustainability debates over the last two decades have shrugged the question off. At most, we'll suggest that sustainability and democracy are necessary partners. We'll argue that you can't bring the (mostly) staggeringly wealthy and materially cosseted societies of the developed world to address the downsides of their lifestyles without legitimate agreement on the need for action." (Smith, 2008, p.1)

Medicare and Democracy

Medicare patients are reported to face access to care that has been greatly reduced and "which will be inevitably rationed through the Affordable Care Act's relentless payment cuts." Medicare has been ended as it is known through 165 provisions or amendments affecting the program." (Moffit, 2012, p.1) The real problem with the restructuring of Medicare is the politicization and the costly micromanagement that today burden the program." (Moffit, 2012)

It is reported that the "variation of a competitive bidding concept have been proposed by respected and thoughtful policy innovators from across the ideological spectrum. Proposals for a competitive bidding reform of Medicare date to the 1970s, and in 1999, the bipartisan Medicare Commission made recommendations stating, "[w]e believe a premium support system is necessary to enable Medicare beneficiaries to obtain secure, dependable, comprehensive high quality health care coverage," and "modeling a system on the one Members of Congress use… is appropriate…" (, p. )

The Ministry of Justice of Stockholm Sweden writes in its report that it is not "a function of government commission to prescribe a remedy for the ailments of the parties" and it is clear that the function of a democratic government is not to prescribe what health care provisions that its citizens should or would seek as a requirement set by the government or its commissions but instead "In order to reinforce representative democracy, the parties must develop both ideas and working forms that match the needs and requirements of citizens." ( )

Berenson (2003) writes in the work entitled "At the Intersection of Health, Health Care and Policy" that the policy community "The policy community accepts with remarkable equanimity that many Medicare beneficiaries receive poor-quality care, which reflects the relatively poor quality of care in the U.S. health system and demonstrates sizable regional variations. In contrast, on the issue of excessive spending, there is an apparent overabundance of caution about not causing any harm to quality or access. The result is policy nihilism, where the problem of excessive regional spending gets better defined, but nothing is done about it." (p.3)

There has been a debate for many decades in the area of the constraint of costs and the effectiveness of policy activity towards this end and if these should be "directed at relatively few 'big-ticket' items, or rather to millions of 'small-ticket' items that cumulatively account for a lot of spending." (Berenson, 2003, p.3) Recommendations have suggested that Medicare should focus cost containment on the small number of beneficiaries who are responsible for disproportionately high spending. In Medicare, 5% of beneficiaries account for 50% of program spending." (Berenson, 2003, p.4) However, the problem with such a focus is that high-cost patients are not necessarily patients with the big-ticket expenses. Additionally presenting a challenge in doing this is that providers simply do not keep financial accounts differentiated by the high or low cost categories of patients and as well there is no clinical differentiation between the high and low cost patient. (Berenson, 2003, paraphrased)

A more democratic method of reducing costs while maintaining quality is addressed in the work of Nix and Senger (2012) who state that over the past ten years "…the use of consumer-directed health plans (CDHPs) has increased substantially. In 2006, Indiana introduced plans with health savings accounts as a coverage option for state employees. A case study by Mercer Health and Benefits LLC, a leading consulting firm, examined the outcome of Indiana's implementation and found generous cost savings and increasing annual enrollment. Another study published in Health Affairs found that greater use of CDHPs that use HSAs or HRAs could result in annual savings as high as $57 billion in the overall health care system. This body of research highlights the proven success of consumer-directed health plans and their potential to address rising health care costs without sacrificing quality of care." (Nix and Senger, 2012, p.1)

Consumer Driven Health Care

Consumer-driven health care is a much more democratic method of health care provision in which the consumer has a direct affect on the health care service provision and choices made for their health care. The Mercer study found that "savings for those enrolled in the HAS plans came from reduced utilization and lower intensity of services. The study found no evidence that participants avoided care; to the contrary, migration was "virtually a one-way flow" from the PPO option to the HSA plans, and if participants were having adverse experiences this would not be the case." In addition, there was "no reporting over the study period of any such issues of adverse results from deferred care." (Nix and Senger, 2012, p.1) The study concludes by stating that sources of savings "appear to come from better use of healthcare resources and more cost conscious decision-making." (Nix and Senger, 2012, p.1)

Cost-Reduction Achieved

Patients in this program were reported to have had "lower hospital admissions and shorter lengths of stay when they were admitted." (Nix and Senger, 2012, p.1) It is concluded as well that health care costs "…can be positively influenced if patients are motivated to be better consumers, empowered with information about provider quality and treatment options, and given access to the tools and support required to understand and improve their health status. Obviously, these individuals and their employers also benefit from improved health status, energy and productivity." (Nix and Senger, 2012, p.1)

Summary and Conclusion

It is not the government's function within the realms of democratic principles and government to make health care choices across-the-board because it is not possible to consider all the diversity of health care needs from the view of government. Cost reduction in health care can only be accomplished through consumer driven health care services and through the principles of democratic representation and the leaving open to consumers of choices concerning their own individual health care.