Book Review: A Borderlands View on Latinos, Latin Americans, and Decolonization: Rethinking Mental Health

Aborderlands view on Latinos, Latin Americans, and decolonization: rethinkingmental health by Pilar Hernandez-Wolfe central thesis focuses on what the author terms “intersectionality”. Intersectionality can be thought of as the interplay of race, ethnicity, gender, sexual orientation, migration, class, language, and macroeconomic and social-ecological influences on our lives. The author, a licensed marriage and family therapist, helps readers climb a virtual mountain of historic underpinnings of social injustice, and arriving at the peak, we are able to understand how this foundation of intersections form the basis of an identity and frequently serve as the basis of individual or familial mental health pathology.

Rather than blame the individual, the author holds superpowers such as the United States, and colonializers, such as Spain, as the responsible parties for much of the suffering in the Americas. Her definition of colonialization is that colonization happens any time an outside culture invades an existent culture, resulting in a loss of knowledge of and appreciation for the existent culture, and giving rise to a new, third culture that lacks understanding of the original culture and ways of being. From this perspective, colonization is a macro-traumatic act, forcing entire societies into submission and giving rise to a new social order where the colonized people internalize globalization and perpetuate colonization against their own people.

People who have internalized inequality and unhelpful bystanders come to perpetuate inequality in their own societies, and learn only upon immigration to the United States, that even if they are considered “White” or  of the ruling class in their country of origin, in the U.S., Latinos are frequently assimilated into the class that is “ruled over”.

Drawing on feminist principals of sharing of economic and social power, the author stipulates that the pathway towards healing lies first in developing critical conscience. Only when people begin to understand the exterior forces that led them to points of crisis in their own lives, can they begin to see inequities in society that harm both the individual as well as anyone they are exercising “power over”. The author explores “Just Therapy” and “Transformative Family Therapy” as theoretical models for treating mental health issues in minority clients. However, I would suggest that beyond looking only at minority clients, the treatment models suggested could be useful for clients of all backgrounds. While White middle class heterosexual clients might not go to marriage therapy looking for someone to “blame” for their problems, the real answer lies in examining personal history and the exposures (biological, social, educational) that have laid the basis of our automatic cognitions. One of the reasons I hypothesize that Cognitive Behavioral Therapy has been indicated for so many conditions is that it is goal focused and practical and its techniques are replicable.

Just Therapy and Transformative Family Therapy may be more difficult to replicate, as one of the central approaches involves males and females breaking into gender congruent groups to discuss the issues that brought them to therapy and develop a conscious awareness of the societal and economic forces that prevail in their lives and may have been the germination bed of their inter-familial issue. Numerous therapists are used and the therapeutic practice itself meets regularly to discuss each therapists’ praxis of the racial, ethnic, gender, sexual-orientation, and class biases that may impacts his or her own ability to deliver Just/Transformative Therapy.

This approach, with its critical analysis of race, ethnicity, gender, sexual identity, class identity, and migration history may not prove helpful for people from highly individualistic societies, or those that are drawn to solution focused therapeutic approaches. However, especially for people who come from societies with a collective orientation, this approach may be more helpful than CBT.

One of the essential take aways from this book is of the need for therapists to examine their own privileges. Rather than identify “White” privilege as the culpable issue, the author takes on the shades of beige and the ways that Latinos in the U.S. may use their “minority” status as a way to rule over Latinos of a “lesser” class. Arguing that everyone has some privilege, the author urges readers to think about all the different ways that their particular race, ethnicity, gender, sexual-orientation, and education has shaped their perception of the world and the ways that these particular facets of identity elevate or lower how they are perceived in society, and how that perception affects the power distance they experience between themselves and their clients.

While the author weaves together theoretical and treatment approaches from a variety of the social sciences, there are portions of the book that would have benefited from the loving hand of a copy editor and additional critical feedback from peers. If the purpose of the chapter that contains information on Just Therapy and Transformative Family Therapy was to provide instruction on how to implement these therapeutic modalities, then the chapter could really benefit from addition of more material that at minimum could provide the standard “Plan-Do-Study-Act” approach used in dissemination sciences. It seemed to me that the foundational planning and strategizing mental health practices would need to undertake in order to implement this approach wasn’t sufficiently covered in a way that would facilitate planning to undertake this type of practice transformation.

This book is informative for graduate level students seeking to deepen their understanding of the historic issues inherent in the mental health treatment of Latinos in the United States. The study guide at the end provides questions for critical consideration and could serve as a study guide for a seminar on Latino mental health. However, this book does not offer typical prevalence or incidence information for students seeking to understand basic information on Latino mental health in the United States. Additional reading would be required to understand the scope and burden of specific mental health problems of Latinos in the U.S.

Public Health Leadership-Evaluation

What is one of the problems with using competencies as a means of evaluating leadership?

The main problem with competency frameworks is that the competencies are not defined with sufficient specificity to permit their measurement. Competencies need to be broken down into specific components that can be measured. There must be an applied research strategy to evaluate the necessary leadership competencies on a regular basis and the competencies should be updated based on organizational objectives. The process of defining the framework for competency based assessment has only recently been developed and it will take some time for a complete performance standards system to be capable of evaluating leadership outcomes.

What are the pros and cons of credentialing leaders?

The supporters of credentialing argue that credentialing increases the credibility of public health professionals both with members of the public as well as with politicians. Furthermore, they argue that credentialing will enable the development of professional standards. Supporters of credentialing want to link credentialing to licensure. The proponents argue that the process of evaluating professional knowledge helps develop standards for professional performance. The critics argue that no credentialing system is possible because of the multidisciplinary background of public health professionals. Furthermore, they point out that schools of public health are accredited and so a degree from an accredited body should be sufficient evidence of competence.

                I understand both sides of this debate. Before I started graduate school it seemed like such a monumental undertaking that is seemed that graduates must have a special level of expertise. However, as I have neared the end of my course work and gotten to know graduates of this program as well as employees of HHS that have masters degrees, I have come to the conclusion that a person of only ordinary intelligence and character can graduate from a MPH program, and the fact of obtaining this degree may or may not indicate their competence to practice public health. Therefore, I can understand the argument that credentialing may serve to raise the bar and establish readiness to practice. In a sense, the argument that graduating is good enough is akin to arguing that doctors, by virtue of graduating from medical school, are prepared to perform as physicians.  

A report from the association of schools of Public Health discusses the factors that need to be addressed in a sound credentialing program. First role delineation that distinguishes between professionals who have different skills and levels of knowledge is a requisite. Second, the credentialing system must specify the knowledge and skills required to carry out the duties of a credentialed public health leader. Third, the system must determine the education, training, or experience necessary to generate the required competencies. Fourth, a testing procedure or other form of assessment must be devised to determine when a practitioner has achieved entry level competency. Lastly, the system must allow for a process for recertification or maintenance of certification through ongoing professional education.

What are five personal leadership lessons you have learned in the last year?

I have learned that it is important to cultivate emotional intelligence and stay in touch with your feelings. I have also learned that self-care is essential. I have the tendency to want to help everyone else around me and forget to care for myself. It is important for leaders to invest sufficient time in self-renewal and rest. Furthermore the issue of work life-balance is important for public health leaders. In a field where there is so much to be done, and where the workforce is committed to principals of social justice, it is easy for public health leaders to become overly invested in the work they do. I think it is important for leaders to manage their time from an integral perspective, making sure that they preserve work-life balance. Another leadership challenge I have grappled with in the past year is how to inspire a strong work ethic in subordinates. Finally, I have learned to work more effectively with partner agencies by clarifying our respective agendas and better defining our roles in campaigns.

What is a 360 degree assessment?

The 360 degree assessment process involves a multilevel evaluation that focuses on whether the leader’s style of leadership supports or obstructs achievement of the mission and goals of the organization. In a comprehensive 360 degree assessment, all key stakeholders have a voice in evaluating the leader and assessing the direction in which the organization is headed. In order for a 360 degree assessment to be carried out, the leaders of the organization must determine whether sufficient enthusiasm for and commitment to the process exists in the organization and whether they are willing to institute changes based on the results of the assessment. Secondly, they must collect high-quality data. Lastly, they must identify possible responses to the results, such as the development of new training programs and initiatives. The 360-degree assessment utilizes the leadership practices inventory (LPI). The five practices in the LPI are 1) modeling the way, 2) inspiring a shared vision, 3) challenging the process, 4) enabling others to act, and 5) encouraging the heart.

What are some difficulties associated with performing a 360 degree assessment?

A 360 degree assessment is often expensive and time consuming. Measurement instruments must be bought and staff must be trained to interpret the results. Furthermore, leaders must be comfortable revealing their self-perceived weaknesses to their colleagues and subordinates must feel comfortable rating their leaders. The last issue is of special concern in smaller organizations, where animosity could occur between leaders and subordinates if negative feedback is given.  

The rating of leaders is further complicated if subordinates know that ratings will be tied to the compensation of the leader. Regardless of employee’s role (leaders and non-leaders alike) all employees are subject to the exterior phenomena of inflation and if annual salary increases are not provided, then the real compensation of the employee decreases over time. Arguably, one of the key factors that influence health and well-being in American society is SES, which is made up in part by household income. If people are not compensated in such a way as to maintain their household income, their personal well-being may decrease. A public health agency needs to grapple with the issue of fair market value of compensation and how performance and compensation will be linked, when deciding how employees will be evaluated.

A final consideration when an organization is deciding whether to perform a 360 degree assessment, is contemplating whether performing the assessment will make a difference. Perhaps the process for changing leadership is so cumbersome that there is no way a leader can be forced out even if he/she fails to perform at a minimum level. A leader may be protected by political or administrative mechanisms that prevent any punitive action from being taken. If this is the case, a 360 degree assessment could simply be a drain on the organization’s time and resources.

What is qualitative leadership assessment and what are some techniques for performing such an assessment?

A qualitative leadership assessment evaluates the leader based on personal traits and behaviors. There are a number of instruments that can be used to perform a qualitative assessment. These include the Myers-Briggs Type Indicator, The Leader Behavior Analysis II, the Team Leadership Practices Inventory, and the Leader Behavior Inventory.  The Myers-Briggs Type Indicator (MBTI) assessment is a psychometric questionnaire designed to measure psychological preferences in how people perceive the world and make decisions. The Leader Behavior Analysis II is a tool for understanding perceptions of one's style by revealing what direct reports actually experience. It presents leadership situations along with four possible responses. Managers' responses to these situations reveal their leadership style flexibility, their primary and secondary styles, their effectiveness in matching the choice of a leadership style to the situation, and their tendencies to misuse or overuse a particular style. The Leadership Practices Inventory (LPI) is a questionnaire with thirty behavioral statements. Leaders complete the LPI-Self, rating themselves on the frequency with which they think they engage in each of the thirty behaviors. Five to ten other people—typically selected by the leaders—complete the LPI-Observer questionnaire, rating the leaders on the frequency with which evaluators think leaders engage in each behavior. Respondents’ feedback is anonymous. The Leader Behavior Inventory is based on five behavioral factors: Visualizing Greatness, Empowering the “We,” Communicating for Meaning, Managing One’s Self, and Care and Recognition.

Regardless of which instrument is used, public health leaders need to develop the competencies to carry out performance monitoring. They need to ensure that performance measurement is accepted by the staff and that the information gained through the monitoring process is used to improve operations. Performance measures for evaluating the activities of public health leaders and their community partners utilizing a systems perspective and the essential public health services paradigm have been developed by the National Public Health Performance Standards Program.

Why is leadership program evaluation important?

Ongoing program evaluation creates an atmosphere in which effective leadership and organizational learning can flourish. Leaders need to show support for program evaluation and include evaluation as part of the mission and vision of their agency. They need to be involved in the evaluation process and work with other agency officials to ensure that the process is successful. No organization can achieve excellence without opportunities for continual learning provided by training and leadership development programs. There are four major standards for program evaluation: utility, feasibility, propriety, and accuracy.

One of the first steps in program evaluation is to determine whether the training program is really necessary.  Once the topic of the program has been determined to be needed, the programs objectives should be set and the program developed. The third step is to offer the training program itself. Measurements should be done before or at the start of the training program and at its conclusion to determine the scope of the changes that occurred. Research can be done on several measures, including the association between program elements and leadership change, the lessons learned from the training course, measurable leadership competencies, the differences between new leaders and established ones, and the differences between trainees and colleagues who have not been trained.

What is one difficulty in evaluating leadership programs?

Because leadership development is sometimes used as a reward for public health professionals, there is a danger that this reward will benefit the individual and not the public health system if the training opportunity is not relevant to the needs of the system. Another challenge is the fact that a leadership development may not show an immediate return on investment. The delay between leadership development and the development of strategic outcomes creates difficulties in determining the value of training programs.  Another challenge is the lack of funding in public health leadership development for the evaluation function. There is also a lack of understanding about what such evaluations are supposed to accomplish.

How do leadership programs differ from other training or education programs?

Leadership development programs are different from other types of training programs because they seek to influence behaviors beyond specific skill sets. Traditional training or education programs seek to impart skills to the participants- teach them Java Script, how to better deal with conflict, or how a clinical trial can best be designed, etc. Because leadership is multidimensional and dependant on the internalization and projection of the organization’s mission and values, leadership development is much more profound than just learning a series of steps to carry out a project or handle a particular situation. 

What leadership issues do you think should be the focus of research?

I think the biggest challenge that leaders face is inspiring their employees to perform at the level of their personal best 100% of the time. Therefore studying the mechanisms whereby leaders can either inspire employees to perform at their peak level or leave the organization should be the topic of leadership research.

What are some benefits that would be gained by keeping a leadership journal?

Leadership is a complex, multi-faceted form of performance. We cannot know leadership exists unless something happens. Therefore it may be useful for the leader to keep a log of the activities and decisions she/he makes and document the outcomes of those decisions. Documenting situations and decisions over time allows a leader to look back and evaluate her evolution over time. This written record would also serve to help the leader construct case studies which could be shared with fellow leaders.

Lean Thinking in Healthcare

Use these comments on Lean Management in Your Term Paper/ Final Paper

I found the topic of lean management to be really fascinating, and think that there are many areas where this sort of efficiency thinking could be put to work.

I think that while we sing the praises of the TPS it is important to remember the Toyota recall problem that occurred in 2009-2010. Ultimately, the NTHSA found that Toyota didn’t have a manufacturing issue with their electronic throttles, but rather Toyota had a problem with lack of transparency and admitting there was a problem with their floor mats and steering columns (You can read press release here http://www.nhtsa.gov/PR/DOT-216-10) While lean thinking and the TPS may produce manufacturing efficiencies, when we are pursuing quality we may sometimes miss the mark, and organizations need to be able to admit when they have failed.

I found that the application of lean thinking in the emergency department to be especially valuable. Patients that are already admitted to the hospital may be less focused on getting out, so trying to speed up the inpatient process may be more challenging. However, patients coming to the ER (in most cases) just want to be treated and released. I found a really interesting video about lean in Great Britain  http://www.youtube.com/watch?v=tOuIrRPI9Xw where they completely re-designed their flow by having the 85% of people that will probably be released see only the receptionist and a nurse practitioner. The receptionist acted as both patient greeter and patient registrar, and the nurse practitioner replaced the triage nurse, the nurse aid that comes out to take you back to the bed and re-check your vital signs, the RN that performs the nursing assessment, and the physician that performs the physical exam and orders tests. The nurse practitioner is able to fill all of those roles, and by having the patient only interact with the NP, wait time and time spent rehearsing the history of present illness to multiple parties is reduced. Only the patients that the NP believes need admission are seen by the ER attending, and the ER attending is primarily responsible for seeing myocardial infarctions and traumas (whose treatment needs are beyond the scope of practice of the NP). An issue that management would have to consider is whether the efficiencies created counterbalance the higher salary they will pay the NP to do some work for which the NP is overqualified

There are many challenges to implementing lean management in an organization. In the aforementioned example, what happened to the jobs of all of the registrars, unit clerks, nurse aids, EKG techs, phlebotomists, and RNs that previously took care of the ER patients?  How do you have a “No Layoff Policy” while reengineering processes and positions? Another challenge that leaders face is resistance to change and negative employee attitudes. Leadership may have previously used some sort of quality or productivity tool and employees may initially see lean as a fad that leadership will eventually outgrow and hence not see the need to realign attitudes and behaviors around lean thinking.  Resistance to change is deeply ingrained in many professionals working in the healthcare field and leadership has to work hard to create buy-in and overcome the “that’s how we did it when I was in medical/nursing school” mentality.

One of the main arguments in favor of lean is that the American healthcare system is full of waste. As a society, we need to re-engineer our medical system because we cannot afford to maintain our status quo. This actually takes the idea of resistance to change to the higher level of society. Is our system wasteful only because we rely on expensive imaging technologies? Or is it also wasteful because our patient’s health literacy and ability to self-manage is insufficient? Or is it wasteful because of concern over medical malpractice causes duplicity in testing? As a people, Americans need to be willing to “trim the fat” that exists in our system; lean thinking can help health systems do this by systematically examining the root causes of problems and engineering long term solutions to solve systemic problems. 

Performance Management- Baldrige Award Winners and the Balanced Scorecard Approach

The positive aspect of the Balanced Scorecard approach is that it looks past simple financial results to the overall big picture of what is going on in the organization overall. This is especially important in businesses that are publically traded since there is a perverse incentive to take actions that “improve performance” on financial statements in the short run but in the long run jeopardize the competitive advantage and growth of the company. An example of this would be a government contracting services firm that dumps employees to reduce their immediate short term cash obligation to pay salaries, but later finds itself unable to bid competitively on new service contracts because they lack the people with skill sets to fulfill the contracts. Under the balanced scorecard, leadership should consider the customers perspective, the financial perspective, the internal business perspective, and the innovation and learning perspective.

The customer’s perspective has to do with how the external public (customer) views the company. An example would be how people view their iPad in comparison to how people view their Dell Streak. If you are Apple, your relationship with iPad users is going well; if you are Dell, your relationship with Streak owners is pretty dispassionate. The status of the relationship with the customer is essential when considering the future of a business. Just as the current status of a marriage relationship can tell us about the future of that marriage relationship, the current status of the company’s relationship with their customer base can be useful in predicting the probable future status.

However, current reality is not 100% predictive of future reality. This is why it is important for companies to consider innovation and learning perspective. Just as people grow and change over time, products and services demanded by the market grow and change over time. To know if the relationship with the customer will last over time, companies must proactively seek out new knowledge and trends. In terms of competitive advantage, companies should strive to be a market leader instead of a market follower in order to achieve maximum financial results. An example of this is Apple. People didn’t know they needed the iPhone until after Apple shared this information with them. All the other companies that produced similar products after Apple could only compete on price, since their product was not considered innovative by the market.

Financial reality is still important, however. Only through adequate cash flow and profitability can the business continue to exist and respond to its internal and external publics. The internal business perspective is critical in evaluating overall business performance. A company such as Starbucks is selling a product, but it could also be argued that they are also selling an experience. Part of that experience is the customer’s interaction with the staff. If companies are not adequately investing in their employees through wages, benefits, training, and the creation of a positive work environment, it is probable that employees will become resentful over time and seek out alternant employment options. For a services or knowledge based company, it is ESSENTIAL that the internal perspective of employee relationship management is prioritized. If the company is more a manufacturing type of firm, the internal business perspective may emphasize productivity or manufacturing excellence.

Since the creation of the managed score card requires data, and data must be generated and organized, it would be good if healthcare entities had a way to integrate external quality measures (from Medicare and the Joint Commission National Patient Safety Goals) in their internal management and processes. I looked at Poudre Valley Health Systems, AlantiCare, and Mercy Health System’s performance measure on their Baldridge applications. One thing I found across the board was that they all commented on how they assure data integrity, security, and HIPPA compliance. The timeliness of the data collection and review are necessary in order for the information to be actionable. By reviewing performance on a frequent basis, health entities can take corrective action to address areas where they are not performing at an adequate level.

Graduate Level Health Economics Essay Final

Three question final- free term papers- free downloads-, health economics, Medicare Part D, moral hazard, market failure, health insurance

1. Drawing on the webinars, webcasts, class discussions, and the book chapters, describe the relationship between high deductible health plans and the concepts of consumer surplus, moral hazard, and welfare loss. (35 points)

Consumer directed health plans (or high deductable health plans) first emerged in the United States market at the end of the 1990’s. This health insurance instrument differs from traditional managed care in having higher annual deductibles, often being linked to health savings accounts, and allowing consumers to experience the costs of their heath care choices until they meet their high annual deductable. The obvious advantage to the consumer of such a high deductable plan is that it allows for lower premiums. Indeed, this is a much more attractive product for healthy individuals that are unlikely to face significant health care needs but who wish to insure against catastrophic losses- such as those that would occur from the sudden onset of a deadly disease. Proponents of high deductable plans argue that these plans incentivize more responsible consumer behavior, and that consumers/patients who face the full costs of their choices will make more intelligent, less wasteful decisions. Opponents argue that because consumers/patients face the full costs of their health care choices until their deductable is met, they may be disincentivized to seek proper preventive care, may be less compliant with prescribed medications, and may actually cost the system more because they will not seek care until their health situation requires aggressive interventions.

Understandably, these issues have significant societal welfare loss implications. Consumer surplus refers to the difference in price between the maximum price the consumer is willing to pay for a product and the actual price they pay for said product. Moral hazard refers to the change in behavior when the entity that is protected from risk by an insurance instrument behaves in a different way than they would if they did not have said policy in place to protect them from the cost affects of their behavior. Welfare loss occurs when there is an incorrect allocation of resources in which society does not reach its maximum utility. Welfare lost can be borne by consumers, society, or producers.

Theoretically, consumer driven health care plans decrease moral hazard because beneficiaries are less protected from the costs of medical care and therefore less likely to create exposure to the risk of high medical bills. By the same token, consumer driven health plans may create favorable selection as consumers with known health problems opt for higher cost, lower deductable plans. There is some possibility that consumer driven health plans could create a consumer surplus because consumers would be willing to pay higher premiums. On closer examination, this would not truly be considered a “consumer surplus” because the higher cost premiums would provide more coverage; a true consumer surplus is only created when market price is artificially less than the true market equilibrium price. Whether consumer driven health plans create a net welfare loss depends on whether they create net costs or benefits for society overall.

2. Harford identifies three key considerations that are important for markets to work and uses these to comment on how to improve our health system. What are those key considerations and how does he weave them into a strategy to fix our current health care system. (35 points)

In order to function efficiently, markets must operate in a state of perfect competition. Perfect competition assumes that there are proper outputs, outputs are produced efficiently, and that the right quantities of outputs are being produced. There are a number of reasons why the market for health insurance is not competitive in the United States, the primary one being an issue of asymmetrical information. Asymmetrical information promotes adverse selection and moral hazard. There are several activities that insurers can engage in to combat asymmetrical information from their side. These include offering different benefit packages that induce beneficiaries to reveal their information. Additionally, they may establish some sort of “signal” to serve as an indicator of likely beneficiary riskiness. Passing on most of the costs of health care is a way that insurers can reduce moral hazard. However, such products may have limited marketability, since the consumer is buying the insurance to protect themselves from the possibility of unacceptable losses.

The three areas of market failure that are addressed in the text are scarcity power, externalities and imperfect information. Mr. Harford also addresses the issue of fairness, which he argues any humane society would want to address. In the United States, in most urban areas, scarcity power in not a big concern among consumers because there are a number of health care providers who may serve as substitutes for each other. Externalities are an issue in health care because if everyone else’s child has been vaccinated for whooping cough, then it is not really necessary for me to have my child vaccinated because herd immunity will probably protect my child from the possibility of contracting this illness. Inside information is the largest obstacle to achieving a more competitive health care marketplace. The suggestion is that consumers should have information readily available in order to allow them to make better decisions. Patients should have the opportunity to utilize this information by choosing providers and treatments.

The ultimate goal of a well-functioning health insurance/health care market is to give consumers the responsibility and information necessary to make choices about their care, while also incentivizing through their own payments to consume health care wisely. The system described is basically a universally mandated (to eliminate adverse selection) consumer driven health plan with obligatory health savings accounts that roll over and allow savings to accumulate during the lifespan. Health care expenses are paid by the individual out of the HSA- this eliminates the problem of moral hazard. During all phases of life, the individual would only desire to spend the funds on treatments that they are convinced would be beneficial, essentially eliminating the problem of wasteful treatment. To address the problem of social justice, catastrophe insurance would step in at a certain point and pay for the expenses for which no reasonable and responsible person could pay for over the course of a lifetime. This would ensure that less lucrative but socially necessary goods such as burn units or transplants would still be available.

3. Medicare part D is the latest in a series of policy adjustments undertaken to deal with catastrophic expenses not covered under Medicare. Discuss the key economic considerations in this the historical case study of the interface between health policy and health economics.

(30 points)

Medicare parts A & B were introduced in 1965 to assist the aged- those 65 and up- in paying for their health care expenses. The benefit design of Parts A & B reflected the social values of the time which included achieving greater income equality and security in old age. Medicare part C was established in the 1980s but became more pronounced in1997 to respond to new care utilization trends in health care markets. Medicare part D was created by the Medicare Modernization Act of 2003 to cover medication expenses. As medical care has advanced since 1965, patients have been living longer and more advanced medications have improved both their quality of life and functioning. Medicare part D came into force in 2006 with premiums and benefits managed by private firms. However, the cost of the program is still heavily subsidized by federal funding. The design of the program reflects its bipartisan support and populist backing. The greater involvement of private firms allows for amore market based approach to managing benefits. Furthermore, the creation of the “doughnut hole” helped limit the expense of the program and theoretically should have incentivized seniors to manage this benefit efficiently.

In the 2003 benefit design, enrollees had to first meet a $250 deductable and they pay a 25% co-pay for expenses between $250 and $2,500. From $2,500 to $5,100 enrollees were responsible for 100% of the cost. After reaching the $5,100 annual cut-off, the government would resume cost sharing, picking up 95% of cost. However, since Medicare has some features of a wealth redistribution program, the impact of this “cost-limiting” mechanism had the biggest impact on those least able to bear the burden. In order to gain support from senior citizens (who tend to vote en masse), part of the Affordable Care Act included a voucher payment to people who “fell inside the doughnut hole” as well as phased in benefits that will help lessen the percentage of the cost of brand-name medications that is paid by the consumer.

Unfortunately, many experts agree that Medicare as it exists is unsustainable and lacks efficiency incentives. Medicare Parts A & B have reimbursed providers through a fee-for-service structure that has incentivized overtreatment and waste. The text offers several possibilities for extending the viability of Medicare. These include raising the age of eligibility, reducing the rate of increase in payments to Medicare providers, increasing the payroll tax that funds Medicare Part A, increasing Part B premiums, scaling the Part B premiums to beneficiaries incomes, transforming Medicare from a defined benefit to a defined contribution program, and changing Medicare to an income related program. Most of these options are unpopular with senior citizens who feel that they have paid into the system their entire lives and that they deserve the benefits they are receiving. Reforms are also unpopular with Baby Boomers who are approaching the age at which they will begin to benefit. Ultimately, the fate of Medicare may be decided by Generation Xers and Yers when the programs are on the brink of bankruptcy because only then might public will be strong enough to confront the gravity and complexity of the Medicare situation.