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Learning Objective #1: discuss the manner in which the politics of health policy shape the context and outcomes of care provision.

Learning Objective #2: identify two ways that changes in Medicare hospice legislation served to further fragment care for the dying.

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Purpose: This study analyzed the impact of the Medicare hospice benefit on the context, processes and outcomes of contemporary end-of-life. Significance: In 1982, Congress enacted the Medicare hospice benefit as a mechanism to improve the quality and decrease the cost of end-of-life care. Over twenty years later, serious inadequacies remain in our models of end-of-life care and legislators continue to grapple with how to configure and finance care for a growing population of medically frail elders. The generation of appropriate policy solutions requires a critical analysis of the current challenges we face within the historically contingent forces that shaped contemporary practice and policy. Methods/Sources: A social history framework was used to consider questions of how norms and boundaries about health care are created and recreated in a market-oriented society, and in turn, how health care innovations are reshaped as they are institutionalized. Data were drawn from archival collections of those who were integral to the development of the hospice care in the United States and Congressional record, testimony, and legislative histories. Results: This historical analysis of the Medicare hospice benefit provides another example of how the policy solutions of today often contain the seeds of tomorrow's problems. I argue that the current "crisis" in the configuration and financing of end-of-life care is neither unanticipated nor was it wholly unintended. As the Medicare hospice benefit moved through the regulatory process, the hospice philosophy was reshaped by the politics of policy and the health care industry. Within this context, competing forces created a paradoxical benefit that both increased and decreased access to quality hospice services and ultimately further fragmented end-of-life care. These findings have broad implications for contemporary initiatives to improve end-of-life care regardless of locale.