Healthcare reform in the United States

See also: Health care in the United States

The debate over health care reform in the United States centers on questions of a right to health care, access, fairness, the quality achieved for the high sums spent, and the sustainability of expenditures that have been rising faster than the level of general inflation and the growth in the economy. Medical debt is the principal cause of personal bankruptcy in the United States. The mixed public-private health care system in the United States is the most expensive in the world, with health care costing more per person than in any other nation. A greater portion of gross domestic product (GDP) is spent on health care in the U.S. than in all but one United Nations member state. A study of international health care spending levels in the year 2000, published in the health policy journal Health Affairs, found that while the U.S. spends more on health care than other countries in the Organisation for Economic Co-operation and Development (OECD), the use of health care services in the U.S. is below the OECD median by most measures. The authors of the study concluded that the prices paid for health care services are much higher in the U.S.

According to the Institute of Medicine of the National Academy of Sciences, the United States is the "only wealthy, industrialized nation that does not ensure that all citizens have coverage". Whether a federal government-mandated system of universal health care should be implemented in the US remains a hotly debated political topic, with Americans divided along party lines in their views regarding whether a new public health plan should be created and administered by the federal government. Those in favor of government-guaranteed universal health care argue that the large number of uninsured Americans creates direct and hidden costs shared by all, and that extending coverage to all would lower costs and improve quality. Opponents of government mandates or programs for universal health care argue that people should be free to opt out of health insurance. Both sides of the political spectrum have also looked to more philosophical arguments, debating whether people have a fundamental right to have health care provided to them by their government.

In spite of the amount spent on health care in the US, a 2008 report by the Commonwealth Fund ranked the United States last in the quality of health care among the 19 compared countries. Other comparisons conclude that the US system performs better in some areas such as the responsiveness of treatment, the amount of technology availible, and higher cure rates for some serious illnesses such as colon, lung, and prostate cancer in men.

Costs

Current figures estimate that spending on health care in the US is about 16% of its GDP. In 2007, an estimated $2.26 trillion was spent on health care in the United States, or $7,439 per capita. Health care costs are rising faster than wages or inflation, and the health share of GDP is expected to continue its upward trend, reaching 19.5 percent of GDP by 2017. As a proportion of GDP, government health care spending in the United States is greater than in most other large western countries. Additionally, a substantial portion is paid by private insurance. A recent study found that medical expenditure was the cause for 60% of personal bankruptcy in the United States. "Unless you're Warren Buffett, your family is just one serious illness away from bankruptcy...for middle-class Americans, health insurance offers little protection...," said Dr. David Himmelstein of Harvard University, who helped compile the study.

The US spends more on health care per capita than any other UN member nation. It also spends a greater fraction of its national budget on health care than Canada, Germany, France, or Japan. In 2004, the US spent $6,102 per capita on health care, 92.7% more than any other G7 country, and 19.9% more than Luxembourg, which, after the US, had the highest spending in the Organisation for Economic Co-operation and Development (OECD). Although the US Medicare coverage of prescription drugs began in 2006, most patented prescription drugs are more costly in the US than in most other countries. Factors involved are the absence of government price controls, enforcement of intellectual property rights limiting the availability of generic drugs until after patent expiration, and the monopsony purchasing power seen in national single-payer systems. Some US citizens obtain their medications, directly or indirectly, from foreign sources, to take advantage of lower prices.

The US system already has substantial public components. Of every dollar spent on health care in the US, 45 cents comes from some level of government. The federal Medicare program covers the elderly and some people with disabilities; the federal-state Medicaid program provides coverage to some of the poor; the State Children's Health Insurance Program (SCHIP) extends coverage to low-income families with children; Native Americans are covered while on the reservation; merchant seamen are covered by the Public Health System; and retired railway workers and military veterans are also covered by the government. Government also affects private sector medicine through licensing and regulatory barriers to entry into health professions.

Health care spending in the U.S. is also highly concentrated. In 1996, 5% of the population accounted for more than half of all costs.

Uninsured

Main article: Uninsured in the United States

People in the US without health insurance coverage at some time during 2007 totaled 15.3% of the population, or 45.7 million people. This number decreased slightly from 47 million in 2006 due to increased publicly sponsored coverage in addition to the fact that about 300,000 more people were covered in Massachusetts under the Massachusetts health care reform law in 2007. It is estimated that the current economic downturn and rising unemployment rate likely will have caused the number of uninsured to grow by at least 2 million in 2008.

Comparisons with other health care systems

U.S. healthcare costs exceed those of other countries, relative to the size of the economy or GDP.

The cost and quality of care in the United States are frequently the two major issues of discussion. While cost comparisons are relatively easy, the reasons for higher costs in the US and quality measures are frequently subject to debate. The US pays twice as much yet lags other wealthy nations in such measures as infant mortality and life expectancy, which are among the most widely collected, hence useful, international comparative statistics. For 2006-2010, the USA's life expectancy will lag 38th in the world, after most rich nations, lagging last of the G5 (Japan, France, Germany, UK, USA) and just after Chile (35th) and Cuba (37th).

In 2000, the World Health Organization (WHO) ranked the US health care system 37th in overall performance, right next to Slovenia, and 72nd by overall level of health (among 191 member nations included in the study). Despite larger spending, the United States has a worse infant mortality rate (6.26) and life expectancy (78.11) than the European Union (5.72 and 78.67).

Another metric used to compare the quality of health care across countries is Years of potential life lost (YPLL). By this measure, the United States comes third to last in the OECD for women (beating Mexico and Hungary) and fifth to last for men (also beating Poland and Slovakia), according to OECD data. Yet another measure is Disability-adjusted life year (DALY); again the United States fares relatively poorly. According to Jonathan Cohn, health care scholars prefer these more "finely tuned" statistical measures for international comparisons in place of the relatively "crude" infant mortality and life expectancy.

Access to advanced medical treatments and technologies in the US is greater than in most other developed nations and waiting times may be substantially shorter for treatment by specialists.

Employer-provided health insurance receives uncapped tax benefits. According to OECD, it "encourages the purchase of more generous insurance plans, notably plans with little cost sharing, thus exacerbating moral hazard". Various health care analysts have asserted that market failure occurs in health care markets, but some have suggested that it is a result of too much government involvement rather than too little. Consumers want unfettered access to medical services; they also prefer to pay through insurance or tax rather than out of pocket. These two needs create cost-efficiency challenges for health care. Some studies have found no consistent and systematic relationship between the type of financing of health care and cost containment.

The consumers of health care often lack basic information compared to the medical professionals they buy it from, and fully informed choices (particularly in emergencies) are often implausible. Meanwhile, health insurance companies and care providers also suffer from information asymmetry, as patients are almost always more aware of their particular family histories and risky behaviors than the firms are. Price theory dictates that the risk cost associated with this lack of information gets passed on to consumers. Demand is likely to be inelastic. The medical profession potentially may set rates that are well above ideal market value, and they are controlled by licensing requirements, with some degree of monopoly or oligopoly control over prices. Monopolies are made more likely by the variety of specialists and the importance of geographic proximity. Private insurers have been perhaps the only stabilizing force, as they pay a contractually fixed cost for a given procedure. With no more than one or two heart specialists or brain surgeons to choose from, competition for patients between such experts is limited, so contractually pre-arranged pricing helps reduce supply-limited pricing.

Increased use of preventive care is often suggested as a way of reducing health care spending. Research suggests, however, that in most cases prevention does not produce significant long-term cost savings. Preventive care is typically provided to many people who would never become ill, and for those who would have become ill, it is partially offset by the health care costs during additional years of life.

Reforming or restructuring the private health insurance market is often suggested as a means for achieving health care reform in the US. Insurance market reform has the potential to increase the number of Americans with insurance, but is unlikely to significantly reduce the rate of growth in health care spending. Careful consideration of basic insurance principles is important when considering insurance market reform, in order to avoid unanticipated consequences and ensure the long-term viability of the reformed system. According to one study conducted by the Urban Institute, if not implemented on a systematic basis with appropriate safeguards, market reform has the potential to cause more problems than it solves.

Since most Americans with private coverage receive it through employer-sponsored plans, many have suggested employer "pay or play" requirements as a way to increase coverage levels. However, research suggests that current pay or play proposals are limited in their ability to increase coverage among the working poor. These proposals generally exclude small firms, do not distinguish between individuals who have access to other forms of coverage and those who do not, and increase the overall compensation costs to employers.

Premium subsidies to help individuals purchase their own health insurance have also been suggested as a way to increase coverage rates. Research confirms that consumers in the individual health insurance market are sensitive to price. Estimates of the demand elasticity in this market vary, but generally fall in the range of -0.3 to -0.1. It appears that price sensitivity varies among population subgroups and is generally higher for younger individuals and lower income individuals. However, research also suggests that subsidies alone are unlikely to solve the uninsured problem in the US.

A report published by the Commonwealth Fund in December 2007 examined 15 federal policy options and concluded that, taken together, they had the potential to reduce future increases in health care spending by $1.5 trillion over the next 10 years. These options included increased use of health information technology, research and incentives to improve medical decision making, reduced tobacco use and obesity, reforming the payment of providers to encourage efficiency, limiting the tax federal exemption for health insurance premiums, and reforming several market changes such as resetting the benchmark rates for Medicare Advantage plans and allowing the Department of Health and Human Services to negotiate drug prices. The authors based their modeling on the effect of combining these changes with the implementation of universal coverage. The authors concluded that there are no magic bullets for controlling health care costs, and that a multifaceted approach will be needed to achieve meaningful progress. The Congressional Budget Office has concluded that increased use of health information technology alone is unlikely to significantly reduce overall health care spending unless it is combined with broader measures to reduce costs.

History of reform efforts

Main article: History of health care reform in the United States

U.S. efforts to achieve universal coverage began with Theodore Roosevelt, who had the support of progressive health care reformers in the 1912 election but was defeated. And President Harry S Truman called for universal health care as a part of his Fair Deal in 1949 but strong opposition stopped that part of the Fair Deal.

The Medicare program was established by legislation signed into law on July 30, 1965, by President Lyndon B. Johnson. Medicare is a social insurance program administered by the United States government, providing health insurance coverage to people age 65 and over, or who meet other special criteria. The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) amended the Employee Retirement Income Security Act of 1974 (ERISA) to give some employees the ability to continue health insurance coverage after leaving employment.

Health care reform was a major concern of the Bill Clinton administration headed up by First Lady Hillary Clinton; however, the 1993 Clinton health care plan was not enacted into law. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) made it easier for workers to keep health insurance coverage when they change jobs or lose a job, and also made use of national data standards for tracking, reporting and protecting personal health information.

During the 2004 presidential election, both the George Bush and John Kerry campaigns offered health care proposals. As president, Bush signed into law the Medicare Prescription Drug, Improvement, and Modernization Act which included a prescription drug plan for elderly and disabled Americans.

Health reform and the 2008 presidential election

Main article: Health care reform in the United States presidential election, 2008

Both of the major party presidential candidates offered positions on health care.

John McCain's proposals focused on open-market competition rather than government funding. At the heart of his plan were tax credits - $2,500 for individuals and $5,000 for families who do not subscribe to or do not have access to health care through their employer. To help people who are denied coverage by insurance companies due to pre-existing conditions, McCain proposed working with states to create what he called a "Guaranteed Access Plan."

Barack Obama called for universal health care. His health care plan called for the creation of a National Health Insurance Exchange that would include both private insurance plans and a Medicare-like government run option. Coverage would be guaranteed regardless of health status, and premiums would not vary based on health status either. It would have required parents to cover their children, but did not require adults to buy insurance.

The Philadelphia Inquirer reported that the two plans had different philosophical focuses. They described the purpose of the McCain plan as to "make insurance more affordable," while the purpose of the Obama plan was for "more people to have health insurance." The Des Moines Register characterized the plans similarly.

A poll released in early November, 2008, found that voters supporting Obama listed health care as their second priority; voters supporting McCain listed it as fourth, tied with the war in Iraq. Affordability was the primary health care priority among both sets of voters. Obama voters were more likely than McCain voters to believe government can do much about health care costs.

Barriers to reform

Jonathan Oberlander, Associate Professor of Health Policy and Management at the University of North Carolina, argues that finding a way to pay for universal coverage is a primary barrier to comprehensive reform. A study published in August 2008 in the journal Health Affairs found that covering all of the uninsured in the US would increase national spending on health care by $122.6 billion, which would represent a 5% increase in health care spending and 0.8% of GDP. The impact on government spending could be higher, depending on the details of the plan used to increase coverage and the extent to which new public coverage crowded out existing private coverage.

Economists Katherine Baicker, who was a member of President Bush's Council of Economic Advisers, and Amitabh Chandra argue that five "myths" about the US health care system hinder reform efforts. While each has a "kernel of truth," they oversimplify complicated issues to the point where they are "false or misleading." The myths they identify are:

• "The Problem With The Health Insurance System Is That Sick People Without Insurance Can’t Find Affordable Policies" - they argue that sick people who have insurance represent a particularly difficult challenge;
• "Covering The Uninsured Pays For Itself By Reducing Expensive And Inefficient Emergency Room Care" - they argue that empirical research demonstrates that people who are insured generate more health care spending, in total, than uninsured individuals;
• "Lack Of Insurance Is The Principal Barrier To Getting High-Quality Care" - they argue that coverage is not enough, but that much more needs to be done to improve the health care system;
• "Employers Can Shoulder More Of The Burden Of Paying For Insurance" - they argue that workers ultimately bear the cost of coverage, regardless of whether or not the employer writes the premium check; and
• "High-Deductible Health Plans And Competition, Not Government Action, Are The Keys To Lower Costs" - they argue that cost sharing is not a magic bullet for reform, though it would help control costs.

A fundamental problem in evaluating reform proposals is the difficulty estimating their cost and potential impact. Because proposals often differ in many important details, it is difficult to provide meaningful side-by-side cost comparisons. The empirical data and theory underlying cost estimates in this area are limited and subject to debate, increasing the variation between estimates and limiting their accuracy.

Peter Orszag has suggested that that behavioral economics is an important factor for improving the health care system, but that relatively little progress has been made when compared to retirement policy.

Public policy debate

Main article: Health care reform debate in the United States

The political debate over health care reform has for several decades revolved around the questions of whether fundamental reform of the system is needed, what form those reforms should take, and how they should be funded. Issues regarding publicly funded health care are frequently the subject of political debate. Whether or not a publicly funded universal health care system should be implemented is one such example.

The health care reform debate in the United States has been influenced by the Tea Party protests phenomenon, as reporters and politicians spend more time reacting to it and less time on the substantive issues below. There is evidence the hyperbole generated by this phenomenon is a form of corporate astroturfing.

Common arguments for and against health care reform

Template:MultiCol From supporters:

• In most cases, people have little influence on whether or not they will contract an illness. Consequently, illness may be viewed as a fundamental part of what it means to be human and, as such, access to treatment for illness should be based on acknowledgement of the human condition, not the ability to pay or entitlement. Therefore, health care may be viewed as a fundamental human right itself or as an extension of the right to life.
• Since people perceive universal health care as free, they are more likely to seek preventative care which, in the long run, lowers their overall health care expenditure by focusing treatment on small, less expensive problems before they become large and costly.
• A universal health care system allows for a larger capital base than can be offered by free market insurers (without violating antitrust laws). A larger capital base "spreads out" the cost of a payout among more people, lowering the cost to the individual.
• Universal health care would provide for uninsured adults who may forgo treatment needed for chronic health conditions.
• In most free-market situations, the consumer of health care is entirely in the hands of a third party who has a direct personal interest in persuading the consumer to spend money on health care in his or her practice. The consumer is not able to make value judgments about the services judged to be necessary because he or she may not have sufficient expertise to do so. This, it is claimed, leads to a tendency to over produce. In socialized medicine, hospitals are not run for profit and doctors work directly for the community and are assured of their salary. They have no direct financial interest in whether the patient is treated or not, so there is no incentive to over provide. When insurance interests are involved this furthers the disconnect between consumption and utility and the ability to make value judgments. Others argue that the reason for over production is less cynically driven but that the end result is much the same..
• The profit motive in medicine values money above public benefit. For example, pharmaceutical companies have reduced or dropped their research into developing new antibiotics, even as antibiotic-resistant strains of bacteria are increasing, because there's less profit to be gained there than in other drug research. Those in favor of universal health care posit that removing profit as a motive will increase the rate of medical innovation.
• Paul Krugman and Robin Wells say that in response to new medical technology, the American health care system spends more on state-of-the-art treatment for people who have good insurance, and spending is reduced on those lacking it.
• The profit motive adversely affects the cost and quality of health care. If managed care programs and their concomitant provider networks are abolished, then doctors would no longer be guaranteed patients solely on the basis of their membership in a provider group and regardless of the quality of care they provide. Theoretically, quality of care would increase as true competition for patients is restored.
• Wastefulness and inefficiency in the delivery of health care would be reduced. A single payer system could save $286 billion a year in overhead and paperwork. Administrative costs in the U.S. health care system are substantially higher than those in other countries and than in the public sector in the US: one estimate put the total administrative costs at 24 percent of U.S. health care spending. It might only take one government agent to do the job of two health insurance agents. According to one estimate roughly 50% of health care dollars are spent on health care, the rest go to various middlemen and intermediaries. A streamlined, non-profit, universal system would increase the efficiency with which money is spent on health care.
• About 60% of the U.S. health care system is already publicly financed with federal and state taxes, property taxes, and tax subsidies - a universal health care system would merely replace private/employer spending with taxes. Total spending would go down for individuals and employers.
• Several studies have shown a majority of taxpayers and citizens across the political divide would prefer a universal health care system over the current U.S. system
• America spends a far higher percentage of GDP on health care than any other country but has worse ratings on such criteria as quality of care, efficiency of care, access to care, safe care, equity, and wait times, according to the Commonwealth Fund.
• A universal system would align incentives for investment in long term health-care productivity, preventive care, and better management of chronic conditions.
• The Big Three of U.S. car manufacturers have cited health-care provision as a financial disadvantage. The cost of health insurance to U.S. car manufacturers adds between USD 900 and USD 1,400 to each car made in the U.S.A.
• In countries in Western Europe with public universal health care, private health care is also available, and one may choose to use it if desired. Most of the advantages of private health care continue to be present, see also Two-tier health care.
• Universal health care and public doctors would protect the right to privacy between insurance companies and patients.
• Public health care system can be used as independent third party in disputes between employer and employee.
• A study of hospitals in Canada found that death rates are lower in private not-for-profit hospitals than in private for-profit hospitals.

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From opponents:

• Health care is not a right. Thus, it is not the responsibility of government to provide health care. Note, this argument is commonly found among developed nations only in the USA. In all other developed nations Health Care is considered to be a right, like education, because it provides services that make the community better and more productive as a whole -- better public policy, it is deemed, to have the state subsidizing health care.
• Free health care can lead to overuse of medical services, and hence raise overall cost.
• Universal health coverage does not in practice guarantee universal access to care. Many countries offer universal coverage but have long wait times or ration care.
• The federal Emergency Medical Treatment and Active Labor Act requires hospitals and ambulance services to provide emergency care to anyone regardless of citizenship, legal status or ability to pay.
• Eliminating the profit motive will decrease the rate of medical innovation.
• It slows down innovation and inhibits new technologies from being developed and utilized. This simply means that medical technologies are less likely to be researched and manufactured, and technologies that are available are less likely to be used.
• Publicly-funded medicine leads to greater inefficiencies and inequalities. Opponents of universal health care argue that government agencies are less efficient due to bureaucracy. Universal health care would reduce efficiency because of more bureaucratic oversight and more paperwork, which could lead to fewer doctor-patient visits. Advocates of this argument claim that the performance of administrative duties by doctors results from medical centralization and over-regulation, and may reduce charitable provision of medical services by doctors.
• Converting to a single-payer system could be a radical change, creating administrative chaos.
• The extra spending in the US is justified if expected life span increases by only about half a year as a result.
• Unequal access and health disparities still exist in universal health care systems.
• The problem of rising health care costs is occurring all over the world; this is not a unique problem created by the structure of the US system.
• Universal health care suffers from the same financial problems as any other government planned economy. It requires governments to greatly increase taxes as costs rise year over year. Universal health care essentially tries to do the economically impossible. Empirical evidence on the Medicare single payer-insurance program demonstrates that the cost exceeds the expectations of advocates. As an open-ended entitlement, Medicare does not weigh the benefits of technologies against their costs. Paying physicians on a fee-for-service basis also leads to spending increases. As a result, it is difficult to predict or control Medicare's spending. The Washington Post reported in July 2008 that Medicare had "paid as much as $92 million since 2000" for medical equipment that had been ordered in the name of doctors who were dead at the time. Medicare's administrative expense advantage over private plans is less than is commonly believed. Large market-based public program such as the Federal Employees Health Benefits Program and CalPERS can provide better coverage than Medicare while still controlling costs as well.
• National health systems tend to be more effective as they incorporate market mechanisms and limit centralized government control.
• Some commentators have opposed publicly-funded health systems on ideological grounds, arguing that public health care is a step towards socialism and involves extension of state power and reduction of individual freedom.
• The right to privacy between doctors and patients could be eroded if government demands power to oversee the health of citizens.
• Universal health care systems, in an effort to control costs by gaining or enforcing monopsony power, sometimes outlaw medical care paid for by private, individual funds.

Other arguments for health care reform

Democrats are far more supportive of health care reform than are Republicans and overall more people would support a socialized medicine based reform than would not, and argue that it has several advantages over the for-profit, free market system. It has been suggested that the largest obstacle is a lack of political will.

One of the leading organizations in support of single-payer health care in the US is Physicians for a National Health Program (PNHP), which seeks to establish a system similar to that in Canada.

Converting to a single-payer system is seen by proponents as a solution to the flaws in the current system. The US health care system is the most expensive in the world. Despite this expenditure, the current US system fails to provide universal coverage. Almost 46 million of the American population, more than 15 percent of the total, lacked health insurance in 2007, including 9.7 million who are not American citizens. Economist Paul Krugman argued in 2005 that the U.S. converting to a single-payer system would save approximately $200 billion annually, mainly due to the removal of insurance company overhead. He stated this would more than offset the cost of providing coverage to those presently uninsured.

The lack of universal coverage contributes to another flaw in the current US health care system: on most dimensions of performance, it underperforms relative to other industrialized countries. In a 2007 comparison by the Commonwealth Fund of health care in the U.S. with that of Germany, Britain, Australia, New Zealand, and Canada, the US ranked last on measures of quality, access, efficiency, equity, and outcomes.

For example, the US ranks 22nd in infant mortality, between Taiwan (which has nationalized health care, see Healthcare in Taiwan) and Croatia, 46th in life expectancy, between Saint Helena and Cyprus, and 37th in health system performance, between Costa Rica and Slovenia.

The US system is often compared with that of its northern neighbor, Canada (see Canadian and American health care systems compared). Canada's system is largely publicly funded. In 2006, Americans spent an estimated US$6,714 per capita on health care, while Canadians spent US$3,678. This amounted to 15.3% of US GDP in that year, while Canada spent 10.0% of GDP on health care.

A 2007 review of all studies comparing health outcomes in Canada and the US found that "health outcomes may be superior in patients cared for in Canada versus the United States, but differences are not consistent."

Proponents of health care reform argue that moving to a single-payer system would reallocate the money currently spent on the administrative overhead required to run the hundreds of insurance companies in the US to provide universal care. An often-cited study by Harvard Medical School and the Canadian Institute for Health Information determined that some 31 percent of US health care dollars, or more than $1,000 per person per year, went to health care administrative costs. Other estimates are lower. One study of the billing and insurance-related (BIR) costs borne not only by insurers but also by physicians and hospitals found that BIR among insurers, physicians, and hospitals in California represented 20-22% of privately insured spending in California acute care settings.

Advocates argue that shifting the US to a single-payer health care system would provide universal coverage, give patients free choice of providers and hospitals, and guarantee comprehensive coverage and equal access for all medically necessary procedures, without increasing overall spending. Shifting to a single-payer system would also eliminate oversight by managed care reviewers, restoring the traditional doctor-patient relationship.

Other arguments against health care reform

While polling data indicate that US citizens are concerned about health care costs and there is substantial support for some type of reform (see Polls, below) most are generally satisfied with the quality of their own health care. According to a Joint Canada/United States Survey of Health in 2003, 86.9% of Americans reported being "satisfied" or "very satisfied" with their health care services, compared to 83.2% of Canadians. In the same study, 93.6% of Americans reported being "satisfied" or "very satisfied" with their physician services, compared to 91.5% of Canadians (according to the study authors, that difference was not statistically significant).

Some U.S. reformers argue for other, more incremental changes to achieve universal health care, such as tax credits or vouchers. However, proponents of a single-payer system, such as Marcia Angell, M.D., former editor of the New England Journal of Medicine, assert that incremental changes in a free-market system are "doomed to fail."

Current reform proposals

Obama administration proposals

See also: Political positions of Barack Obama

In July 2008, candidate Obama promised to "bring down premiums by $2,500 for the typical family." His advisers have said that the $2,500 premium reduction includes, in addition to direct premium savings, the average family's share of the reduction in employer-paid health insurance premiums and the reduction in the cost of government health programs such as Medicare and Medicaid. Ken Thorpe of Emory University issued estimates that support Obama's proposal. Other health analysts, such as Joe Antos of the American Enterprise Institute, Karen Davis of the Commonwealth Fund and Jonathan B. Oberlander of the University of North Carolina at Chapel Hill expressed skepticism that Obama's proposals would achieve the stated level of cost savings.

A September 2008 critique of Obama's health care ideas published in Health Affairs concludes that it does not address the core economic causes of rising health care spending, but would "greatly increase" federal regulation of health coverage. Its authors include a volunteer adviser to the presidential campaign of Senator John McCain and a scholar with the American Enterprise Institute.

The proposal includes implementing guaranteed eligibility for affordable health care for all Americans, paid for by insurance reform, reducing costs, and requiring employers to either furnish meaningful coverage or contribute to a new public plan. He would provide for mandatory health care insurance for children.

The outlines of Obama's health care proposal were described in his October 2008 campaign document entitled "Barack Obama and Joe Biden’s plan to lower health care costs and ensure affordable, accessible health coverage for all.". The plan aims to "improve efficiency and lower costs in the health care system by adopting state-of-the-art health information technology systems; by ensuring that patients receive and providers deliver the best possible care, including prevention and chronic disease management services; reforming the market structure to increase competition; and offering federal reinsurance to employers to help ensure that unexpected or catastrophic illnesses do not make health insurance unaffordable or out of reach for businesses and their employees."

For those not insured through employment, Obama's October 2008 proposal includes a National Health Insurance Exchange that would include both private insurance plans and a Medicare-like, government-run option. Coverage would be guaranteed regardless of health status, and premiums would not vary based on health status either. The campaign estimated the cost of the program at $60 billion annually. According to the Associated Press, the program will need to attract young, healthy people into buying coverage to work, but at the state level guaranteed issue requirements have "often had the opposite effect." The plan requires that parents cover their children, but does not require adults to buy insurance.

An April 2009 reform plan, which President Obama was said to support and which is thought to be gaining support in Congress, would give the public the choice of a public sector competitor in the private health insurance market. An article in The Economist said that the inclusion of a public sector option could trigger insurance opposition which, in conjunction with employer health-care provider opposition, could kill health care reform.

In contrast to earlier advocacy of a publicly-funded health care program, in August 2009 Obama administration officials announced they would support a health insurance cooperative in response to deep political unrest amongst Congressional Republicans and amongst citizens in town hall meetings held across America.

Congressional proposals

On August 9, 2009, the New York Times published a primer and table summarizing Congressional proposals including areas of agreement and disagreement. Some provisions of the Congressional proposals are directly contrary to the reform proposals that President Obama campaigned on; for example, the Congressional proposals would mandate all employers and individuals to purchase insurance or pay a penalty, and the Senate Finance Committee proposal would omit a public option from insurance choices.

On May 5, 2009, the US Senate Finance Committee held hearings on Health care reform. On the panel of the "invited stakeholders," no supporter of the Single-payer health care system was invited. The panel featured Republican senators and industry panelists who argued against any kind of expanded health care coverage. The preclusion of the single payer option from the discussion caused significant protest by doctors in the audience.

There is one bill currently before Congress but others are expected to be presented soon. A merged single bill is the likely outcome. The main sticking points at the markup stage of the Affordable Health Choices Act currently before the House of Representatives have been in two areas: whether the government should provide a public insurance plan option to compete with the private insurance sector, and whether comparative effectiveness research should be used to contain costs met by the public providers of health care. Some Republicans have expressed opposition to the public insurance option believing that the government will not compete fairly with the private insurers. Republicans have also expressed opposition to the use of comparative effectiveness research (CER) to limit coverage in any public sector plan (including any public insurance scheme or any existing government scheme such as Medicare), which they regard as rationing by the back door. Democrats have claimed that the bill will not do this but are reluctant to introduce a clause that will prevent, arguing that it would limit the right of the Department of Health and Human Services to prevent payments for services that clearly do not work. America's Health Insurance Plans, the umbrella organization of the private health insurance providers in the United States has recently urged the use of CER to cut costs by restricting access to ineffective treatments and cost/benefit ineffective ones. Republican amendments to the bill would not prevent the private insurance sectors from citing CER to restrict coverage and apply rationing of their funds, a situation which would create a competition imbalance between the public and private sector insurers. A proposed but not yet enacted short bill with the same effect is the Republican sponsored Patients Act 2009.

On June 15, 2009, the U.S. Congressional Budget Office (CBO) issued a preliminary analysis of the major provisions of the Affordable Health Choices Act. The CBO estimated the ten-year cost to the federal government of the major insurance-related provisions of the bill at approximately $1.0 trillion. Over the same ten-year period from 2010 to 2019, the CBO estimated that the bill would reduce the number of uninsured Americans by approximately 16 million. At about the same time, the Associated Press reported that the CBO had given Congressional officials an estimate of $1.6 trillion for the cost of a companion measure being developed by the Senate Finance Committee. In response to these estimates, the Senate Finance Committee delayed action on its bill and began work on reducing the cost of the proposal to $1.0 trillion, and the debate over the Affordable Health Choices act became more acrimonious. Congressional Democrats were surprised by the magnitude of the estimates, and the uncertainty created by the estimates has increased the confidence of Republicans who are critical of the Obama Administration's approach to health care.

However, in a June New York Times editorial, economist and commentator Paul Krugman argued that despite these estimates universal health coverage is still affordable. "The fundamental fact is that we can afford universal health insurance--even those high estimates were less than the $1.8 trillion cost of the Bush tax cuts."

On July 2, 2009, the U.S. Congressional Budget Office issued a preliminary estimate of another draft version of the Affordable Health Choices Act. The cost was lower than the earlier estimate, due to several changes in the draft legislation. The premium subsidies were significantly reduced, a penalty was added for employers who do not offer subsidized coverage to their employees, and the ability of workers to claim a subsidy for individual coverage on the basis that their employer's plan was too expensive was limited. The new estimate placed the 10-year net increase in the federal budget deficit at $597 billion, and the net reduction in the uninsured at 20 million. While the proposal included a "public plan" option, the CBO said that it did not have a material effect on either the cost of the proposal or on the number of people who would be covered ". . . largely because the public plan would pay providers of health care at rates comparable to privately negotiated rates—and thus was not projected to have premiums lower than those charged by private insurance plans . . ." The draft proposal evaluated by CBO did not include Medicaid expansions or other subsidies for individuals below 150% of the Federal Poverty Level. In a July New York Times editorial, Paul Krugman said that after adding an expansion of Medicaid for the poor and near-poor "we’re probably looking at between $1 trillion and $1.3 trillion" for the federal budget cost of the reform package (not counting unfunded mandates on employers and individuals).

In late July 2009 the director of the Congressional Budget Office testified that the proposals then under consideration would significantly increase federal spending and did not include the "fundamental changes" needed to control the rapid growth in health care spending. The CBO reviewed the potential impact of an independent Medicare Advisory Council, and estimated that it would save $2 billion over 10 years. The advisory panel had been pushed by the Obama administration as a key mechanism for reducing long-term health care costs. Republicans immediately began using the CBO estimate to argue that the Democratic reform proposals would not control health care costs.

States

See also: History of health care reform in the United States

A few states have taken serious steps toward universal health care coverage, most notably Minnesota and Massachusetts, with a recent example being the Massachusetts 2006 Health Reform Statute. The influx of more than a quarter of a million newly insured residents has led to overcrowded waiting rooms and overworked primary-care physicians who were already in short supply in Massachusetts. Other states, while not attempting to insure all of their residents, cover large numbers of people by reimbursing hospitals and other health care providers using what is generally characterized as a charity care scheme; New Jersey is perhaps the best example of a state that employs the latter strategy.

Several single payer referendums have been proposed at the state level, but so far all have failed to pass: California in 1994, Massachusetts in 2000, and Oregon in 2002.

The percentage of residents that are uninsured varies from state to state. Texas has the highest percentage of residents without health insurance at 24%. New Mexico has the second highest percentage of uninsured at 22%.

States play a variety of roles in the health care system including purchasers of health care and regulators of providers and health plans, which give them multiple opportunities to try to improve how it functions. While states are actively working to improve the system in a variety of ways, there remains room for them to do more.

San Francisco has established a program to provide health care to all uninsured residents (Healthy San Francisco).

Public opinion

Main article: Public opinion on health care reform in the United States

Survey research in recent decades has shown that Americans generally see expanding coverage as a top national priority, and a majority express support for universal health care. There is, however, much more limited support for tax increases to support health care reform. Most Americans report satisfaction with their own personal health care. Confidence in government, and the willingness to support large expansions of government, have declined significantly since the 1960s. Support for a single-payer system is less than the level of dissatisfaction with the current system and desire for increased coverage might suggest.

In an article published in the May/June 2008 issue of Health Affairs, pollsters William McInturff and Lori Weigel concluded that the current health care debate is very similar to that of the early 1990s, when the 1993 Clinton health care plan was under consideration. Similarities noted by the authors include a strong desire for change, a weakening economy, and an increased willingness to accept a larger governmental role in health care. New factors include high military spending and a higher burden placed on businesses by health care costs. However, the authors argue that many of the barriers to reform that existed in the early 1990s are still in play, including a strong resistance to government as the sole provider of care ("'I like national health insurance,' patiently explained one focus-group respondent. 'I just don’t want the government to run it.'"). The authors conclude that incremental change appears more likely than wholesale restructuring of the system.

A poll released in March 2008 by the Harvard School of Public Health and Harris Interactive found that Americans are divided in their views of the US health system, and that there are significant differences by political affiliation. When asked whether the US has the best health care system or if other countries have better systems, 45% said that the US system was best and 39% said that other countries' systems are better. Belief that the US system is best was highest among Republicans (68%), lower among independents (40%), and lowest among Democrats (32%). Over half of Democrats (56%) said they would be more likely to support a presidential candidate who advocates making the US system more like those of other countries; 37% of independents and 19% of Republicans said they would be more likely to support such a candidate. 45% of Republicans said that they would be less likely to support such a candidate, compared to 17% of independents and 7% of Democrats. Differing levels of satisfaction with the current system result in differences in the preferred policy solutions of Democrats and Republicans. Democrats are more likely to believe that the primary responsibility for ensuring access to health care should fall on government, while Republicans are more likely to see health care as an individual responsibility, and are more likely to believe that private industry is more effective in providing coverage and controlling cost than government. Democrats are more likely to support higher taxes to expand coverage, and more likely to require everyone to purchase coverage.

A 2008 survey of over two thousand doctors published in Annals of Internal Medicine, shows that physicians support universal health care and national health insurance by almost 2 to 1.

A Pew Research Center poll issued in June 2009 found that "[m]ost Americans believe that the nation’s health care system is in need of substantial changes." However, the survey found that, compared to the early 1990s when the Clinton Health Reform plan was being considered, fewer Americans believed the country was spending too much on health care, fewer believed that the health care system was in crisis, and fewer supported a complete restructuring of the system. Most supported extending coverage to the uninsured and slowing the increase in health care costs, but neither issue found the same level of support as they did in 1993. "[F]ar fewer [said that] health care expenses are a major problem for themselves and their families than was the case in 1993."

A June 2009 New York Times/CBS News poll found that Americans overwhelmingly support substantial changes to the health care system and are strongly behind a government-run insurance plan to compete with private insurers. They said the government could do a better job of holding down health-care costs than the private sector. The poll found that 72 percent of those questioned supported a government-administered insurance plan — something like Medicare for those under 65 — that would compete for customers with private insurers. Twenty percent said they were opposed. Nearly 60% of respondents said that they would be willing to pay higher taxes so everyone could have health insurance; 40% were willing to pay as much as $500 more per year. However, the poll also found "considerable unease about the impact of heightened government involvement, on both the economy and the quality of the respondents’ own medical care." While 85% supported fundamental restructuring of the health care system, 77% reported that they were very or somewhat satisfied with their own care.

A Washington Post/ABC News poll released in June of 2009 found that "[a] majority of Americans see government action as critical to controlling runaway health-care costs, but there is broad public anxiety about the potential impact of reform legislation and conflicting views about the types of fixes being proposed on Capitol Hill." Respondents were asked if they were concerned that "health-care reform would lead to higher costs, lower quality, fewer choices, a bigger deficit, diminished insurance coverage and more government bureaucracy." In each case, most respondents answered that they were "very concerned." "About six in 10" said that they were at least somewhat concerned about all six potential issues. Over 80% reported that they were satisfied with their own quality of care "and relatively content with their own current expenses." Questions that equated a public plan option with the popular Medicare program or "emphasized the prospect of more choices" received broad support (62%). But questions "framed with an explicit counterargument" received "a more tepid response." Support dropped to 37% when "respondents were told that [a public option] meant some insurers would go out of business." Most (58%) saw "government reform as necessary to stall skyrocketing costs and expand coverage for the uninsured," but 39% were concerned that it "would do more harm than good." When asked how reform would affect their own care, half said they thought it would stay about the same, while 31% expected it to become worse.

A NBC/Wall Street Journal poll released in June 2009 found that 76% percent of people feel a it is extremely important or quite important to give people a choice of a public plan. However the survey also suggests that Obama has not yet completed a sale of his plan. When only asked whether they thought Obama's health plan was a good thing they answered 33% good idea/32% bad idea/30% not sure. After being read a short description of the plan 55% were in favor.

Prescription drug prices

Main article: Prescription drug prices in the United States

During the 1990s, the price of prescription drugs became a major issue in American politics as the prices of many new drugs increased exponentially, and many citizens discovered that neither the government nor their insurer would cover the cost of such drugs. In absolute currency, the U.S. spends the most on pharmaceuticals per capita in the world. However, national expenditures on pharmaceuticals accounted for only 12.9% of total health care costs, compared to an OECD average of 17.7% (2003 figures). Some 23% of out-of-pocket health spending by individuals is for prescription drugs.

See also

• United States National Health Care Act
• Single-payer health insurance
• America's Affordable Health Choices Act

Related articles

• Health care compared - tabular comparisons of the US, Canada, and other countries not shown above.
• Health care reform
• Health care reform debate in the United States
• Health economics
• Health insurance exchange
• Health policy analysis
• Health care politics
• List of healthcare reform advocacy groups in the United States
• National health insurance
• Healthcare rationing in the United States

Further reading

• Doctors support universal health care: survey, Reuters, March 31, 2008 (first reported in Annals of Internal Medicine).
• Health Care Cost Survey Reveals High-Performing Companies Gain Health Dividend (2009) from Towers Perrin
• Hidden costs, value lost: uninsurance in America. Institute of Medicine Committee on the Consequences of Uninsurance. Washington, DC: National Academies Press, 2003.
• Paying More, Getting Less from Dollars & Sense
• Reducing Costs While Improving the U.S. Health Care System: The Health Care Reform Pyramid by Deloitte, January 2009
• Sick Around the World: Can the U.S. learn anything from the rest of the world about how to run a health care system? from Frontline, PBS.
• Barack Obama - Town Hall Transcript - August 11, 2009
• Charlie Rose Show - Interview with Mayo Clinic President & CEO Denis Cortese
• The New Yorker-Atul Gawande-The Cost Conundrum-June 2009

External links

Regierung

• HealthReform.gov official government site
• Health Insurance Reform Reality Check official White House rumor control site
• Health Care from WhiteHouse.gov

News media

• Health Care in America from CNN
• Health Care Reform & YouTube from Governing Dynamo, includes nearly all White House videos on health care reform
• Health Care Reform collected news coverage from The New York Times
• RX for Change: Legislation collected news coverage from NPR
• Healthcare Reform collected news coverage from Reuters
• Health-Care Reform 2009 collected news coverage from The Washington Post
  • In Search of Health Care Reform interactive overview

Interest groups

• Health Action Now! from AARP
• American Medical Student Association (AMSA) - Statement advocating universal single-payer bill H.R. 676
• Americans for Free Choice in Medicine (AFCM)
• Brookings Institution Engelberg Center for Health Care Reform
• Cato on Health Care Reform
• Health Care for America NOW!. An advocacy group that supports a public insurance option and H.R. 3200 expanding the purchase of health insurance.
• Healthcare-NOW!, a nonprofit advocacy group for single-payer universal health care
• healthcare4every1 Campaign
• Health Reform from the Kaiser Family Foundation
  • States Moving Towards Comprehensive Health Care Reform in the U.S.
• Leadership Conference for Guaranteed Health Care (LCGHC) advocating universal single-payer bill H.R. 676
• Federal Health Care Reform from the National Conference of State Legislatures
• National Nurses Organizing Committee (NNOC) advocating universal single-payer bill H.R. 676
• National Physicians Alliance (NPA)
• Physicians for a National Health Program, advocating universal single-payer, H.R. 676
• Progressive Democrats of America, advocates for universal single-payer bill H.R. 676
• SHOUTAmerica.com: A Community for Healthcare Reform
• Simple argument for Why We Need Government-Run, Universal, Socialized, (call it whatever you want) Health Insurance (4.5 stars on Youtube with 34K views) from Andy Lubershane at Worldchanging
• Single Payer Action, activist organization supporting universal single-payer bill H.R. 676
• Small Businesses for Health Care Reform

• The Heartland Institute - Health Care Issues
• The Heritage Foundation's health care research site
• UHCAN, health care reform resources, and various national and state groups' contact information.
• Universal Health Care Foundation of Connecticut
• Universal Health Care in the United States video and summary of event held at the Woodrow Wilson Center, October 2007.