Health care reform in the United States

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Health care reform in the United States
General
Debate for and against History Public opinion Drug prices Uninsured
Specific proposals
Health insurance exchange Healthy Americans Act United States National Health Insurance Act
Systems
Canadian and American health care systems compared National health insurance Publicly-funded health care Single-payer health care Universal health care
Reform advocacy groups
American Medical Association American Medical Student Association California Nurses Association/National Nurses Organizing Committee Healthcare-NOW! Physicians for a National Health Program Progressive Democrats of America
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Health care in the United States
Government
Centers for Medicare and Medicaid Services Medicare Medicaid Military Health System TRICARE Department of Veterans Affairs (VA) Indian Health Service State Children's Health Insurance Program (SCHIP) EMTALA Federal Employees Health Benefits Program
Private
Health maintenance organization (HMO) Managed care Medical underwriting Preferred provider organization (PPO)
Private consumer driven
Flexible spending account (FSA) Health Reimbursement Account Health savings account High Deductible Health Plan (HDHP) Medical savings account
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The debate over health care reform in the United States centers around 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. 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 any other United Nations member state except for the Marshall Islands.^[1] 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.^[2]

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".^[3] 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 of the US health system and what should be done to improve it. 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.^[4] Opponents of government mandates or programs for universal health care argue that people should be free to opt out of health insurance.^[5] 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.^[6][7]

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.^[8] Other comparisons conclude that the US system performs better on some measures, such as responsiveness and higher cure rates for some serious illnesses such as cancer.^{[9][10][11][12]}

Contents 1 Costs 2 Uninsured 3 Comparisons with other health care systems 4 History of reform efforts 4.1 Health reform and the 2008 presidential election 5 Barriers to reform 6 Public policy debate 6.1 The case for publicly funded health care 6.2 The case against publicly funded health care 7 Current reform proposals 7.1 Obama administration proposals 7.2 Congressional proposals 8 States 9 Public opinion 10 Prescription drug prices 11 See also 12 References 13 Further reading 14 External links

[edit] Costs

Current estimates put spending on health care in the US at approximately 16% of GDP.^[13][14] In 2007, an estimated $2.26 trillion was spent on health care in the United States, or $7,439 per person.^[15] Health care costs are rising faster than wages or inflation, and the health share of GDP is expected to continue its historical upward trend, reaching 19.5 percent of GDP by 2017.^[13] As a proportion of GDP, government health care spending in the United States is larger than in most other large western countries.^[16] On top of that, there is substantial expenditure paid from private insurance. A recent study found that medical expenditure was the cause for 60% of all personal bankruptcy in the United States. According to Dr. David Himmelstein of Harvard University who helped author the study, "Unless you're Warren Buffett, your family is just one serious illness away from bankruptcy...for middle-class Americans, health insurance offers little protection..."^[17]

The US spends more on health care per capita than any other UN member nation.^[1] It also spends a greater fraction of its national budget on health care than Canada, Germany, France, or Japan. In 2004 the US spent $6,102USD per person 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).^[18] Although the US Medicare coverage of prescription drugs began in 2006, most patented prescription drugs are significantly 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 monopoly purchasing power seen in national single-payer systems^{[citation needed]}. 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.^[19] 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, merchant seamen are covered by the Public Health System, and retired railway workers and military veterans are also covered by the government.^[20] 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.^[21][22]

[edit] Uninsured

People in the US without health insurance coverage at some time during 2007 totaled 15.3% of the population, or 45.7 million people.^[23][24] This number has decreased slightly from 47 million in 2006 due to increased publicly sponsored coverage and that about 300,000 more people are now covered in Massachusetts, which implemented the Massachusetts health care reform law in 2007.^[25] 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.^[25]

[edit] Comparisons with other health care systems

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 World Health Organization (WHO), in 2000, ranked the US health care system 37th in overall performance and 72nd by overall level of health (among 191 member nations included in the study).^[26][27] Despite larger spending, the United States has only slightly better infant mortality rate (6.30)^[28] and life expectancy (78.14)^[29] than the European Union (6.38^[28] and 77.32^[29]). However, David Hogberg, a political scientist, has written that infant mortality and life expectancy are not accurate ways to compare the U.S. health care system to others.^[30]

For example, the US CDC suggests that higher rates of infant mortality in the US are "due in large part to disparities which continue to exist among various racial and ethnic groups in this country, particularly African Americans".^[31] Some studies claim the data collected regarding infant mortality and life expectancy do not lend themselves to fair comparison.^[32]

Access to advanced medical treatments and technologies is greater than in most other developed nations and waiting times may be substantially shorter for treatment by specialists.^[9]

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".^[33] Various health care analysts have asserted that market failure occurs in health care markets,^[34] but some have suggested that it is a result of too much government involvement rather than too little.^[35][36] 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.^[37] Some studies have found no consistent and systematic relationship between the type of financing of health care and cost containment.^[38]

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.^[39]

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.^[40] 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.^[41] 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.^[40]

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.^[42]

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.^[43][44]

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.^[45] 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.^[46][47]

[edit] History of reform efforts

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.^[48]

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 who are either 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 provided national standards for protecting personal health information.

During the 2004 presidential election, both the George Bush and John Kerry campaigns offered health care proposals.^[49][50] 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.^[51]

[edit] Health reform and the 2008 presidential election

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."^[52]

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."^[53] The Des Moines Register characterized the plans similarly.^[54]

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.^[55]

[edit] 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.^[56] 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.^[57]

Economists Katherine Baicker, who was a member of President Bush's Council of Economic Advisers,^[58] 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.^[59]

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.^[60]

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.^[61]

[edit] Public policy debate

The political debate over health care reform has for several decades centered 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.^[62] Whether or not a publicly funded universal health care system should be implemented is one such example.^[63]

[edit] The case for publicly funded health care

Democrats are far more supportive of publicly funded health care than are Republicans^[64] 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.^[65]

One of the leading organizations in support of single payer 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.^[66] 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,^[23] including 9.7 million who are not American citizens.^[67] 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.^[68] 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.^[68]

For example, the US ranks 22nd in infant mortality, between Taiwan and Croatia,^[69] 46th in life expectancy, between Saint Helena and Cyprus,^[70] and 37th in health system performance, between Costa Rica and Slovenia.^[71]

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.^[72] 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."^[73]

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^[74] of insurance companies in the US to provide universal care.^[75] 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.^[76]

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.^[77]

[edit] The case against publicly funded health care

Those who oppose publicly funded health care argue that there are flaws in publicly funded health care systems, such as those which operate in Canada, the United Kingdom and Germany. They argue that these systems have poor quality of care, long waiting lists, and slow access to new drugs.^{[10][11][12][78]}

Several criticisms have been leveled against the idea of changing the U.S. health care system to a single-payer system.

Supporters of the for-profit, free market health care system contend that the high level of administrative costs cited by advocates of publicly funded care arise out of the substantial level of government regulation that exists in the United States health care sector.^[79] According to a study by the Cato Institute this regulation provides benefits in the amount of $170 billion but costs the public up to $340 billion.^[79]

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.^[80] 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).

For this reason, some U.S. reformers argue for other, more incremental changes to achieve universal health care, such as tax credits or vouchers.^[81] 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."^[82]

[edit] Current reform proposals

[edit] Obama administration proposals

Barack Obama as president has initiated a series of actions intended to reform health care. The full elements in his plan were outlined in a 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.

The plan includes implementing guaranteed eligibility for affordable health care for all Americans, paid for by insurance reform, reducing costs, removing patent protection for pharmaceuticals, and requiring employers to either furnish meaningful coverage or contribute to a new public plan.^[83][84] He would provide for mandatory health care insurance for children.

Obama has 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 has 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 the Obama plan would achieve the stated level of cost savings.^[85]

For those not insured through employment, Obama proposes 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 estimates the cost of the program at $60 billion annually.^[86] 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.^[86] A critique of Obama's health care plan 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.^[87]

A reform plan, which Obama is 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. ^[88]

In June 2009 President Barak Obama participated in a open debate with members of the public, which was aired by ABC News as a special edition of Primetime.^[89]

[edit] Congressional proposals

On May 5, 2009, US Senate Finance Committee held hearings on Health care reform. On the panel of the "invited stakeholder", no supporter of the Single-payer health care system was invited.^[90] The panel featured Republican senators and industry panelists who argued against any kind of expanded health care coverage.^[91] The preclusion of the single payer option from the discussion caused significant protest by doctors in the audience.^[91]

There is one bill currently before Congress but others are expected to be presented soon. A merged single bill is the likely outcome.^{[citation needed]} The Affordable Health Choices Act is currently before the House of Representatives and the main sticking points at the markup stage of the bill have been in two areas; should the government provide a public insurance plan option to compete head to head with the private insurance sector, and secondly should comparative effectiveness research be used to contain costs met by the public providers of health care.^{[citation needed]} 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 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.^{[citation needed]} 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 DHHS to prevent payments for services that clearly do not work.^{[citation needed]} 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.^{[citation needed]} A proposed but not yet enacted short bill with the same effect is the Republican sponsored Patients Act 2009.^{[citation needed]}

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. ^[92] 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.^[92] 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.^[92] 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.^[93] 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.^[94][95] 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.^[96][97]

However, in a June New York Times editorial, economist 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."^[98]

[edit] 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.^[99] 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.^[100] 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,^[101] Massachusetts in 2000, and Oregon in 2002.^[102]

The percentage of residents that are uninsured varies from state to state. Texas has the highest percentage of residents without health insurance at 24%.^[103] New Mexico has the second highest percentage of uninsured at 22%.^[103]

States play a variety of roles in the health care system including purchasers of health care and regulators of providers and health plans,^[104] 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.^[105]

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

[edit] Public opinion

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.^[106] There is, however, much more limited support for tax increases to support health care reform.^[106][107] 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.^[107]

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 relatively 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.^[108]

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.^[109][110] 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.^[111]

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.^[112]

A Pew Research Center poll issued in June of 2009 found that "[m]ost Americans believe that the nation’s health care system is in need of substantial changes."^[113] 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.^[113] 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.^[113] "[F]ar fewer [said that] health care expenses are a major problem for themselves and their families than was the case in 1993."^[113]

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.^[114] 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.^[114] 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."^[114] While 85% supported fundamental restructuring of the health care system, 77% reported that they were very or somewhat satisfied with their own care.^[114]

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."^[115][116] 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."^[115][116] "About six in 10" said that they were at least somewhat concerned about all six potential issues.^[115] Over 80% reported that they were satisfied with their own quality of care "and relatively content with their own current expenses."^[115] 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."^[115][116] 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."^[115][116] 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.^[115][116]

[edit] Prescription drug prices

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).^[117] Some 25% of out-of-pocket spending by individuals is for prescription drugs.^[118]

[edit] See also

• Health care reform
• Health economics
• Health insurance exchange
• Health policy analysis
• Health care politics
• List of healthcare reform advocacy groups in the United States
• National health insurance
• United States National Health Insurance Act

[edit] References

[edit] 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.

[edit] External links

• 1payer.net, citizen action site for single-payer universal health care
• American Medical Student Association (AMSA) - Statement supporting universal health care
• Americans for Free Choice in Medicine (AFCM)
• Barack Obama & Joe Biden's plan to lower health care costs and ensure affordable, accessible health coverage for all
• Health Care for America NOW!. An advocacy group that supports a public health insurance option for universal health care.
• Health Revolution Petition
• Healthcare-NOW!, a nonprofit advocacy group for single-payer universal health care
• healthcare4every1 Campaign
• Leadership Conference for Guaranteed Health Care (LCGHC)
• National Nurses Organizing Committee (NNOC)
• National Physicians Alliance (NPA)
• Physicians for a National Health Program
• Progressive Democrats of America, advocates for single-payer system
• Republicans for Single-Payer Universal Healthcare Republicans who support single-payer healthcare.
• SHOUTAmerica.com: A Community for Healthcare Reform
• Single Payer Action, activist organization supporting single-payer universal health care
• Small Businesses for Health Care Reform
• States Moving Towards Comprehensive Health Care Reform in the U.S. from The Henry J. Kaiser Family Foundation
• 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.

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