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Health care reform in the United States
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Health care in the United States

The debate over health care reform in the United States centers on questions about whether there is a fundamental right to health care, on who should have access to health care and under what circumstances, on the quality achieved for the high sums spent, the sustainability of expenditures that have been rising faster than the level of general inflation and the growth in the economy, the role of the federal government in bringing about such change, and concerns over unfunded liabilities. In sixty two percent of all personal bankruptcy in the United States, medical debt is cited as a factor, the biggest single factor of all.[1][2] which is almost unknown in other countries in the developed world.[3][4] The United States spends a greater portion of total yearly income in the nation on health care than any United Nations member state except for East Timor (Timor-Leste),[5] although the actual use of health care services in the U.S., by most measures of health services use, is below the median among the world's developed countries.[6]

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".[7] Americans are divided along party lines in their views regarding the role of government in the health economy and especially whether a new public health plan should be created and administered by the federal government.[8] Those in favor of 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.[9] Opponents of laws requiring people to have health insurance argue that this impinges on their personal freedom and that other ways to reduce health care costs should be considered.[10] Both sides of the political spectrum have also looked to more philosophical arguments, debating whether people have a fundamental right to have health care which needs to be protected by their government.[11][12]

The focus is currently on the recently passed Affordable Health Care for America Act in the House of Representatives and the Senate, and the Patient Protection and Affordable Care Act, which was also passed by the Senate.


Comparisons with other countries

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


Current figures estimate that spending on health care in the U.S. is about 16% of its GDP.[13][14] In 2007, an estimated $2.26 trillion was spent on health care in the United States, or $7,439 per capita.[15] 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.[13] In fact, government health care spending in the United States is consistently greater, as a portion of GDP, than in Canada, Italy, the United Kingdom and Japan (countries that have predominantly public health care).[16] And an even larger portion is paid by private insurance and individuals themselves. A recent study found that medical expenditure was a significant contributing factor in 62% of personal bankruptcies in the United States during 2007.[17] "Unless you're [billionaire] 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.[18]

The U.S. spends more on health care per capita than any other UN member nation.[5] It also spends a greater fraction of its national budget on health care than Canada, Germany, France, or Japan. In 2004, the U.S. 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 U.S., had the highest spending in the Organisation for Economic Co-operation and Development (OECD).[19] Although the U.S. Medicare coverage of prescription drugs began in 2006, most patented prescription drugs are more costly in the U.S. 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.[20] Some U.S. citizens obtain their medications, directly or indirectly, from foreign sources, to take advantage of lower prices.

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. The authors of the study concluded that the prices paid for health care services are much higher in the U.S.[6]

Medicare and Medicaid Spending as % GDP

The Congressional Budget Office has argued that the Medicare program as currently structured is unsustainable without significant reform, as tax revenues dedicated to the program are not sufficient to cover its rapidly increasing expenditures. Further, the CBO also projects that "total federal Medicare and Medicaid outlays will rise from 4 percent of GDP in 2007 to 12 percent in 2050 and 19 percent in 2082—which, as a share of the economy, is roughly equivalent to the total amount that the federal government spends today. The bulk of that projected increase in health care spending reflects higher costs per beneficiary rather than an increase in the number of beneficiaries associated with an aging population."[21] The Government Accountability Office reported that the unfunded liability facing Medicare as of January 2007 was $32.1 trillion, which is the present value of the program deficits expected for the next 75 years in the absence of reform.[22] According to the Centers for Medicare and Medicaid Services, spending on Medicare will grow from approximately $500 billion during 2009 to $930 billion by 2018. Without changes, the system is guaranteed “to basically break the federal budget,” President Obama said at a White House news conference July 22.[23]

A new study (published December 15, 2009 in Proceedings of the National Academy of Sciences) from authors at Duke University, National Council of Spinal Cord Injury Association, Brigham Young University, and North Carolina State University shows that it might be more accurate to think of health care spending as an investment that can spur economic growth. The study also shows that government projections of health care costs and financing may be unduly pessimistic.[24]

Prescription drug prices

During the 1990s, the price of prescription drugs became a major issue in American politics as the prices of many new patented drugs increased sharply, and many citizens discovered that neither the government nor their insurer would pay the monopoly price 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).[25] Some 23% of out-of-pocket health spending by individuals is for prescription drugs.[26]

Impact on U.S. economic productivity

On March 1, 2010, billionaire Warren Buffett (who is considered one of the world’s most savvy investors[27]) said that the high costs paid by U.S. companies for their employees’ health care put them at a competitive disadvantage. He compared the roughly 17% of GDP spent by the U.S. on health care with the 9% of GDP spent by much of the rest of the world, noted that the U.S. has fewer doctors and nurses per person, and said, “[t]hat kind of a cost, compared with the rest of the world, is like a tapeworm eating at our economic body.”[28]

Quality of care

Life expectancy in the United States is 78.11 years, lower than the 78.67 years for the European Union.[29]. For 2006-2010, the U.S. life expectancy will lag 38th in the world, after most developed nations, lagging last of the G6 (Japan, France, Germany, Italy, U.K., U.S.) and just after Chile (35th) and Cuba (37th).[30]

The U.S. also has a worse infant mortality rate, 6.26 per 1000 live births compared to 5.72 for the European Union.[31] The Center for Disease Control and Prevention (CDC) suggests that higher rates of infant mortality in the U.S. are "due in large part to disparities which continue to exist among various racial and ethnic groups in this country, particularly African Americans".[32] Some studies claim the data collected regarding infant mortality and life expectancy do not lend themselves to fair comparison, as there may be differences in whether patients seek help, their ethnic background, diet, lifestyle, and the specific legal definition of a live birth.[33]

In 2000, the World Health Organization (WHO) ranked the U.S. 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).[34][35] The WHO study has been criticized by the free market advocate David Gratzer because "fairness in financial contribution" was used as an assessment factor, marking down countries with high per-capita private or fee-paying health treatment.[36] One study found that there was little correlation between the WHO rankings for health systems and the satisfaction of citizens using those systems.[37] Some countries, such as Italy and Spain, which were given the highest ratings by WHO were ranked poorly by their citizens while other countries, such as Denmark and Finland, were given low scores by WHO but had the highest percentages of citizens reporting satisfaction with their health care systems.[37] WHO staff, however, say that the WHO analysis does reflect system "responsiveness" and argue that this is a superior measure to consumer satisfaction, which is influenced by expectations.[38]

The United States ranked last across a range of measures of health care in a comparison of 19 industrialised countries, despite spending more than twice as much per person on health as any other of the countries. [39] The 2007 comparison by the Commonwealth Fund of health care in the U.S. with that of Germany, Britain, Australia, New Zealand, and Canada, the U.S. ranked last on measures of quality, access, efficiency, equity, and outcomes. This was attributed firstly to the lack of universal insurance, but also due to slow adoption of information technology and a lack of national policies to improve performance.[40] A followup in 2008 found that the U.S. had improved in some areas, but remained in last place because the other countries were improving more quickly.[41]

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 (ahead of only Mexico and Hungary) and fifth to last for men (ahead of Poland and Slovakia additionally), according to OECD data. Yet another measure is Disability-adjusted life year (DALY); again the United States fares relatively poorly.[citation needed] 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.[42]

The U.S. system is often compared with that of its northern neighbor, Canada. Canada's system is largely publicly funded. In 2006, Americans spent an estimated $6,714 per capita on health care, while Canadians spent US$3,678.[43] This amounted to 15.3% of U.S. GDP in that year, while Canada spent 10.0% of GDP on health care. The Canadian system has been criticized regarding long wait times — 5.5 weeks for oncology and 40 weeks for orthopedic surgery — and provincial health ministers announced a plan to reduce these to four weeks for radiation therapy for cancer and 26 weeks for hip replacement surgery.[44] A 2007 review of all studies comparing health outcomes in Canada and the U.S. found that the quality of care in Canada is at least as good as that in the U.S.[45]


According to the U.S. Census Bureau, people in the U.S. without health insurance coverage at some time during 2007 totaled 15.3% of the population, or 45.7 million people.[46][47] According to the Census Bureau, 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.[48] In 2009, the Census Bureau estimated that there are 47 million Americans who do not have any health insurance at all.[49] Other studies, which complement the Census Bureau and include data from the Agency for Healthcare Research and Quality, have placed the number of uninsured for all or part of the years 2007-2008 as high as 86.7 million, about 29% of the U.S. population, or about one-in-three among those under 65 years of age.[50][51]

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.[48][50] Fareed Zakaria wrote that only 38% of small businesses provide health insurance for their employees during 2009, versus 61% in 1993, due to rising costs.[52]

During September 2009, Senator Dick Durbin (D-IL) stated that the average family pays an additional $1,000 per year in insurance premiums to cover the uninsured.[53] President Obama, in his September 9 remarks to a joint session of Congress on health care, called the cost of uninsured Americans "a hidden and growing tax."[54] However, CBO found that while broadening insurance coverage might lead to less cost shifting, "that effect would probably be relatively small and would not directly produce net savings in national or federal spending on health care."[55] The Pacific Research Institute, a conservative think-tank, argues that the uninsured subsidize the insured, do not drive up the cost of health care, and use fewer services than the insured.[56] A 2004 editorial in USA Today asserted that United States Department of Health and Human Services (HHS) data show the uninsured are unfairly billed for services at rates far higher—on average 305% at urban hospitals in California—than are the insured; USA Today concluded that "millions of [uninsured patients] are forced to subsidize insured patients."[57] According to the editorial:

"Many hospitals say they have to charge the uninsured high 'sticker prices' or risk violating a federal ban on charging Medicare patients more than other customers. Hospitals also must try to collect what patients owe, or they could lose Medicare reimbursement for bad debts, notes a 2003 study by the Commonwealth Fund, a health-policy-research foundation."[57]

The Boston Globe reported that, since Massachusetts mandated the uninsured to purchase insurance, emergency visits and costs have increased;[58] insurance premiums have increased faster than the rest of the United States, and are now the highest in the country.[59] Writing in the New York Times opinion blog "Room for Debate" the single-payer health care advocate Marcia Angell, former editor-in-chief of the New England Journal of Medicine, described the Massachusetts mandates as "a windfall for the insurance industry" and wrote, "Premiums are rising much faster than income, benefit packages are getting skimpier, and deductibles and co-payments are going up."[60] Michael Cannon of the Cato Institute, a conservative libertarian think-tank, writes that Massachusetts' law forcing everyone to buy insurance has reportedly caused costs there to increase faster than in the rest of the country,[61] and argues that without the uninsured, "The insured would pay more, not less."[62]

A 2009 Harvard study published in the American Journal of Public Health found more than 44,800 excess deaths annually in the United States associated with uninsurance,[63][64] and more broadly, the total number of people in the United States, whether insured or uninsured, who die because of lack of medical care were estimated in a 1997 analysis to be nearly 100,000 per year.[65] In a study by the Manhattan Institute, a conservative think-tank, Frank R. Lichtenberg of Columbia University found that the correlation between life expectancy and health insurance was not statistically significant.[66] He did find that access to advanced drugs (newly approved by the FDA) had a statistically significant correlation with higher rates of life expectancy.

History of reform efforts

The U.S. system already has substantial public components. The federal Medicare program covers nearly 45 million elderly and some people with disabilities. The Military Health System, TRICARE, and the Veterans Health Administration cover a total of 9.2 active military personnel and veterans and their families.[67][68] The federal-state Medicaid program provides coverage to the poor. The State Children's Health Insurance Program (SCHIP) extends coverage to low-income families with children. Native Americans are covered on the reservation (by tribal hospital). Members of many American Indian tribes or Alaskan Native communities are covered by the Indian Health Service pursuant to treaties, laws, or executive orders, but coverage is rarely equivalent to private insurance, with one-third less funding than the average American per capita and one-half that of American prisoners.[69] Merchant marines were eligible for publicly funded care through the Marine Hospital Service (later renamed Public Health Service from 1798 until the program was shut down by Ronald Reagan in 1981.[70]

Health reform became a coordinated movement during the unsuccessful 1912 campaign of progressive candidate Theodore Roosevelt. Franklin Delano Roosevelt attempted to make a national health insurance program part of Social Security, but deferred action until 1944, when he endorsed the Wagner-Murray-Dingell Bill. After Roosevelt's death in 1945, Harry S. Truman continued support of an expanded bill, but was defeated by lobbying from the American Medical Association, conservatives opposed to labor unions, and refocusing of concerns after the outbreak of the Korean War. On October 1949, Congress adjourned without acting on S. 1679 and H.R. 4312.[71][72][73][74]

Debate continued along party lines, with Republicans favoring a voluntary choice of government or private insurance for those over 65, and Democrats seeking to create a national healthcare benefit. By the 1964 presidential election, one-half of those over 65 lacked health insurance. Medicare program was established by legislation signed into law on July 30, 1965, by President Lyndon B. Johnson, as a part of his "Great Society".[71] 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.

In his 1974 State of the Union address, President Richard M. Nixon called for comprehensive health insurance.[75] On February 6, 1974, he introduced the Comprehensive Health Insurance Act. Nixon's plan would have mandated employers to purchase health insurance for their employees, and in addition provided a federal health plan, similar to Medicaid, that any American could join by paying on a sliding scale based on income.[76] The New York Daily News writes that Ted Kennedy rejected the universal health coverage plan offered by Nixon because it wasn't everything he wanted it to be. Kennedy later realized it was a missed opportunity to make major progress toward his goal.[77]

Former President Jimmy Carter wrote in 1982 that Ted Kennedy’s disagreements with Carter's proposed approach thwarted Carter’s efforts to provide a comprehensive health-care system for the country.[78]

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.[79]

Health care reform was a major concern of the Bill Clinton administration headed 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.[80]

During the 2004 presidential election, both the George Bush and John Kerry campaigns offered health care proposals.[81][82] 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.[83]

In February 2009, President Barack Obama signed H.R. 2, to provide coverage for millions of children through the Children's Health Insurance Program, and signed the American Recovery and Reinvestment Act to make investments in computerized medical records and preventive services.

Public policy debate

Public funding

Issues regarding publicly funded health care are frequently the subject of political debate.[84] Whether or not a publicly funded universal health care system should be implemented is one such example.[85]

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.[86] A study published in August 2008 in the journal Health Affairs found that covering all of the uninsured within the existing private-based U.S. health care system 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.[87]

However, in his April 1, 2009 testimony before the Congressional Forum on National Lessons for Health Reform, Dr. Leonard Rodberg, PhD, of the Urban Studies Dept., Queens College/CUNY, argued that a single payer national health insurance plan would cost no more than the U.S. is spending now on healthcare and provide mechanisms for containing the growth in cost—while covering every American with comprehensive health care services.[88]

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.[89]

Insurer competition and public alternative

According to economist and former US Secretary of Labor Robert Reich, only a "big, national, public option" can force insurance companies to cooperate, share information, and reduce costs. Scattered, localized, "insurance cooperatives" are too small to do that and are "designed to fail" by the moneyed forces opposing Democratic health care reform.[90][91]

And in 2009 the Congressional Budget Office found that the inclusion of a strong public option would lower the cost of health care reform in the U.S. by tens of billions of dollars.[92]

Another approach to increase competition was to propose the repeal of an antitrust exemption for insurance companies. A bill to this end was proposed by Senator Patrick Leahy and others in 2007.[93] A 2009 bill introduced by Representative Tom Perrielo was passed by the House of Representatives by a vote of 406 to 19.[94]

Delivery and payment systems

A variety of general and specific reform strategies have been proposed regarding the healthcare delivery and payment systems. Examples include: comparative effectiveness research; independent review panels; doctor's incentives; tax reform; prevention and wellness; insurance company anti-trust reforms; coverage mandates; tort reform; rationing of care; healthcare technology and process standardization; and single payer payment processing.[95][96]

Surgeon Atul Gawande wrote in The New Yorker that the Senate and House bills passed contain a variety of pilot programs that may have a significant impact on cost and quality over the long-run, although these have not been factored into CBO cost estimates. He stated these pilot programs cover nearly every idea healthcare experts advocate, except malpractice/tort reform. He argued that a trial and error strategy, combined with industry and government partnership, is how the U.S. overcame a similar challenge in the agriculture industry in the early 20th century.[97]

Peter Orszag has suggested 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.[98]


America's health care industry has spent hundreds of millions of dollars in 2009 alone to block the introduction of public medical insurance and stall other reforms proposed by President Obama and by others. There are six registered healthcare lobbyists for every member of Congress. The campaign against health care system reform has been waged in part through substantial donations to key politicians. The single largest recipient of health industry political donations and chairman of the Senate Committee on Finance that drafted Senate health care legislation is Senator Max Baucus (D-MT).[99] A single health insurance company, Aetna, has contributed more than $110,000 to one legislator, Senator Joe Lieberman (ID-CT), in 2009.[100]

Economists Katherine Baicker, who was a member of President Bush's Council of Economic Advisers,[101] 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 include "The Problem With The Health Insurance System Is That Sick People Without Insurance Can’t Find Affordable Policies" and "Covering The Uninsured Pays For Itself By Reducing Expensive And Inefficient Emergency Room Care" [102]

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.[103] There is, however, much more limited support for tax increases to support health care reform.[103][104][105] Roughly two-in-three (64%) of Americans report they are "very or completely satisfied with their plan".[106] As of 2009, 58% supported a national health plan "in which all Americans would get their insurance through an expanded, universal form of Medicare-for-all"[107] but only 47% supported one "in which all Americans would get their insurance from a single government plan."[108] Polls of public support for a government-run insurance plan to compete with private insurers, the so-called "public option", have varied widely between 40% to 83% in support of such a plan, depending on the particular poll.[109] One polling analyst, Nate Silver, recommends the Time/SRBI and Quinnipiac polls as being most accurately phrased, which narrows down support to 56-62%.[110]

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.[111]

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 U.S. health system, and that there are significant differences by political affiliation. When asked whether the U.S. has the best health care system or if other countries have better systems, 45% said that the U.S. system was best and 39% said that other countries' systems are better. Belief that the U.S. 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 U.S. 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.[112][113] 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.[114]

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.[115]

A CBS News/New York Times poll taken in April 2009 found that healthcare is the most important issue after the economy, and that 57 percent of Americans are willing to pay higher taxes for universal healthcare, compared to 38 percent that are not. Also 54 percent of Americans feel that providing health insurance for all is more important than the problem of keeping health costs down (49 percent).[116]

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."[117] 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.[117] 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.[117] "[F]ar fewer [said that] health care expenses are a major problem for themselves and their families than was the case in 1993."[117]

A Time Magazine poll from July 2009 asked respondents if they would favor a "national single-payer plan similar to medicare for all" from Congress. The survey found 49% in support with 46% opposed and 5% unsure.[118]

In an August 2009 poll, SurveyUSA showed the majority of Americans (77%) feel that it is either "Quite Important" or "Extremely Important" to "give people a choice of both a public plan administered by the federal government and a private plan for their health insurance."[119]

In 2010, 82% of Obama voters who voted for Brown in Massachusetts support the public option.[120]

State-level reform efforts

A few states have taken serious steps toward universal health care coverage, most notably Minnesota, Massachusetts, and Connecticut, with a recent example being the Massachusetts 2006 Health Reform Statute.[121] 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.[122] In July 2009, Connecticut passed into law a plan called SustiNet, with the goal of achieving health-care coverage of 98% of its residents by 2014.[123] 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,[124] Massachusetts in 2000, and Oregon in 2002.[125] The state legislature of California has twice passed SB 840, The Health Care for All Californians Act, a single-payer health care system. Both times, Governor Arnold Schwarzenegger (R) vetoed the bill, once in 2006 and again in 2008.[126][127][128]

The percentage of residents that are uninsured varies from state to state. Texas has the highest percentage of residents without health insurance at 24%.[129] New Mexico has the second highest percentage of uninsured at 22%.[129]

States play a variety of roles in the health care system including purchasers of health care and regulators of providers and health plans,[130] 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.[131]

San Francisco has established a program to subsidize medical care for certain uninsured residents (Healthy San Francisco).

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."[132]

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.[133][134][135]

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."[136] The Des Moines Register characterized the plans similarly.[137]

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.[138]

Federal proposals during the Obama administration

There have been a number of different health care reforms proposed during the Obama administration to improve the U.S. health care system. These include variety of specific types of reform ranging from increased use of health care technology through changing the anti-trust rules governing health insurance companies and tort-reform to rationing of care. The Obama administration has suggested a package of reforms, as have several Congressional legislative proposals.

President's plan, 2009

The President's plan, and arguments on its behalf, are available on the White House website.[139]

During a June 2009 speech, President Barack Obama outlined his strategy for reform. He mentioned electronic record-keeping; preventing expensive conditions; reducing obesity; refocusing doctor incentives from quantity of care to quality; bundling payments for treatment of conditions rather than specific services; better identifying and communicating the most cost-effective treatments; and reducing defensive medicine.[140]

President Obama further described his plan in a September 2009 speech to a joint session of Congress. His plan mentions: deficit neutrality; not allowing insurance companies to discriminate based on pre-existing conditions; capping out of pocket expenses; creation of an insurance exchange for individuals and small businesses; tax credits for individuals and small companies; independent commissions to identify fraud, waste and abuse; and malpractice reform projects, among other topics.[141][142]

President's plan, 2010

On February 22, 2010, President Barack Obama released his plan for health care reform. In his plan he outlines the key elements on which he wants to focus. Key elements of his plan are: policies to improve the affordability and accountability; policies to crack down on waste, fraud and abuse; policies to contain costs and ensure fiscal sustainability; and other policy improvements.[143]

On February 25 President Obama held a Bipartisan Health Care Summit at the Blair House. Among the topics discussed were the rising costs of health care and unfair insurance practices. There were several issues that Republicans and Democrats shared agreement on, issues such as: Preventing waste and fraud in Medicare and Medicaid; addressing medical malpractice reform; reforming the insurance market; and giving individuals more choices in coverage, and giving small businesses the opportunity to pool coverage for their employees.[144] One on the disagreements discussed was the call from Republicans to throw out the current bill, and start over. President Obama said he doesn’t want to scrap a year’s worth of work and start over saying “the millions of Americans that are suffering can't afford another year-long debate. There's too much at stake.”[145]

On March 2 President Obama sent a letter to Speaker of the House Nancy Pelosi, Senator Harry Reid, Senator Mitch McConnell, and Representative John Boehner. In the letter he referenced four Republican ideas that he thought deserved to be explored more. Those ideas were: random undercover investigations of health care providers that receive reimbursements from Medicare, Medicaid, and other Federal programs; expanding the proposed grants of $23 million to $50 million for states that demonstrate alternatives to resolving medical malpractice disputes; increasing Medicaid payments to doctors; and the possibility of expanding Health Savings Accounts, and making clearer language in the President’s proposal to allow for high deductible plans. [146] He also spoke of provisions in the legislation that he felt should not be in there, such as the Medicare Advantage provision that provided transitional extra benefits to Florida residents, and the Nebraska FMAP provision which would have covered that state's expanded Medicare coverage in perpetuity. [147][148]

On March 8th, in Glenside, Pennsylvania, the president gave a speech entitled "Fighting for Health Insurance Reform", in which he restated the country's need for a sustainable health care system. He explained why he believes health insurance reform is a necessity and called on Congress to put aside politics and hold a final up-or-down vote on reform.[149]

Congressional proposals

Summary of differences between proposed Health Reform Bills
H.R. 3962, Affordable Health Care for America Act
"House bill"
H.R. 3590, Patient Protection and Affordable Care Act
"Senate bill"
Financing Places a 5.4% surtax on incomes over $500,000 for individuals and $1,000,000 for families.[150] Increases the Medicare payroll tax from 1.45% to 2.35% on incomes over $200,000 for individuals and $250,000 for families.[150]
Abortion Insurance plans that cover abortions (except those already allowed by the Hyde Amendment) will not be eligible for federal subsidies.[151][152] Insurance plans that participate in the newly-created exchanges will be permitted to include abortion coverage, but a separate payment, not using federal funds, must be made for the portion of the premium attributable to abortion coverage.[153][152] Each state will have the option to exclude plans covering abortions from their insurance exchange.[153][154]
Public option Yes.[150] No. Instead, the federal government will mandate that newly-created State insurance exchanges include at least two national plans that are created by the Office of Personnel Management. Of these two national plans, at least one will have to be a private non-profit plan.[155][156]
Insurance exchanges A single national insurance exchange will be created to house private insurance plans as well as a public option. Individual states could run their own exchanges under federal guidelines.[155][154] Each state will create its own insurance exchange under federal guidelines.[154]
Medicaid eligibility Expanded to 150% of the federal poverty level[150] Expanded to 133% of the federal poverty level[150]
Illegal immigrants They are allowed to participate in the insurance exchanges, but cannot receive federal subsidies. They cannot participate in the exchange or receive subsidies.
CBO estimate of outlays $1,050 billion dollars over 10 years.[155] $871 billion dollars over 10 years.[155]
CBO estimate of proposal's net effect Deficit would be reduced a total of $138 billion 2010-2019 after tax receipts and cost reductions.[157] Deficit would be reduced a total of $132 billion 2010-2019 after tax receipts and cost reductions.[158]
Takes effect November 22, 2010 December 26, 2011

Currently, there are two major proposals being considered in Congress.

On November 7, 2009, the House passed their version of a health insurance reform bill, the Affordable Health Care for America Act, 220-215.

On December 24, 2009, the Senate passed their version, the Patient Protection and Affordable Care Act, 60-39.[159]

The two bills are similar in a number of ways. In particular, both bills:[160]

  • Expand Medicaid eligibility up the income ladder (to 133% of the poverty line in the Senate bill and 150% in the House bill).
  • Establish health insurance exchanges, and subsidize those making up to 400 percent of the poverty line
  • Offer tax credits to certain small businesses (under 25 workers) who provide employees with health insurance
  • Impose a penalty on employers who do not offer health insurance to their workers
  • Impose a penalty on individuals who do not buy health insurance
  • Offer a new voluntary long-term care insurance program
  • Pay for new spending, in part, through cutting Medicare Advantage, slowing the growth of Medicare provider payments, reducing Medicare and Medicaid drug prices, cutting other Medicare and Medicaid spending, and raising various taxes.
  • Impose a $2,500 limit on contributions to flexible spending accounts (FSAs), which allow for payment of health costs with pre-tax funds, to pay for a portion of health care reform costs.[161]

The two bills are also similar in that neither would have much, if any, effect on the rising costs experienced by most Americans who currently have private health insurance.[162][163][164][165] Additionally, the seven million Americans with FSAs above $2,500 would see an increase in taxes due to the proposed $2,500 cap on FSA contributions.[166]

The biggest difference between the bills, currently, is in how they are financed. In addition to the items listed in the above bullet point, the House relies mainly on a surtax on income above $500,000 ($1 million for families). The Senate, meanwhile, relies largely on an "excise tax" for high cost 'Cadillac' insurance plans, as well as an increase in the Medicare payroll tax for high earners.[167] The Senate Finance Committee approved provisions that would lump FSAs together with high-cost insurance plans and subject them to this excise tax.

Some economists believe the excise tax to be best of the three revenue raisers above, since (due to health care cost growth) it would grow fast enough to more than keep up with new coverage costs, and it would help to put downward pressure on overall health care cost growth.[168]

Unlike the House bill, the Senate bill would also include a Medicare Commission which could modify Medicare payments in order to keep down cost growth.

The bills would need to go to Conference where differences between them may be resolved. If the Joint Conference Committee is able to resolve any differences between each chamber's passed version of comprehensive health care reform, the resulting Committee Report becomes the lead proposal and goes back to each chamber to be voted on by the full-body. The Committee Report, if passed, can then be presented to President Barack Obama for his signature into law or be vetoed back to Congress. Congressional leaders plan to bypass submitting the bills to a conference committee in order to expedite the process.[169]

Differences in how each chamber determines subsidies

A graphic that demonstrates how the subsidies are more generous for those closer to the poverty line and drop off as a family's distance from the poverty line increases. The rate at which the subsidy falls off decreases with increased distance from the poverty line. The curve representative of the "house bill" is concave and has a negative second derivative. The curve representative of the "senate bill" is linear from 100% FPL to 300% FPL and then flattens out at 9.8% of annual income until 400% FPL.
The relationship between a family's poverty level and the percentage of their income that is allotted to pay for health insurance. Note that the Senate Bill provides for Medicaid coverage up to 133% of the federal poverty level while the House Bill provides for Medicaid coverage up to 150% of the federal poverty level. Adapted from the texts of the House Bill and Senate Bill.

How each bill determines subsidies also differs. Each bill subsidizes the cost of the premium and the out-of-pocket costs but are more or less generous based on the relationship of the family's income to the federal poverty level.

The amount of the subsidy given to a family to cover the cost of a premium is calculated using a formula that includes the family's income relative to the federal poverty level. The federal poverty level is related to a determined percentage that defines how much of that family's income can be put towards a health insurance premium. For instance, under the House Bill, a family at 200% of the federal poverty level will spend no more than 5.5% of its annual income on health insurance premiums. Under the Senate Bill, the same family would spend no more than 6.3% of its annual income on health insurance premiums. The difference between the family's maximum contribution to health insurance premiums and the cost of the health insurance premium is paid for by the federal government. To understand how each bill can affect different poverty levels and incomes, see the Kaiser Family Foundation's subsidy calculator

Subsidies under House bill

The House plan subsidizes the cost of the plan and out-of-pocket expenses. The cost of the plan is subsidized according to the family's poverty level, decreasing the subsidy as the poverty level approaches 400%. The out-of-pocket expenses are also subsidized according to the poverty level at the following rates. The out-of-pocket expenses are subsidized initially and are not allowed to exceed a particular amount that will rise with the premiums for basic insurance.

For those making between This much of the out-of-pocket expenses are covered And no more than this much will be spent by the individual (family) on out-of-pocket expenses.
up to 150% of the FPL 97% $500 ($1,000)
150% and 200% of the FPL 93% $1,000 ($2,000)
200% and 250% of the FPL 85% $2,000 ($4,000)
250% and 300% of the FPL 78% $4,000 ($8,000)
300% and 350% of the FPL 72% $4,500 ($9,000)
350% and 400% of the FPL 70% $5,000 ($10,000)
Subsidies under Senate bill

The Senate plan subsidizes the cost of the plan and out-of-pocket expenses. The cost of the plan is subsidized according to the family's poverty level, decreasing the subsidy as the poverty level approaches 400%. The out-of-pocket expenses are also subsidized according to the poverty level at the following rates. The out-of-pocket expenses are subsidized initially and are not allowed to exceed a particular amount that will rise with the premiums for basic insurance.

For those making between This much of the out of the out-of-pocket expenses are covered
up to 200% of the FPL 66%
200% and 300% of the FPL 50%
300% and 400% of the FPL 33%

The Senate Bill also seeks to reduce out-of-pocket costs by setting guidelines for how much of the health costs can be shifted to families within 200% of the poverty line. A family within 150% of the FPL cannot have more than 10% of their health costs incurred as out-of-pocket expenses. A family between 150% and 200% of the FPL cannot have more than 20% of their health costs incurred as out-of-pocket expenses.

The House and Senate bills would differ, somewhat, in their overall impact. According to Congressional Budget Office estimates, the Senate bill would cover an additional 31 million people, cost nearly $850 billion for coverage provisions over ten years, reduce the ten year deficit by $130 billion, and reduce the deficit in the second decade by around 0.25% of GDP. The House bill, meanwhile, would cover an additional 36 million people, cost roughly $1050 billion in coverage provisions, reduce the ten year deficit by $138 billion, and slightly reduce the deficit in the second decade.[170]

See also


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