Health care reform in the United States

Health care reform in the United States

] Current estimates put U.S. health care spending at approximately 16% of GDP. [ "National Health Expenditure Data: NHE Fact Sheet,"] Centers for Medicare and Medicaid Services, referenced February 26, 2008] [ [ "The World Health Report 2006 - Working together for health."] ] In 2007, the U.S. spent a projected $2.26 trillion on health care, or $7,439 per person. [ [ "National Health Expenditures, Forecast summary and selected tables"] , Office of the Actuary in the Centers for Medicare & Medicaid Services, 2008. Accessed March 20, 2008.] 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.

The United States is the only wealthy, industrialized nation that does not have a universal health care system, according to the Institute of Medicine of the National Academy of Sciences. [ Insuring America's Health: Principles and Recommendations] , Institute of Medicine at the National Academies of Science, 2004-01-14, accessed 2007-10-22] US citizens and non-citizens without health insurance coverage at some time during 2007 totaled 15.3% of the population, or 45.7 million people, down from 15.8% and 47 million in 2006. [ "Income, Poverty, and Health Insurance Coverage in the United States: 2007."] U.S. Census Bureau. Issued August 2008.] [ "Income, Poverty, and Health Insurance Coverage in the United States: 2006."] U.S. Census Bureau. Issued August 2007.]

International comparisons that could lead to conclusions about the quality of the health care received by Americans are inconclusive and subject to debate. The US lags other wealthy nations in such measures as infant mortality and life expectancy, [ PR-2000/ WHO Issues New Healthy Life Expectancy Rankings ] ] but it is unclear whether these statistics have anything to do with the structure of the health care system. [ Don't Fall Prey to Propaganda: Life Expectancy and Infant Mortality are Unreliable Measures for Comparing the U.S. Health Care System to Others ] ] Other comparisons indicate that the US system performs better on some measures, such as responsiveness and higher cure rates for serious illnesses such as cancer.Clifford Krauss, [ "As Canada's Slow-Motion Public Health System Falters, Private Medical Care Is Surging,"] The New York Times, February 26, 2006] [ Why Isn't Government Health Care The Answer?] , "Free Market Cure", 16 July 2007] [ The Myths of Single-Payer Health Care] , "Free Market Cure", 16 July 2007] [ A Story Michael Moore Didn't Tell] , "Washington Post", 18 July 2007]

Whether a government-mandated system of universal health care should be implemented in the U.S. 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 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. [cite web |url= |title=Insuring America's Health: Principles and Recommendations |accessdate=2007-10-27 |work=Institute of Medicine of the National Academies ] Opponents of government mandates or programs for universal health care argue that people should be free to opt out of health insurance [cite web |url= |title=No Health Insurance? So What? |accessdate=2007-10-27 | date=2002-10-03 | work=The Cato Institute ] and that government programs would require higher taxes, increase utilization, and reduce health care quality. Opponents also claim that the current level of government involvement in US health care contributes to higher costs, and point to free-market solutions to increase efficiency, stimulate innovation, and make consumers rather than third parties more responsible for cost decisions. 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.


The cost and quality of care in the United States are frequently the two major issues of discussion. The US performs worse than the average developed country in health measures such as infant mortality, maternal death [Philip J. Hilts, [ "In a Ranking of Maternal Health, U.S. Trails Most Developed Nations"] , The New York Times, July 26, 1995] , and life expectancy, but the causes of these disparities are subject to debate. 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". [ Infant Mortality Fact Sheet ] ] Some studies claim the data collected regarding infant mortality and life expectancy do not lend themselves to fair comparison.

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.

The US spends more on health care per capita than any other UN member nation. It also spends a greater fraction of its national budget on health care than Canada, Germany, France, or Japan. In 2004 the US spent $6,102USD 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). [] 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 Fact|date=October 2007. 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. [cite news |first=Julie |last=Appleby |title=Universal care appeals to USA |url= |work= |publisher=USA Today |date=2006-10-16 |accessdate=2007-05-22 ] The federal Medicare program covers the elderly and people with disabilities, 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, merchant seamen are covered by the Public Health System, and retired railway workers and military veterans are also covered by the government. [ [ U.S. Department of Health & Human Services, Centers for Medicare and Medicaid Services] ] Government also affects private sector medicine through licensing and regulatory barriers to entry into health professions.

Various health care analysts have asserted that market failure occurs in health care markets, [ [ Economics of health care. Market failure - an overview ] ] but some have suggested that it is a result of too much government involvement rather than too little. [] [ [ America's Socialized Health Care ] ] 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.cite book |title=Crisis of Abundance: Rethinking How We Pay for Health Care |last=Kling |first=Arnold |authorlink=Arnold Kling |year=2006 |publisher=Cato Institute |isbn=978-1930865891 |pages= ] Some studies have found no consistent and systematic relationship between the type of financing of health care and cost containment. [Sherry A. Glied, [ "Health Care Financing, Efficiency, and Equity"] , National Bureau of Economic Research Working Paper No. 13881, March 2008]

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. [David Brown, [ "In the Balance: Some Candidates Disagree, but Studies Show It's Often Cheaper To Let People Get Sick,"] The Washington Post, April 8, 2008]

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. 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.Linda J. Blumberg and Len Nichols, [ "Health Insurance Market Reforms: What They Can and Cannot Do,"] Urban Institute, November 01, 1995]

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. [Richard Burkhauser and Kosali Simon, [ "The Economics of “Pay or Play” Employer Mandates: Who Gets What From Employer “Pay or Play” Mandates,"] Employment Policies Institute, November 2007]

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. [ [ "The Price Sensitivity of Demand for Nongroup Health Insurance,"] Congressional Budget Office, 2005 ] [M. Susan Marquis, Melinda Beeuwkes Buntin, Jose J. Escarce, Kanika Kapur, and Jill M. Yegian, [ "Subsidies and the Demand for Individual Health Insurance in California,"] Health Services Research 39:5 (October 2004)]

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. [Cathy Schoen, Stuart Guterman, Anthony Shih, Jennifer Lau, Sophie Kasimow, Anne Gauthier, and Karen Davis, [ "BENDING THE CURVE: OPTIONS FOR ACHIEVING SAVINGS AND IMPROVING VALUE IN U.S. HEALTH SPENDING,"] Commonwealth Fund, December 2007] 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 combined with broader measures to reduce costs. [U.S. Congressional Budget Office, [ "Evidence on the Costs and Benefits of Health Information Technology,"] Pub. No. 2976, May 2008] [ [ "Health Care Marketplace | CBO Finds Health Information Technology Unlikely To Generate Significant Savings,"] Kaiser Daily Health Policy Report, Kaiser Family Foundation, May 22, 2008]

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. [Sherry Glied, Dahlia K. Remler and Joshua Graff Zivin, [,%20Remler%20&%20Zivin,%2080-4.pdf "Inside the Sausage Factory: Improving Estimates of the Effects of Health Insurance Expansion Proposals,"] The Milbank Quarterly, Vol. 80, No. 4, 2002]

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. [Peter Orszag, [ "Behavioral Economics: Lessons from Retirement Research for Health Care and Beyond,"] Presentation to the Retirement Research Consortium, August 7, 2008]

A study published in August of 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. [Jack Hadley, John Holahan, Teresa Coughlin, and Dawn Miller, [ "Covering The Uninsured In 2008: Current Costs, Sources Of Payment, And Incremental Costs,"] Health Affairs web exclusive, August 25, 2008]

History of reform efforts

U.S. efforts to achieve universal coverage began with Theodore Roosevelt and continue to today. 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.

In 2001, a Patients' Bill of Rights was debated in Congress, which would have provided patients with an explicit list of rights concerning their healthcare. This initiative was essentially taking some of ideas found in the Consumers' Bill of Rights and applying it to the field of healthcare. It was undertaken in an effort to ensure the quality of care of all patients by preserving the integrity of the processes that occur in the healthcare industry. [ Summary of the McCain-Edwards-Kennedy Patients' Bill of Rights] Standardizing the nature of healthcare institutions in this manner proved rather provocative. In fact, many interest groups, including the American Medical Association (AMA) and the pharmaceutical industry came out vehemently against the congressional bill. Basically, providing emergency medical care to anyone, regardless of health insurance status, as well as the right of a patient to hold their health plan accountable for any and all harm done proved to be the biggest stumbling blocks for this bill. [Ibid.] As a result of this intense opposition, the Patients' Bill of Rights initiative eventually failed to pass Congress in 2002.

Expanding health care was one focus of John Kerry's 2004 presidential campaign.

More recently, President George W. Bush signed into law the Medicare Prescription Drug, Improvement, and Modernization Act which included a prescription drug plan for elderly and disabled Americans. [] Health care reform have also been advanced as part of the 2008 presidential campaign platforms of both Hillary Clinton and Barack Obama.

In January 2007 Rep. John Conyers, Jr. (D-MI) has introduced The United States National Health Insurance Act (HR 676) in the House of Representatives. As of January 2008, HR 676 has 88 co-sponsors. [cite web |url= |title=H.R. 676 |accessdate=2007-08-28 |work=Library of Congress THOMAS ] Also in January 2007, Senator Ron Wyden introduced the Healthy Americans Act (S. 334) in the Senate. As of May 2008, S. 334 had 14 cosponsors. [cite web |url= |title=S. 334 |accessdate=2008-05-05 |work=Library of Congress THOMAS ]

Political debate

Issues regarding publicly funded health care are frequently the subject of political debate. [ [ Democracy Now! | Election Issue 2004: A Debate on Healthcare ] ] Whether or not a publicly funded universal health care system should be implemented is one such example. [ [ "The Great Health Care Debate of 1993-94" ] ]

The case for publicly funded health care

Supporters of publicly funded health care claim that publicly funded health care has several advantages over free market provisions. It has been suggested that the largest obstacle is a lack of political will. [ [ Timid ideas won't fix health mess] . By Marie Cocco, Sacramento Bee, February 10, 2007]

One of the leading organizations in support of single payer in the U.S. 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 U.S. health care system is the most expensive in the world. [cite news |url= |title=Expenditure on Health |publisher=OECD Health Division |accessdate=2007-03-13] Despite this expenditure, the current U.S. system fails to provide universal coverage. Almost 46 million Americans, more than 15 percent of the population, lacked health insurance in 2007. The lack of universal coverage contributes to another flaw in the current U.S. health care system: on most dimensions of performance, it underperforms relative to other industrialized countries.cite web |url= |title=Mirror, Mirror on the Wall: An International Update on the Comparative Performance of American Health Care | date=2007-05015 |accessdate=2007-05-22 |work=Report by the Commonwealth Fund ] 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 U.S. ranked last on measures of quality, access, efficiency, equity, and outcomes.

For example, U.S. ranks 22nd in infant mortality, between Taiwan and Croatia, [cite news |url= |title=Rank Order - Infant Mortality Rate |publisher=CIA World Factbook |accessdate=2007-03-13] 46th in life expectancy, between Saint Helena and Cyprus, [cite news |url= |title=Rank Order - Life Expectancy at Birth |publisher=CIA World Factbook |accessdate=2007-03-13] and 37th in health system performance, between Costa Rica and Slovenia. [cite news |url= |title=The World Health Report 2000 |publisher=World Health Organization |accessdate=2007-03-13] None of these rankings however were claimed to be related to the US health care system.

The U.S. 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 2005, Americans spent an estimated US$6,401 per capita on health care, while Canadians spent US$3,326. [ OECD Health Data 2007: How Does Canada Compare] ] This amounted to 15.3% of U.S GDP in that year, while Canada spent 9.8% of GDP on health care.

A 2007 review of all studies comparing health outcomes in Canada and the U.S. found that "health outcomes may be superior in patients cared for in Canada versus the United States, but differences are not consistent." [] Open Medicine, Vol 1, No 1 (2007), Research: A systematic review of studies comparing health outcomes in Canada and the United States, Gordon H. Guyatt, et al.] 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 [The trade association [ AHIP] , America's Health Insurance Plans, has some 1,300 members.] of insurance companies in the U.S. to provide universal care. [ [ "The Health Care Crisis and What to Do About It"] By Paul Krugman, Robin Wells, New York Review of Books, March 23, 2006] An often-cited study by Harvard Medical School and the Canadian Institute for Health Information determined that some 31 percent of U.S. health care dollars, or more than $1,000 per person per year, went to health care administrative costs. [ [ Costs of Health Administration in the U.S. and Canada] Woolhandler, et al, NEJM 349(8) Sept. 21, 2003]

Theoretically, advocates suggest, shifting the U.S. to a single-payer health care system could 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 could also theoretically eliminate oversight by managed care reviewers, restoring the traditional doctor-patient relationship.Physicians for a National Health Program. [ "What is Single Payer?"] ]

Quality of care

One political advocacy group has claimed that a free market solution to health care provides a lower quality of care, with higher mortality rates, than publicly funded systems. [ For-Profit Hospitals Cost More and Have Higher Death Rates] , "Physicians for a National Health Program"] The quality of health maintenance organizations and managed care have also been criticized by this same political advocacy group. [ [ For-Profit HMOs Provide Worse Quality Care] , "Physicians for a National Health Program"]

According to a 2000 study of the World Health Organization, publicly funded systems of industrial nations spend less on health care, both as a percentage of their GDP and per capita, and enjoy superior population-based health care outcomes. [ [ Prelims i-ixx/E ] ] However, commentators have criticized the WHO's comparison method for being biased; the WHO study marked down countries for having private or fee-paying health treatment and rated countries by comparison to their expected health care performance, rather than objectively comparing quality of care. [Glen Whitman, [ "WHO’s Fooling Who? The World Health Organization’s Problematic Ranking of Health Care Systems,"] Cato Institute, February 28, 2008]

While most Americans are generally satisfied with the quality of their own health care, [ Satisfaction with health care and physician services, Canada and United States, 2002 to 2003] ] some medical researchers say that patient satisfaction surveys are a poor way to evaluate medical care. Researchers at the RAND Corporation and the Department of Veterans Affairs asked 236 elderly patients at 2 managed care plans to rate their care, then examined care in medical records, as reported in Annals of Internal Medicine. There was no correlation. "Patient ratings of health care are easy to obtain and report, but do not accurately measure the technical quality of medical care," said John T. Chang, UCLA, lead author. [ [ Capital: In health care, consumer theory falls flat] David Wessel, Wall Street Journal, September 7, 2006.] [cite press release |title=Rand study finds patients' ratings of their medical care do not reflect the technical quality of their care |publisher=RAND Corporation |date=2006-05-01 |url= |accessdate=2007-08-27] [ [ Patients' Global Ratings of Their Health Care Are Not Associated with the Technical Quality of Their Care] , John T. Chang, et al., Ann Intern Med. 2006 May 2;144(9):665-72. [PMID16670136] ]

Cost and efficiency

Proponents of publicly funded health care point out that the United States, which has a partly free market health care system, spends a higher proportion of its GDP on health care (15.2%) than any other country in the world, except for the tiny Marshall Islands. The number of employers who offer health insurance is declining. Costs for employer-paid health insurance are rising rapidly: since 2001, premiums for family coverage have increased 78%, while wages have risen 19% and inflation has risen 17%, according to a 2007 study by the Kaiser Family Foundation.cite press release |title=Health Insurance Premiums Rise 6.1 Percent In 2007, Less Rapidly Than In Recent Years But Still Faster Than Wages And Inflation |publisher=Kaiser Family Foundation |date=2007-09-11 |url= |accessdate=2007-09-13] Private insurance in the US varies greatly in its coverage; one study by the Commonwealth Fund published in "Health Affairs" estimated that 16 million U.S. adults were underinsured in 2003. The underinsured were significantly more likely than those with adequate insurance to forgo health care, report financial stress because of medical bills, and experience coverage gaps for such items as prescription drugs. The study found that underinsurance disproportionately affects those with lower incomes — 73% of the underinsured in the study population had annual incomes below 200% of the federal poverty level. [cite journal | coauthors = Cathy Schoen, M.S., Michelle M. Doty, Ph.D., Sara R. Collins, Ph.D., and Alyssa L. Holmgren | title = Insured But Not Protected: How Many Adults Are Underinsured? | journal = Health Affairs Web Exclusive |date=2005-06-14 | url = | pmid = 15956055 |accessdate = 2007-08-11 | doi = 10.1377/hlthaff.w5.289 | author = Schoen, C. ] One indicator of the consequences of Americans' inconsistent health care coverage is a study in "Health Affairs" that concluded that half of personal bankruptcies involved medical bills, [ [ "Illness And Injury As Contributors To Bankruptcy"] , by David U. Himmelstein, Elizabeth Warren, Deborah Thorne, and Steffie Woolhandler, Health Aff (Millwood). 2005 Jan-Jun;Suppl Web Exclusives:W5-63-W5-73. [PMID15689369] ] although other sources dispute this. [Todd Zywicki, [ "An Economic Analysis of the Consumer Bankruptcy Crisis"] , 99 NWU L. Rev. 1463 (2005)]

Proponents of health care reforms involving expansion of government involvement to achieve universal health care argue that the need to provide profits to investors in a predominantly free market health system, and the additional administrative spending, tends to drive up costs, leading to more expensive health care provision.

The case against publicly funded health care

Those who oppose publicly funded health care, predominantly on the political right, have pointed out a number of flaws in publicly funded health care systems, such as those which operate in Canada, the United Kingdom and Germany. Public health care systems have been criticized for poor quality of care, long waiting lists, and slow access to new drugs. For example, according to a 1998 medical study, financial considerations prevented 500-600% more Canadian and British citizens from getting lifesaving dialysis medical care than happened with Americans. [Dialysis decision making in Canada, the United Kingdom, and the United States. MCKENZIE J. K. ; MOSS A. H. ; FEEST T. G. ; STOCKING C. B. ; SIEGLER M. American journal of kidney diseases. 1998, vol. 31, no1, pp. 12-18 (23 ref.) [] ]

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

Supporters of the free market medicine would 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's health care sector.cite journal | title = Health Care Regulation: A $169 Billion Hidden Tax | author = Christopher J. Conover | year = 4-10-2004 | journal = Cato Policy Analysis | volume = 527 | pages = 1–32 | url =] According to a Cato Institute study, this regulation provides benefits in the amount of $170 billion but costs the public up to $340 billion.

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

For this reason, some U.S. reformers argue for other, more incremental changes to achieve universal health care, such as tax credits or vouchers. [Emanuel EJ, Fuchs VR. [ Health care vouchers -- a proposal for universal coverage] . N Engl J Med 2005;352:1255-1260.] 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." [cite web |url= |title=Are we in a health care crisis? |accessdate=2007-05-22 |work=PBS companion website: The Health Care Crisis: Who's At Risk? ]

Quality of care

International comparisons of health care quality are difficult and have yielded mixed results. For example, an international comparison of health systems in six countries by the Commonwealth Fund ranked the UK's publicly funded system first overall and first in quality of care. Systems in the United States and Canada tied for the lowest overall ranking and toward the bottom for quality of care. [ "Mirror, Mirror on the Wall: An International Update on the Comparative Performance of American Health Care"] by Karen Davis, Ph.D., Cathy Schoen, M.S., Stephen C. Schoenbaum, M.D., M.P.H., Michelle M. Doty, Ph.D., M.P.H., Alyssa L. Holmgren, M.P.A., Jennifer L. Kriss, and Katherine K. Shea Commonwealth Fund, May 15, 2007.]

Overall, Canadians are quite satisfied with the quality of health care they receive. In a regularly conducted opinion poll, 70% of Canadians reported that they were either very satisfied or somewhat satisfied with the quality of care they receive compared to 30% being somewhat dissatisfied or very dissatisfied. The main factor of dissatisfaction is waiting times. [ A POLLARA Report: Health Care in Canada Survey: Retrospective 1998-2003] A 2006 study by Nadeen Esmail and Michael Walker of the Fraser Institute found that Canadians are more likely than citizens of most other developed countries to experience long waiting lists for medical care, and that access to doctors is comparatively difficult; the study criticized the Canadian model of universal health care. [ [ How Good is Canadian Health Care] , Fraser Institute, 24 July 2007]

Public health care varies significantly from country to country. Many countries allow for private medicine in addition to the public health care system. Some countries, e.g. Norway, have more doctors per capita than the United States. [ [ Core Health Indicators ] ] Also, the US does not have any official record for waiting lists, but a 2005 survey by the Commonwealth Fund of sick adults in six nations found that only 47% of US patients could get a same- or next-day appointment for a medical problem, worse than every other country except Canada. [ [ The Doctor Will See You—In Three Months ] ]

Innovation and development of new treatments

Free market advocates say that the largely free market system of health care in the United States has led to the faster development of more advanced medical treatment and new drugs, and that cancer patients in the United States for many forms of cancer, including those of the breast, thyroid and lung, have higher survival rates than their counterparts in publicly-funded health systems in Europe. Some analysts have pointed out the difficulty of comparing international health statistics. In particular, the mortality rates for cancer in the United States is at about the same level as many other countries, suggesting that the higher survival rates are a function of the way cancer is diagnosed. [ [ Ezra Klein: Rudy and "Socialized Medicine" ] ] Market advocates say that public care systems, in which there is more bureaucratic government involvement and less financial incentive in the health care industry, lead to less motivation for medical innovation and invention. [Pipes, S. [ Border Crossings] , Pacific Research Institute, October 17, 2003. Retrieved September 18, 2006.]

By some criteria, the United States, with its partly free-market health care system, is the world leader in medical innovation. [Tyler Cowen, [ "Poor U.S. Scores in Health Care Don’t Measure Nobels and Innovation"] , The New York Times, October 5, 2006.] According to economist Tyler Cohen quoted in "The New York Times", the American system leads in converting new ideas into workable commercial technologies, and the research environment in the United States, compared with Europe, is richer, more competitive, more meritocratic and less tolerant of waste. Cohen argues that the American government could use its size to bargain down health care prices, but in the longer run it would cost lives because of the reduced innovation. Cohen argues that one reason America's leadership in innovation does not translate into relatively higher life expectancy is that other wealthy countries also benefit from US medical innovations. Economist Arnold Kling says that America's role in medical innovation is crucial not just for Americans, but for the entire world. [Citation | last = Kling | first = Arnold | author-link = Arnold Kling | url = | title = Two heath-care documentaries | periodical = The Washington Times | date = June 30, 2007 | year = 2007] In June 2008 the Financial Times reported that leading pharmaceutical companies, including Pfizer, Roche and Merck-Serono, were reducing the amount of clinical research they performed in the United Kingdom. The companies say that the policies of the National Institute for Health and Clinical Excellence (NICE) result in too few UK patients receiving "gold standard" care to provide the comparison group needed for clinical trials. [Andrew Jack, [ "Big drugs companies shift trials from UK,"] The Financial Times, June 26, 2008]

Impact on physicians

Some commentators have pointed out that in publicly funded systems, health care workers' pay is often unrelated to quality or speed of care. There is also less financial motivation for the most able people to enter health care professions. For example, in Canada, which has a publicly funded health system, the average physician earns roughly half the annual salary earned by counterparts in the United States, according to 1996 health data collected by the OECD. [ [ Health Care Systems: An International Comparison.] Strategic Policy and Research Intergovernmental Affairs, May 2001.] This difference in physician income reflects Canada's more limited spending on health care overall; in 2004, combined public and private spending on health care consumed 15.4% of U.S. annual GDP; in Canada, 9.8% of GDP.cite web |url= |title=World Health Organization: Core Health Indicators |accessdate=2007-06-20 |format= |work= ] By limiting the amount of money in the health care system through political mechanisms, shortages of health care resources (such as physicians, nurses, medical equipment, medical devices, pharmaceuticals, and hospitals) are more likely to occur, sometimes resulting in longer waits for care.

Common arguments for and against a national health care system

Common arguments forwarded by supporters of universal health care systems include:
* Health care is a human right,United Nations, [ Universal Declaration of Human Rights] , Adopted and proclaimed by General Assembly resolution 217 A (III) of 10 December 1948. Article 25 states: "Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control."] and as such, access to health treatment should not be based on ability to pay. [ [ The Right to Health in the United States of America: What Does it Mean?] , Center for Economic and Social Rights, October 2004] [ [ Human Rights, Homelessness and Health Care] , National Health Care for the Homeless Council] Center for Economic and Social Rights. [ "The Right to Health in the United States of America: What Does it Mean?"] October 29, 2004.] National Health Care for the Homeless Council. [ "Human Rights, Homelessness and Health Care".] ] or entitlement. [Kereiakes DJ, Willerson JT. [ "US health care: entitlement or privilege?."] "Circulation." 2004 March 30;109(12):1460-2.]
* Since people perceive universal health care as "free", they are more likely to seek preventative care which makes them better off in the long run. [ "The Best Care Anywhere"] by Phillip Longman, Washington Monthly, January 2005.]
* Universal health care would provide for uninsured adults who may forgo treatment needed for chronic health conditions. []
* In most free-market situations, the consumer of health care is entirely in the hands of a third party who has a direct personal interest in persuading the consumer to spend money on health care in his or her practice. The consumer is not able to make value judgments about the services judged to be necessary because he or she may not have sufficient expertise to do so. [Blomqvist, Åke; Léger, Pierre Thomas (2005) [ “Information asymmetry, insurance and the decision to hospitalize,”] Journal of Health Economics, Vol 24(4), pp. 775-793.] This, it is claimed, leads to a tendency to over produce. In socialized medicine, hospitals are not run for profit and doctors work directly for the community and are assured of their salary. They have no direct financial interest in whether the patient is treated or not, so there is no incentive to over provide. When insurance interests are involved this furthers the disconnect between consumption and utility and the ability to make value judgments. [ [ British National Party - Chairman Nick Griffin - Working to secure a future for British children ] ] Others argue that the reason for over production is less cynically driven but that the end result is much the same. [ NPR discussion with author Shannon Brownlee who argues that the system overly rewards doing stuff] .
* The profit motive in medicine values money above public benefit.cite journal |author=Woolhandler S, Himmelstein DU, Angell M, Young QD |title=Proposal of the Physicians' Working Group for Single-Payer National Health Insurance |journal=JAMA |volume=290 |issue=6 |pages=798–805 |year=2003 |pmid=12915433 |doi=10.1001/jama.290.6.798 |url= |accessdate=2008-01-20] For example, pharmaceutical companies have reduced or dropped their research into developing new antibiotics, even as antibiotic-resistant strains of bacteria are increasing, because there's less profit to be gained there than in other drug research. [cite news |first=Sabin |last=Russell |title=Bacteria race ahead of drugs
url= |work= |publisher=San Francisco Chronicle |date=2008-01-20 |accessdate=2008-01-20
] Those in favor of universal health care posit that removing profit as a motive will increase the rate of medical innovation. [For example, the recent discovery that dichloroacetate (DCA) can causes regression in several cancers, including lung, breast and brain tumors. [ Alberta scientists test chemotherapy alternative Last Updated: Wednesday, January 17, 2007] The DCA compound is not patented or owned by any pharmaceutical company, and, therefore, would likely be an inexpensive drug to administer, Michelakis added. The bad news, is that while DCA is not patented, Michelakis is concerned that it may be difficult to find funding from private investors to test DCA in clinical trials. [ University of Alberta - Small molecule offers big hope against cancer. January 16, 2007] ]
* Paul Krugman and Robin Wells say that in response to new medical technology, the American health care system spends more on state-of-the-art treatment for people who have good insurance, and spending is reduced on those lacking it. [ Paul Krugman, Robin Wells, [ "The Health Care Crisis and What to Do About It"] ]
* The profit motive adversely affects the cost and quality of health care. If managed care programs and their concomitant provider networks are abolished, then doctors would no longer be guaranteed patients solely on the basis of their membership in a provider group and regardless of the quality of care they provide. Theoretically, quality of care would increase as true competition for patients is restored. [ [ Pajamas Media ] ]
* Wastefulness and inefficiency in the delivery of health care would be reduced.Paul Krugman and Robin Wells, [ The Health Care Crisis and What to Do About It] , New York Review of Books, 2006-03-23, accessed 2007-10-28] A single payer system could save $286 billion a year in overhead and paperwork.Public Citizen. [ "Study Shows National Health Insurance Could Save $286 Billion on Health Care Paperwork:"] ] Administrative costs in the U.S. health care system are substantially higher than those in other countries and than in the public sector in the US: one estimate put the total administrative costs at 24 percent of U.S. health care spending. [ Reinhardt, Hussey and Anderson, "U.S. Health Care Spending In An International Context", Health Affairs, 23, no. 3 (2004): 10-25] Universal health care could reduce wastefulness in the delivery of health care by adding a middle man, the government, to regulate the supply of health care.Fact|date=November 2007 For example, it might only take one government agent to do the job of two health insurance agents. [William F. May. [ "The Ethical Foundations of Health Care Reform,"] "The Christian Century", June 1-8, 1994, pp. 572-576.] According to one estimate roughly 50% of health care dollars are spent on healthcare, the rest go to various middlemen and intermediaries. A streamlined, non-profit, universal system would increase the efficiency with which money is spent on health care. [ Statement of Dr. Marcia Angell introducing the U.S. National Health Insurance Act] , Physicians for a National Health Program, February 4, 2003. Accessed March 4, 2008]
* About 60% of the U.S. health care system is already publicly financed with federal and state taxes, property taxes, and tax subsidies - a universal health care system would merely replace private/employer spending with taxes. Total spending would go down for individuals and employers. [ "Won’t this raise my taxes?"] ]
* Several studies have shown a majority of taxpayers and citizens across the political divide would prefer a universal health care system over the current U.S. systemTeixeira , Ruy. [ "Healthcare for All?"] MotherJones September 27, 2005 .] CBSNews. [ "Poll: The Politics Of Health Care"] CBSNews March 1, 2007 .] Blake, Aaron. [ "Poll shows many Republicans favor universal health care, gays in military"] June 28, 2007.]
* America spends a far higher percentage of GDP on health care than any other country but has worse ratings on such criteria as quality of care, efficiency of care, access to care, safe care, equity, and wait times, according to the Commonwealth Fund.
* A universal system would align incentives for investment in long term health-care productivity, preventive care, and better management of chronic conditions.
* Ensuring the health of all citizens benefits a nation economically.Fact|date=March 2008 Universal health care could act as a subsidy to business, at no cost thereto. (Indeed, the Big Three of U.S. car manufacturers cite health-care provision as a reason for their ongoing financial travails. The cost of health insurance to U.S. car manufacturers adds between USD 900 and USD 1,400 to each car made in the U.S.A.) [ [,,1948040,00.html "Detroit's big three seek White House help"] Guardian Unlimited, November 15, 2006]
* In countries in Western Europe with public universal health care, private health care is also available, and one may choose to use it if desired. Most of the advantages of private health care continue to be present, see also Two-tier health care. [cite web
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title = "Uguali e diversi" davanti alla salute
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* Universal health care and public doctors would protect the right to privacy between insurance companies and patients. [cite web
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title = Il segreto professionale nella relazione medico-paziente
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* Public health care system can be used as independent third party in disputes between employer and employee. [cite web
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title = LEGGE 20 maggio 1970, n. 300 (Statuto dei lavoratori)
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* A study of hospitals in Canada found that death rates are lower in private not-for-profit hospitals than in private for-profit hospitals. [Devereaux PJ, Choi PT, Lacchetti C, Weaver B, Schunemann HJ, Haines T, Lavis JN, Grant BJ, Haslam DR, Bhandari M, Sullivan T, Cook DJ, Walter SD, Meade M, Khan H, Bhatnagar N, Guyatt GH. A systematic review and meta-analysis of studies comparing mortality rates of private for-profit and private not-for-profit hospitals. CMAJ. 2002 May 28;166(11):1399-406. PMID 12054406. [ Free Full Text] .]

Common arguments forwarded by opponents of universal health care systems include:
* Health care is not a right. Sade RM. "Medical care as a right: a refutation." "N Engl J Med." 1971 December 2;285(23):1288-92. PMID 5113728. (Reprinted as [ "The Political Fallacy that Medical Care is a Right."] )] David E. Kelley, A Life of One's Own:Individual Rights and the Welfare State, Cato Institute, October 1998, ISBN 1-882577-70-1] As such, it is not the responsibility of government to provide health care. [Michael Tanner, [ "Individual Mandates for Health Insurance: Slippery Slope to National Health Care,"] Cato Institute, Policy Analysis No. 565, April 5, 2006]
* Free healthcare can lead to overuse of medical services, and hence raise overall cost. [Heritage Foundation News Release, [ "British, Canadian Experience Shows Folly of Socialized Medicine, Analyst Says,"] Sept. 29, 2000] The Cure: How Capitalism Can Save American Health Care [] ]
* Universal health coverage does not in practice guarantee universal access to care. Many countries offer universal coverage but have long wait times or ration care.Michael Tanner, [ "The Grass Is Not Always Greener A Look at National Health Care Systems Around the World,"] Cato Institute, March 18, 2008]
*The federal Emergency Medical Treatment and Active Labor Act requires hospitals and ambulance services to provide emergency care to anyone regardless of citizenship, legal status or ability to pay. The health care safety net, which includes free medical clinics, charity care, nonprofits and government-run community hospitals, provides necessary care to the uninsured.cite web |url= |title=Report Brief: America's Health Care Safety Net: Intact but Endangered |accessdate=2007-10-22 |date=2000-01-01 |format=PDF |publisher=Institute of Medicine, National Academies of Science]
* Eliminating the profit motive will decrease the rate of medical innovation.Friedmen, David. "The Machinery of Freedom." Arlington House Publishers: New York, 1978. p 65-69.]
* It slows down innovation and inhibits new technologies from being developed and utilized. This simply means that medical technologies are less likely to be researched and manufactured, and technologies that are available are less likely to be used. [Miller, Roger Leroy, Daniel K. Benjamin, and Douglass Cecil North. "The Economics of Public Issues". 13th ed. Boston: Addison-Wesley, 2003.]
* Publicly-funded medicine leads to greater inefficiencies and inequalities. Goodman, John. [ "Five Myths of Socialized Medicine."] Cato Institute: "Cato's Letter". Winter, 2005.] Opponents of universal health care argue that government agencies are less efficient due to bureaucracy. Universal health care would reduce efficiency because of more bureaucratic oversight and more paperwork, which could lead to fewer doctor-patient visits. [Cato Handbook on Policy, [ "Chapter 7: Health Care,"] Cato Institute 6th Edition (2005)] Advocates of this argument claim that the performance of administrative duties by doctors results from medical centralization and over-regulation, and may reduce charitable provision of medical services by doctors.
* Converting to a single-payer system could be a radical change, creating administrative chaos. [cite news |first=Leif Wellington |last=Haase | title=Universal Coverage: Many Roads to Rome? | url= | |publisher=Mother Jones |date=2006-03-09 |accessdate=2007-05-21]
* In a single-payer system where hospitals and practitioners remain private, public money goes into private hands and therefore must be guarded to protect public trust. This could require a level of bureaucracy similar to the bureaucracy associated with private insurance.
* Countries with health systems based on greater government control tend to have more obstacles to care, such as long wait times, rationing and restrictions on the choice of doctors. Universal heath care would result in increased wait times, which could result in unnecessary deaths. [ [ Cato-at-liberty » Depends on What the Meaning of “Universal” Is ] ] Data on liver and heart transplants suggest that access to transplants (especially the sickest patients) and outcomes are as among the best in the world. [Scott Gottlieb, [ "Edwards and Organ Transplants,"] The Wall Street Journal, January 11, 2008; Page A11] The extra spending in the US is cost effective if expected life span increases by only about half a year as a result.Arnold Kling, [ "Crisis of Abundance: Rethinking How We Pay for Health Care (Paperback)"] ]
* Unequal access and health disparities still exist in universal health care systems.Victor R. Fuchs and Ezekiel J. Emanuel, [ "Health Care Reform: Why? What? When?,"] Health Affairs, November/December 2005]
* The problem of rising health care costs is occurring all over the world; this is not a unique problem created by the structure of the US system.
* Universal health care suffers from the same financial problems as any other government planned economy. It requires governments to greatly increase taxes as costs rise year over year. Universal health care essentially tries to do the economically impossible.Lawrence R. Huntoon, [ "Universal Health Coverage --- Call It Socialized Medicine"] ] Empirical evidence on the Medicare single payer-insurance program demonstrates that the cost exceeds the expectations of advocates.Sue Blevins, [ Universal Health Care Won't Work -- Witness Medicare] , The Cato Institute, 2003-04-11, accessed 2007-10-28] As an open-ended entitlement, Medicare does not weigh the benefits of technologies against their costs. Paying physicians on a fee-for-service basis also leads to spending increases. As a result, it is difficult to predict or control Medicare's spending. The Washington Post reported in July 2008 that Medicare had "paid as much as $92 million since 2000" for medical equipment that had been ordered in the name of doctors who were dead at the time. [Christopher Lee, [ "Billings Used Dead Doctors' Names,"] The Washington Post, July 9, 2008] Large market-based public program such as the Federal Employees Health Benefits Program and CalPERS can provide better coverage than Medicare while still controlling costs as well. [Michael J. O’Grady, [ "Health Insurance Spending Growth - How Does Medicare Compare?,"] Joint Economic Committee, June 17, 2003] [Jeff Lemieux, [ "Medicare vs. FEHB Spending: A Rare, Reasonable Analysis,"] [] , June 2003]
* National health systems tend to be more effective as they incorporate market mechanisms and limit centralized government control.
* Some commentators have opposed publicly-funded health systems on ideological grounds, arguing that public health care is a step towards socialism and involves extension of state power and reduction of individual freedom. [ [ Moore "World of We"] , "National Review", 13 July 2007]
* The right to privacy between doctors and patients could be eroded if government demands power to oversee the health of citizens. [ [ Universal Health Care Won't Work - Witness Medicare ] ]
* A single-payer system could put the government, rather than health care providers and insurers, in the role of deciding which procedures and medications would be covered.
* Universal health care systems, in an effort to control costs by gaining or enforcing monopsony power, sometimes outlaw medical care paid for by private, individual funds. [ [ Cato-at-liberty » Revolt Against Canadian Health Care System Continues ] ] [Kent Masterson Brown, [ "The Freedom to Spend Your Own Money on Medical Care A Common Casualty of Universal Coverage,"] Cato Institute, October 15, 2007]

Debate in the 2008 U.S. Presidential election

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

John McCain's proposals focus on open-market competition rather than government funding or control. At the heart of his plan are 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 would work with states to create what he calls a "Guaranteed Access Plan".

Barack Obama has called for universal health care. His health care plan would create 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 require parents to cover their children, but does not require adults to buy insurance.

"The Philadelphia Inquirer" reports that the two plans have different philosophical focuses. They describe the purpose of the McCain plan is to "make insurance more affordable," while the purpose of the Obama plan is for "more people to have health insurance." [Stacey Burling, [ "Rivals' prescriptions for an ailing system,"] The Philadelphia Inquirer, September 28, 2008] "The Des Moines Register" characterizes the plans similarly. [TONY LEYS, [ "Health plans pit low-cost vs. public coverage,"] The Des Moines Register, September 29, 2008]

Critics of McCain's plan argue that it would not significantly reduce the number of uninsured Americans, would increase costs, reduce consumer protections and lead to less generous benefit packages.Thomas Buchmueller, Sherry A. Glied, Anne Royalty, and Katherine Swartz, [ "Cost And Coverage Implications Of The McCain Plan To Restructure Health Insurance,"] "Health Affairs", September 16, 2008] Critics of Obama's plan argue that it would increase federal regulation of private health insurance without addressing the underlying incentives behind rising health care spending.Joseph Antos, Gail Wilensky, and Hanns Kuttner, [ "The Obama Plan:More Regulation, Unsustainable Spending,"] "Health Affairs", September 16, 2008] Mark Pauly has suggested that a combination of the two approaches would work better than either one alone. [Mark V. Pauly, [ "Blending Better Ingredients For Health Reform,"] "Health Affairs", September 16, 2008] The Tax Policy Center, a project of the Brookings Institution and the Urban Institute, compared costs of each plan and estimated that Obama's proposals could cost $1.6 trillion over 10 years, while the tax-related provisions of McCain's proposals could cost $1.3 trillion over the same period.

John McCain

McCain is against publicly funded health care, universal health care, or health coverage mandates. [cite web| last = Hamby| first = Peter | title = McCain calls Obama health care plan 'HillaryCare'| publisher = CNN| date = July 17, 2008| url = | accessdate = 2008-07-22] Instead, he favors tax credits of up to $5,000 for families to get health insurance. [ McCain's Health Care Proposal], Oct. 10, 2007] His plan focuses on enhancing competition in the health care industry as a way to lower costs. [ [ McCain health plan aims to give options], Oct. 11, 2007] To that end, McCain would allow citizens to purchase health insurance nationwide instead of limiting them to in-state companies, and to buy insurance through any organization or association they choose as well as through their employers or buying direct from an insurance company. In an October 2007 statement, McCain said: "In health care, we believe in enhancing the freedom of individuals to receive necessary and desired care. We do not believe in coercion and the use of state power to mandate care, coverage or costs."

On April 29, 2008, McCain detailed his health care plan in the context of his campaign for President. His plan focused on open-market competition rather than government funding or control. At the heart of his plan are 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. He says the money could be used to purchase insurance and force insurance companies to be competitive with their costs in order to attract consumers. [ [ McCain's Health Care Proposal], April 29, 2008] McCain would pay for the tax credits by eliminating the tax break currently offered to employers for providing health insurance to employees. [ [ Tax credits at heart of McCain's health care proposal] ,, April 29, 2008] A critique of McCain's health care plan published in "Health Affairs" projected that the loss of tax benefits would cause businesses to drop 20 million people from employer-sponsored coverage, while the individual insurance market would grow to 21 million people.Colliver, Victoria [ McCain, Obama agree: health care needs fixing] , San Francisco Chronicle, 2008-10-01, accessed 2008-10-01.] To help people who are denied coverage by insurance companies due to pre-existing conditions, McCain would work with states to create what he calls a "Guaranteed Access Plan". He did not provide details, but pointed to states such as Florida and North Carolina where such systems are in place. [ [ McCain health plan eyes 'uninsurables'] USA Today, April 29, 2008] His health care plan has an estimated annual cost of $7 billion, according to McCain's health-policy experts. [Mike Allen and Jonathan Martin, [ "McCain moves to middle on health care"] , "Politico", April 29, 2008] His campaign has acknowledged that the health plan he had outlined would have the effect of increasing tax payments for some workers, primarily those with high incomes and expensive health plans. [Kevin Sack and Michael Cooper, [ "McCain Health Plan Could Mean Higher Tax"] , "New York Times", May 1, 2008]

Barack Obama

On January 24, 2007, Obama spoke about his position on health care at Families USA, a health care advocacy group. Obama said, "The time has come for universal health care in America [...] I am absolutely determined that by the end of the first term of the next president, we should have universal health care in this country." Obama went on to say that he believed that it was wrong that forty-seven million Americans are uninsured, noting that taxpayers already pay over $15 billion annually to care for the uninsured. [Pickler, Nedra, [ Obama calls for universal health care] , "Associated Press", January 25, 2007 (accessed January 25, 2007)] Obama cites cost as the reason so many Americans are without health insurance. [ [ Obama's Health Care Plan | WEEK News 25 | Political ] ] Obama's health care 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. [ [ - Healthcare] 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 Senator 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. [Kevin Sack, [ "Obstacles for Obama in Meeting Health Care Goal,"] The New York Times, July 23, 2008]

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.Associated Press, [ "Coverage Guarantee Can Hit Young The Hardest: Obama Health Plan Follows Where Some States Have Struggled,"] September 11, 2008] 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. 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.

Use of the term "Socialized Medicine"

The issue of health care in the 2008 U.S. presidential election has caused a resurgence in use of the term by Republicans. [ [ "Tempering health-care goals; Democrats' proposals build on current system, reject single-payer"] , Laura Meckler, Wall Street Journal, 25 January 2008. "Say something too kind about single-payer and there's a Republican around the corner ready to brand you a socialist"..."Say something too harsh and you will alienate many on the left wing of the party."] For example, in a July 2007 campaign speech, Republican presidential candidate Rudy Giuliani made a direct connection between socialized medicine and socialism. [ CNN, "Giuliani attacks Democratic health plans as 'socialist'", July 31, 2007. "The American way is not single-payer, government-controlled anything. That's a European way of doing something; that's frankly a socialist way of doing something. That's why when you hear Democrats in particular talk about single-mandated health care, universal health care, what they're talking about is socialized medicine."] Giuliani also quoted statistics from his health care advisor, Canadian psychiatrist David Gratzer, [ Editorials, Political Cartoons, and Polls from Investor's Business Daily - Rudy Is Right In Data Duel About Cancer ] ] to support his claim that he had a better chance of surviving prostate cancer in the U.S. than he would have had in England. According to cancer experts cited in fact check articles by the Annenberg Public Policy Center's, the "St. Petersburg Times" and its, "The New York Times", "The Washington Post", and "The Times", Giuliani's statistics were "false" and very "misleading" and his conclusions were complete "nonsense".cite web |date=2007-10-30 | url = | title = A Bogus Cancer Statistic | publisher =] cite web |date=2007-11-08 | url = | title = Bogus Cancer Stats, Again | publisher =] [cite web |date=2007-11-03 | url = | title = Giuliani's dose of fear | publisher = "St. Petersburg Times"] cite web |date=2007-10-31 | url = | title = A cancer ad gone wrong for Rudy | publisher =] cite web |date=2007-12-02 | url = | title = The Public Editor. Fact and Fiction on the Campaign Trail | publisher = "The New York Times"] cite web |date=2007-12-31 | url = | title = The 2007 Pinocchio Awards. The top ten fibs of the past year | publisher = "The Washington Post"] cite web |date=2007-12-22 | url = | title = The worst junk stats of 2007 | publisher = "The Times"]
In response, Canadian psychiatrist and Giuliani health care advisor David Gratzer said: "The mayor is right."

Krugman and others have compared statistical apples to oranges. My 44% figure, replicated by economist John Goodman and others, looks at a snapshot in time, based on decade-old OECD data; Krugman's 74% is a five-year relative survival rate from government sources today.
Annenberg's found no merit in Gratzer's response:
[ Marie Diener-West] , professor of biostatistics at Johns Hopkins Bloomberg School of Public Health, said Gratzer's attempts to calculate cancer survival rates were “inappropriate” and “very misleading."
[ Peter Albertsen] , professor and chief of urology at the University of Connecticut Health Center, called Gratzer's calculations a “very dangerous thing to do” and “complete nonsense.”
Nor did "The Washington Post", which awarded Giuliani and Gratzer's response the same "Four Pinocchios" rating (reserved for "whoppers") [cite web |date=2007-09-01 |title=The Pinocchio Test |publisher=The Washington Post |url=] it awarded Giuliani and Gratzer's original claim. [cite web |date=2007-10-30 |title=Rudy Wrong On Cancer Survival Chances |publisher=The Washington Post |url=]


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. [ ['s Pros & Cons of Massachusetts' Mandatory Health Insurance Program] ] 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. It is typical for most forms of general liability insurance sold in the U.S., such as home, automobile, or business insurance to have a significant premium allocation for medical damages. In the event that a third party is responsible for injury or illness (e.g., the responsible driver in an automobile accident), action can be taken in the U.S. court system to prove liability and collect the money for medical bills from the responsible party's liability insurances.

Several single payer referendums have been proposed at the state level, but so far all have failed to pass: California in 1994, [ [ The California Single-Payer Debate, The Defeat of Proposition 186 - Kaiser Family Foundation ] ] Massachusetts in 2000, and Oregon in 2002. [ [ Free-Market Reformers Are Winners in Election 2002 - by Joe Moser - The Heartland Institute ] ]

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. [ [ California Healthcare for All] ] [ [ California] ] [ [] ]

The percentage of residents that are uninsured varies from state to state. Texas has the highest percentage of residents without health insurance at 24%. [ Total Population - Kaiser State Health Facts] ] New Mexico has the second highest percentage of uninsured at 22%.

States play a variety of roles in the health care system including purchasers of health care and regulators of providers and health plans, [ [ Managed Care & Health Insurance - Kaiser State Health Facts]] 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. [Catherine Hess, Sonya Schwartz, Jill Rosenthal,Andrew Snyder, and Alan Weil, [ "States’ Roles in Shaping High Performance Health Systems,"] The Commonwealth Fund, April 2008]

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


Survey research shows that Americans see expanding coverage as a top national priority, and a majority express support for universal health care.Thomas Bodenheimer, [ "The Political Divide In Health Care: A Liberal Perspective,"] Health Affairs, November/December 2005] There is, however, much more limited support for tax increases to support health care reform.Robert J. Blendon and John M. Benson, [ "Americans’ Views On Health Policy: A Fifty-Year Historical Perspective,"] Health Affairs, March/April 2001] Most Americans report satisfaction with their own personal health care. Confidence in government, and the willingness to support large expansions of government, have declined significantly since the 1960s. Support for a single-payer system is less than the level of dissatisfaction with the current system and desire for increased coverage might suggest.

In recent public opinion polls, majorities of Americans say that the current health care system needs fundamental changes, and that they are dissatisfied with the quality and costs of health care, although they are satisfied with the quality of their own health care. Those polled believe the federal government should guarantee insurance for all Americans, even if they had to pay higher taxes. In some polls, respondents prefer a universal health insurance program, "like Medicare," even if it limited their choice of doctors, and even if there were waiting lists for non-emergency treatments. But respondents were split when they were asked whether the federal government should require all Americans to participate in a national health plan.

According to a New York Times/CBS News poll in February 2007, [New York Times/CBS News Poll, Feb. 23-27, 2007, N=1,281 adults nationwide. cite news |url= |title=The New York Times/CBS News Poll, Feb. 23-27, 2007 |publisher: The New York Times |accessdate=2007-08-19] 54% of respondents said that "fundamental changes are needed" in the health care system, and 36% said that "Our health care system has so much wrong with it that we need to completely rebuild it." 57% were dissatisfied with the quality of health care in this country, although 77% were satisfied with the health care they themselves received. 81% were dissatisfied with the cost of health care, and 52% were dissatisfied with the costs of their own health care. 65% said that providing for the uninsured was more important than keeping costs down. 95% said that it is a serious problem that many Americans do not have health insurance. 64% said that the federal government should guarantee health insurance for all Americans, and 60% would pay higher taxes to do so. But only 43% said that it would be fair for the government in Washington to require all Americans to participate in a national health care plan funded by taxpayers, compared to 48% who said it would be unfair.

According to a Washington Post-ABC News poll in October 2003, [ [] "Washington Post-ABC News Poll: Health Care," October 20, 2003] [ [] America's HealthTogether] 62% of respondents preferred "a universal health insurance program, in which everybody is covered under a program like Medicare that's run by the government and financed by taxpayers," compared to 32% who preferred the current system, in which most people get their health insurance from employers. 56% would support a universal health insurance program even if it limited their own choice of doctors, and 63% would support it even if it meant there were waiting lists for some non-emergency treatments.

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. [ [ "Most Republicans Think the U.S. Health Care System is the Best in the World. Democrats Disagree.,"] Press Release, Harvard School of Public Health and Harris Interactive, March 20, 2008] [ [ "Americans’ Views on the U.S. Health Care System Compared to Other Countries,"] Harvard School of Public Health and Harris Interactive, March 20, 2008]

Another poll released in February 2008, conducted by the Harvard School of Public Health and Harris Interactive, indicated that Americans are also divided in their opinions of "socialized medicine," and this split too correlates strongly with their political party affiliation. [cite press release |title=Poll Finds Americans Split by Political Party Over Whether Socialized Medicine Better or Worse Than Current System |publisher=Harvard School of Public Health |date=2007-02-14 |url= |accessdate=2008-02-27 |quote= ] Two-thirds of those polled said they understood the term "socialized medicine" very well or somewhat well. When offered descriptions of what such a system could mean, strong majorities believed that it means "the government makes sure everyone has health insurance" (79%) and "the government pays most of the cost of health care" (73%). One-third (32%) felt that socialized medicine is a system where "the government tells doctors what to do". The poll showed "striking differences" by party affiliation. Among Republicans polled, 70% said that socialized medicine would be worse than the current system. The same percentage of Democrats (70%) said that a socialized medical system would be better than the current system. Independents were more evenly split, with 43% saying socialized medicine would be better and 38% worse.

Physicians' opinions on a national health insurance program have evolved. A 2008 survey of doctors, published in "Annals of Internal Medicine", shows that physicians support universal health care and national health insurance by almost 2 to 1. [ [ Doctors support universal health care: survey] , Reuters, March 31, 2008 (first reported in Annals of Internal Medicine).]

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. [William D. McInturff and Lori Weigel, [ "Déjà Vu All Over Again: The Similarities Between Political Debates Regarding Health Care In The Early 1990s And Today,"] Health Affairs, Volume 27, Number 3, May/June 2008]

Polling data from June 2008 show that Americans who are currently covered at work are hesitant about moving away from the employment-based system. Majorities say that it would make it harder to find a plan that meets their needs, make it harder to keep up with administration issues, harder to find and keep coverage, and harder to get health insurance at a good price. [Drew Altman, [ "Moving Away From Employer Based Coverage: Don't Forget Public Opinion,"] The Kaiser Family Foundation, June 26, 2008] [ [ "Economy continues to dominate issue list, while gas prices jump in importance; Iraq and health care round out top issues,"] The Kaiser Family Foundation, Kaiser Health Tracking Poll: Election 2008, Issue 8, June 2008]

In August 2008, the "Chicago Tribune" reported that health care was falling behind in the polls as an issue in the presidential election, having been superseded by the economy, the Iraq War and the price of gasoline. [Jill Zuckman, [,0,6366402.story "Health care no longer primary ailment,"] Chicago Tribune, August 21, 2008] A September 2008 poll of registered voters by the Kaiser Family Foundation somewhat disputes this conclusion, ranking health care as the third most important issue, superseded only by the economy and only slightly by the Iraq War. [ [ Kaiser Health Tracking Poll: Election 2008 - Issue 10, October 2008] ]

Price of prescription drugs

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). [cite web|url=|title=OECD Health Data, How Does the United States Compare|publisher=Organisation for Economic Co-operation and Development|accessdate=2007-04-14] Some 25% of out-of-pocket spending by individuals is for prescription drugs.cite journal |author=Heffler S, Smith S, Keehan S, Clemens MK, Zezza M, Truffer C |title=Health spending projections through 2013 |journal=Health Aff (Millwood) |volume=Suppl Web Exclusives |issue= |pages=W4–79–93, See especially exhibit 5 |year=2004 |pmid=15451969 |doi=10.1377/hlthaff.w4.79 |url=]

The U.S. government has taken the position (through the Office of the United States Trade Representative) that U.S. drug prices are rising because U.S. consumers are effectively subsidizing costs which drug companies cannot recover from consumers in other countries (because many other countries use their bulk-purchasing power to aggressively negotiate drug prices).Fact|date=February 2007 The U.S. position is that the governments of such countries should either deregulate their markets or directly remit the difference (between what the companies would earn in an open market versus what they are earning now) to drug companies or to the U.S. government. In turn, those companies would be able to lower prices for U.S. consumers. Currently, the U.S., as a purchaser of pharmaceuticals, negotiates some drug prices but is forbidden by law from negotiating drug prices for the Medicare program.Fact|date=February 2007

ee also

*Health care
*Health care economics
*Health care in the United States
*Health care reform
*Health insurance
*Health insurance in the United States
*Health policy analysis
*Health care politics
*Health care systems
*Medicare Rights Center
*National health insurance
*Publicly-funded health care
*Single-payer health care
*Socialized medicine
*Uninsured in the United States
*Universal health care


External links

* [ 2008 Health Care Cost Survey] from Towers Perrin
* [ 2008 Presidential Candidates' Health Reform Proposals] from The Commonwealth Fund
* [ American Medical Student Association (AMSA) - Statement supporting universal health care]
* [ Americans for Free Choice in Medicine (AFCM)]
* [ "healthcare4every1" Campaign]
* [ Health Care Issues] The Heartland Institute
* [ Heritage Foundation's health care research site]
* [ Hidden costs, value lost: uninsurance in America.] Institute of Medicine Committee on the Consequences of Uninsurance. Washington, DC: National Academies Press, 2003.
* [ National Physicians Alliance (NPA)]
* [ Paying More, Getting Less] from Dollars & Sense
* [ Physicians for a National Health Program]
* [ 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.
* [ States Moving Towards Comprehensive Health Care Reform in the U.S.] from The Henry J. Kaiser Family Foundation
* [ Universal Health Care Action Network (UHCAN)] Supports grassroots organizing at the local and state levels
* [ Universal Health Care in the United States] Video and summary of event held at the Woodrow Wilson Center, October 2007.

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