Health care reform debate in the United States
Encyclopedia
The health care reform debate in the United States has been a political issue for many years, focusing upon increasing coverage, decreasing the cost and social burden of healthcare, insurance reform, and the philosophy of its provision, funding, and government involvement. Following the election of Barack Obama
, who campaigned heavily on accomplishing health care reform, legislation was enacted in March 2010.
The U.S. has the highest healthcare costs relative to the size of the economy (GDP) in the world, with an estimated 50.2 million citizens (approximately 15.6% of the September 2011 estimated population of 312 million) without insurance coverage. Further, an estimated 77 million Baby Boomers are reaching retirement age, which combined with significant annual increases in healthcare costs per person will place enormous budgetary strain on U.S. state and federal governments. The long-term fiscal health of the U.S. federal government is primarily related to whether healthcare costs can be brought under control.
According to the Congressional Budget Office
, the primary House and Senate bills would reduce the total deficit during the 2010-2019 period by $138 billion and $132 billion, respectively. However, whether reforms will reduce costs remains a matter of contention by experts.
Various general and specific reform strategies are under debate in the Congress and media. Examples include comparative effectiveness research, independent review panels, doctor incentives (paying for quality rather than quantity of healthcare), tax reform, reducing defensive medicine, insurance regulation, prevention and wellness, incentives for more doctors and nurses, expanded use of technology, rationing of care, single-payer systems
, etc.
Both advocates and critics of reform have mobilized citizens to support their views, with particularly visible demonstrations occurring as congressional leaders returned to their districts during August, 2009.
have also been criticized by this same political advocacy group.
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. However, conservative commentator David Gratzer
and the Cato Institute
, a libertarian think tank, have both 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.
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 in two different 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.
There are health losses from insufficient health insurance. A 2009 Harvard study published in the American Journal of Public Health found more than 44,800 excess deaths annually in the United States due to Americans lacking health insurance. More broadly, estimates of 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.
(Timor-Leste). 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 prices have risen 17%, according to a 2007 study by the Kaiser Family Foundation
.
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.
However, a study published by the Kaiser Family Foundation
in 2008 found that the typical large employer Preferred provider organization
(PPO) plan in 2007 was more generous than either Medicare
or the Federal Employees Health Benefits Program Standard Option. 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, although other sources dispute this.
Proponents of health care reforms involving expansion of government involvement to achieve universal health care argue that the need to provide profits to investor
s in a predominantly free market health system, and the additional administrative spending, tends to drive up costs, leading to more expensive health care provision.
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.
(who is considered one of the world’s most savvy investors) 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.”
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.
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.
OMB Director Peter Orszag
described aspects of the Obama administration's strategy during an interview in November 2009: "In order to help contain [Medicare and Medicaid] cost growth over the long term, we need a new health care system that has digitized information... in which that information is used to assess what’s working and what’s not more intelligently, and in which we’re paying for quality rather than quantity while also encouraging prevention and wellness." He also argued for bundling payments and accountable care organization
s, which reward doctors for teamwork and patient outcomes.
Mayo Clinic
President and CEO Denis Cortese has advocated an overall strategy to guide reform efforts. He argued that the U.S. has an opportunity to redesign its healthcare system and that there is a wide consensus that reform is necessary. He articulated four "pillars" of such a strategy:
Writing in The New Yorker
, surgeon Atul Gawande
further distinguished between the delivery system, which refers to how medical services are provided to patients, and the payment system, which refers to how payments for services are processed. He argued that reform of the delivery system is critical to getting costs under control, but that payment system reform (e.g., whether the government or private insurers process payments) is considerably less important yet gathers a disproportionate share of attention. Gawande argued that dramatic improvements and savings in the delivery system will take "at least a decade." He recommended changes that address the overutilization
of healthcare; the refocusing of incentives on value rather than profits; and comparative analysis of the cost of treatment across various healthcare providers to identify best practices. He argued this would be an iterative, empirical process and should be administered by a "national institute for healthcare delivery" to analyze and communicate improvement opportunities.
described how the cost of treating the most common form of early-stage, slow-growing prostate
cancer ranges from an average of $2,400 (watchful waiting to see if the condition deteriorates) to as high as $100,000 (radiation beam therapy):
According to economist Peter A. Diamond
and research cited by the Congressional Budget Office
(CBO), the cost of healthcare per person in the U.S. also varies significantly by geography and medical center, with little or no statistical difference in outcome.
Comparative effectiveness research has shown that significant cost reductions are possible. OMB Director Peter Orszag
stated: "Nearly thirty percent of Medicare's costs could be saved without negatively affecting health outcomes if spending in high- and medium-cost areas could be reduced to the level of low-cost areas."
Atul Gawande quoted one surgeon who stated: "We took a wrong turn when doctors stopped being doctors and became businessmen." Gawande identified various revenue-enhancing approaches and profit-based incentives that doctors were using in high-cost areas that may have caused the over-utilization of healthcare. He contrasted this with lower-cost areas that used salaried doctors and other techniques to reward value, referring to this as a "battle for the soul of American medicine."
Various legislative proposals under serious consideration propose fining larger employers who do not provide a minimum standard of health care insurance and mandating
that people purchase private health care insurance. This is the first time that the Federal government has mandated people to buy insurance, although nearly all states in the union currently mandate the purchase of auto insurance. The legislation also taxes certain very high payout insurance policies (so-called "Cadillac policies") to help finance subsidies for poorer citizens. These will be offered on a sliding scale to people earning less than four times the federal poverty level to enable them to buy health insurance if they are not otherwise covered by their employer.
The issue of concentration of power by the insurance industry has also been a focus of debate as in many states very few large insurers dominate the market. Legislation which would provide a choice of a not-for-profit insurer modeled on Medicare but funded by insurance premiums has been a contentious issue. Much play has been made to changes to the Medicare Advantage scheme which will reduce public subsidies given to private insurance plans selling such plans by forcing insurers to compete and which it is estimated has increased the profitability of private insurance companies selling these products. No cuts are made to guaranteed coverage benefits in the bills before congress.
Certain proposals include a choice of a not-for-profit insurer modeled on Medicare (sometimes called the "government option"). Democratic legislators have largely supported the proposed reform efforts, while Republicans have criticized the government option or expanded regulation of healthcare.
The GAO
reported in 2002 (using 2000 data) that: "The median
number of licensed carriers in the small group market per state was 28, with a range from 4 in Hawaii to 77 in Indiana. The median market share of the largest carrier was about 33 percent, with a range from about 14 percent in Texas to about 89 percent in North Dakota."
The GAO
reported in 2008 (using 2007 data for the most part) that: "The median number of licensed carriers in the small group market per state was 27. The median market share of the largest carrier in the small group market was about
47 percent, with a range from about 21 percent in Arizona to about 96 percent in Alabama. In 31 of the 39 states supplying market share information, the top carrier had a market share of a third or more. The five largest carriers in the small group market, when combined, represented three quarters or more of the market in 34 of the 39 states supplying this information, and they
represented 90 percent or more in 23 of these states....the median market share of all the BCBS carriers in 38 states reporting this information in 2008 was about 51 percent, compared to the 44 percent reported in 2005 and the 34 percent reported in 2002 for the 34 states supplying information in each of these years."
has also described how the tax treatment of insurance premiums may affect behavior:
In November 2009, The Economist
estimated that taxing employer-provided health insurance (which is presently exempt from tax) would add $215 billion per year to federal tax revenue during the 2013-2014 periods. Peter Singer
wrote in the New York Times that the current exclusion of insurance premiums from compensation represents a $200 billion subsidy for the private insurance industry and that it would likely not exist without it. In other words, taxpayers might be more inclined to change behavior or the system itself if they were paying $200 billion more in taxes each year related to health insurance. To put this amount in perspective, the federal government collected $1,146 billion in income taxes in 2008, so $200 billion represents a 17.5% increase in the effective tax rate.
:
Both Mayo Clinic CEO Dr. Denis Cortese and Surgeon/Author Atul Gawande have argued that such panel(s) will be critical to reform of the delivery system and improving value. Washington Post columnist David Ignatius
has also recommended that President Obama engage someone like Cortese to have a more active role in driving reform efforts.
" to provide incentives for healthier behavior, either by levying the tax on products (such as soft drinks) that are thought to contribute to obesity, or to individuals based on body measures, as is done in Japan.
may refer to the restriction of medical care service delivery based on any number of objective or subjective criteria. Republican Newt Gingrich
argued that the reform plans supported by President Obama expand the control of government over healthcare decisions, which he referred to as a type of healthcare rationing. President Barack Obama
has argued that U.S. healthcare is already rationed, based on income, type of employment, and medical pre-existing condition
s, with nearly 46 million uninsured. He argued that millions of Americans are denied coverage or face higher premiums as a result of medical pre-existing conditions.
Peter Singer
wrote in the New York Times in July 2009 that healthcare is rationed in the United States and argued for improved rationing processes:
According to PolitiFact, private health insurance companies already ration health care by income, by denying health insurance to those with pre-existing conditions and by caps on health insurance payments. Rationing exists now, and will continue to exist with or without health care reform. David Leonhardt
also wrote in the New York Times in June 2009 that rationing is a part of economic reality: "The choice isn’t between rationing and not rationing. It’s between rationing well and rationing badly. Given that the United States devotes far more of its economy to health care than other rich countries, and gets worse results by many measures, it’s hard to argue that we are now rationing very rationally."
Palin's death panel
remarks were based on the ideas of Betsy McCaughey. During 2009, former Alaska Governor Sarah Palin
wrote against alleged rationing, referring to what by her interpretation was a "downright evil" "death panel" in current reform legislation known as H.R. 3200 Section 1233. However, Palin supported similar end of life discussion and advance directives for patients in 2008. Defenders of the plan indicated that the proposed legislation H.R. 3200 would allow Medicare for the first time to cover patient-doctor consultations about end-of-life planning, including discussions about drawing up a living will or planning hospice treatment. Patients could seek out such advice on their own, but would not be required to. The provision would limit Medicare coverage to one consultation every five years. Rep. Earl Blumenauer
, D-Ore., who sponsored the H.R. 3200 end of life counseling provision, said the measure would block funds for counseling that presents suicide or assisted suicide as an option, and called references to death panels or euthanasia "mind-numbing". Republican Senator Johnny Isakson
, who co-sponsored a 2007 end-of-life counseling provision, called the euthanasia claim "nuts". Analysts who examined the end-of-life provision Palin cited agree that Palin's claim is incorrect. According to TIME and ABC, Palin and Betsy McCaughey made false euthanasia claims.
The federal requirement that hospitals help patients with things like living wills
began when Republican George H. W. Bush
was President. Section 1233 merely allows doctors to be paid for their time. However, an NBC poll indicates that as of August, 2009, 45% of Americans believed in the death panel story.
Slate
columnist Christopher Beam used the term "deathers" to refer to those who believed rationing and euthanasia would become likely for senior citizens. The Rachel Maddow
Show aired a program called "Obama and the Deathers" in which Maddow discussed conspiracy theories that included "a secret plot to kill old people." Daily Kos
and other web sites had used the term for about a week before Hari Sevugan
, national spokesman for the Democratic National Committee
, sent out an email with the subject line "Murkowski: Deathers 'Lying' 'Inciting Fear.'" The message included an article about a town hall
statement by Senator
Lisa Murkowski
, a Republican
from Alaska
, that no version of health care reform included "death panels".
Sevugan explained the term "deathers" to Patricia Murphy, who writes a Politics Daily
column called "The Capitolist":
Others, such as former Republican Secretary of Commerce Peter G. Peterson
, have indicated that some form of rationing is inevitable and desirable considering the state of U.S. finances and the trillions of dollars of unfunded Medicare liabilities. He estimated that 25-33% of healthcare services are provided to those in the last months or year of life and advocated restrictions in cases where quality of life cannot be improved. He also recommended that a budget be established for government healthcare expenses, through establishing spending caps and pay-as-you-go rules that require tax increases for any incremental spending. He has indicated that a combination of tax increases and spending cuts will be required. All of these issues would be addressed under the aegis of a fiscal reform commission.
costs are significant and should be addressed via tort reform
. At the same time, a Hearst Newspapers investigation concluded that up to 200,000 people per year die from medical errors and infections in the United States. None of the three major bills under consideration lower recoverable damages in tort
suits. Medical malpractice, such as doctor errors resulting in harm to patients, has several direct and indirect costs:
How much these costs are is a matter of debate. Some have argued that malpractice
lawsuits are a major driver of medical costs. However, the direct cost of malpractice suits amounts to only about 0.5% of all healthcare spending, and a 2006 Harvard study showed that over 90% of the malpractice suits examined contained evidence of injury to the patient and that frivolous suits were generally readily dismissed
by the courts. A 2005 study estimated the cost around 0.2%, and in 2009 insurer WellPoint Inc. said "liability wasn’t driving premiums." Counting both direct and indirect costs, other studies estimate the total cost of malpractice "is linked to" between 5% and 10% of total U.S. medical costs. A 2004 report by the Congressional Budget Office
put medical malpractice costs at 2% of U.S. health spending and "even significant reductions" would do little to reduce the growth of health-care expenses.
Conservative columnist Charles Krauthammer
argued that between $60–200 billion per year could be saved through tort reform. Physician and former Democratic National Committee Chairman Howard Dean
explained why tort reform is not part of the bills under consideration: "When you go to pass a really enormous bill like that, the more stuff you put it in it, the more enemies you make, right?...And the reason tort reform is not on the bill is because the people who wrote it did not want to take on the trial lawyers in addition to everybody else they were taking on. That is the plain and simple truth."
However, even successful tort reform might not lead to lower aggregate liability: for example, medical commentators have argued that the current contingent fee system skews litigation towards high-value cases while ignoring meritorious small cases; aligning litigation more closely with merit might thus increase the number of small awards, offsetting any reduction in large awards. A New York study found that only 1.5% of hospital negligence led to claims; moreover, the CBO observed that "health care providers are generally not exposed to the financial cost of their own malpractice risk because they carry liability insurance, and the premiums for that insurance do not reflect the records or practice styles of individual providers but more-general factors such as location and medical specialty." Given that total liability is small relative to the amount doctors pay in malpractice insurance premiums, alternative mechanisms have been proposed to reform malpractice insurance.
The American Academy of Family Physicians predicts a shortage of 40,000 primary care doctors (including family practice, internal medicine, pediatrics and obstetrics/gynecology) by 2020. The number of medical students choosing the primary care specialty has dropped by 52% since 1997. Currently, only 2% of medical school graduates choose primary care as a career. An amendment to the Senate health bill includes $2 billion in funds over 10 years to create 2,000 new residency training slots geared toward primary care medicine and general surgery. Writing in Forbes, a physician argued that this is a "tiny band-aid at best," advocating full loan repayments and guaranteed positions upon graduation.
The U.S. had 2.3 doctors per 1,000 people in 2002, ranking 52nd. Germany and France had approximately 3.4 and ranked in the top 25. The OECD average in 2008 was 3.1 doctors per 1,000 people, while the U.S. had 2.4.
The American Association of Colleges of Nurses cited studies estimating that a shortage of registered nurses would reach 230,000 by 2025 as America ages, with over 135,000 open positions during 2007. An additional 30% more nurses would have to graduate annually to keep up with demand. A study by Price Waterhouse advanced several strategies for addressing the nursing shortage, including developing more public-private partnerships, federal and state-level grants for nursing students and educators, creating healthy work environments, using technology as a training tool, and designing more flexible roles for advanced practice nurses given their increased use as primary care providers.
In addition, the U.S. also does not measure favorably vs. OECD countries in terms of acute care hospital beds. Only four OECD countries have fewer acute care hospital beds per capita than the U.S, which has 2.7 per 1,000 population versus an OECD average of 3.8. Japan has 8.2 acute care beds per 1,000 population.
lists Medicare as a "high-risk" government program due to its vulnerability to improper payments. Fewer than 5% of Medicare claims are audited. Medicare fraud accounts for an estimated $60 billion in Medicare payments each year, and "has become one of, if not the most profitable, crimes in America." Criminals set up phony companies, then invoice Medicare for fraudulent services provided to valid Medicare patients who never receive the services. These costs appear on the Medicare statements provided to Medicare card holders. The program pays out over $430 billion per year via over 1 billion claims, making enforcement challenging. Its enforcement budget is "extremely limited" according to one Medicare official. U.S. Attorney General Eric Holder
said in an interview: "Clearly more auditing needs to be done and it needs to be done in real time." The Obama administration is providing Medicare with an additional $200 million to fight fraud as part of its stimulus package, and billions of dollars to computerize medical records and upgrade networks, which should assist Medicare in identifying fraudulent claims.
The over 1,300 U.S. health insurance companies have different forms and processes for billing and reimbursement, requiring enormous costs on the part of service providers (mainly doctors and hospitals) to process payments. For example, the Cleveland Clinic, considered a low-cost, best-practices hospital system, has 1,400 billing clerks to support 2,000 doctors. Further, the insurance companies have their own overhead functions and profit margins, much of which could be eliminated with a single payer system. Economist Paul Krugman estimated in 2005 that converting from the current private insurance system to a single-payer system would enable $200 billion per year in cost savings, primarily via insurance company overhead. One advocacy group estimated savings as high as $400 billion annually for 2009 and beyond.
The US system is often compared with that of its northern neighbor, Canada (see Canadian and American health care systems compared
). Canada's system is largely publicly funded. In 2006, Americans spent an estimated US$6,714 per capita on health care, while Canadians spent US$3,678. This amounted to 15.3% of US GDP in that year, while Canada spent 10.0% of GDP on health care. A study by Harvard Medical School and the Canadian Institute for Health Information determined that some 31% of US health care dollars, or more than $1,000 per person per year, went to health care administrative costs.
Advocates argue that shifting the US to a single-payer health care system would provide universal coverage, give patients free choice of providers and hospitals, and guarantee comprehensive coverage and equal access for all medically necessary procedures, without increasing overall spending. Shifting to a single-payer system would also eliminate oversight by managed care reviewers, restoring the traditional doctor-patient relationship.
Advocates argue that the largest obstacle to single-payer, universal system in the U.S. is a lack of political will.
(R) has proposed the Roadmap for America's Future, which is a series of budgetary reforms. His January 2010 version of the plan includes the transition of Medicare to a voucher system, meaning individuals would receive a voucher which could be used to purchase health insurance in the private market. This would not affect those near retirement or currently enrolled. A series of graphs and charts summarizing the impact of the plan are included. Economists have both praised and criticized particular features of the plan. The CBO also partially scored the bill.
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 the Patient Protection and Affordable Care Act
.
Republicans continue to claim that they had a workable bill to extend coverage to all Americans and not cost the taxpayer a singe penny. The Empowering Patients First Act
which was proposed as a replacing amendment to the Senate Bill during the bill mark-up. However, this alternative bill was rejected by the Senate Finance Committee. The Congressional Budget Office said that it would not reduce the percentage of working age people who do not have insurance over the next 10 years, and that it estimated it would encourage health insurers to reduce rather than increase insurance coverage as it would remove mandated coverage rules that currently apply in some states. This bill would have given the insurance industry greater access to government funds through new insurance subsidies. It does not have any taxation provisions and though it would reduce the deficit over 10 years by $18 billion, this is a considerably smaller deficit reduction than either the House or the Senate bills.
' insurance plans, as well as an increase in the Medicare payroll tax for high earners.
Most 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. In contrast, the House bill's insurance mandate
has been described as "an economic assault on the young" by, for example, Robert J. Samuelson
for The Washington Post
.
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.
Services marketed as preventive care are a subject of continuing debate. Years of study
have shown that most common services provide no benefit to patients. The House and Senate bills would mandate the purchase of policies that pay 100% of the cost of certain services, with no co-pay; when the Senate bill was amended to mandate paying for tests that a federal panel
and U.S. News & World Report
said "do more harm than good," The New York Times
wrote, "This sorry episode does not bode well for reform efforts to rein in spending on other procedures based on sound scientific evidence of their potential benefits and risks for patients."
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
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.
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.
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 a family 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 bill would differ, somewhat, in their overall impact. The Senate bill would cover an additional 31 million people, at a federal budget cost of nearly $850 billion (not counting unfunded mandates) 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.
The Senate bill also begins most provisions a year later than the House bill in order to make costs seem smaller:
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.
. The shift in parties was even more pronounced during the first three months of 2009, when Democrats collected 60% of the $5.4 million donated by health-care companies and their employees, the data show. Lawmakers that chair key committees have been leading recipients, some of whom received over $1.0 million in contributions.
Matt Taibbi
wrote in Rolling Stone
that President Obama and key senators who have advocated single-payer systems in the past are unwilling to face the insurance companies and their powerful lobbying efforts. Key politicians on the Senate Finance Committee involved in crafting legislation have received over $2 million in campaign contributions from the healthcare industry. Several of the firms invited to testify at the hearings sent lobbyists that had formerly worked for Senator Max Baucus
, the chair of the committee. Mr. Baucus stated in February 2009 that: "There may come a time when we can push for single-payer. At this time, it's not going to get to first base in Congress."
George McGovern
wrote that significant campaign funds were given to the chairman and ranking minority member of the Senate Finance Committee, which has jurisdiction over health-care legislation: "Chairman Max Baucus of Montana, a Democrat, and his political action committee have received nearly $4 million from the health-care lobby since 2003. The ranking Republican, Charles Grassley of Iowa, has received more than $2 million. It's a mistake for one politician to judge the personal motives of another. But Sens. Baucus and Grassley are firm opponents of the single-payer system, as are other highly placed members of Congress who have been generously rewarded by the insurance lobby."
executive Wendell Potter
of the Center for Media and Democracy
- whose funding comes from groups such as the Tides Foundation- argue that the hyperbole generated by this phenomenon is a form of corporate astroturfing
, which he says that he used to write for CIGNA
. Opponents of more government involvement, such as Phil Kerpen of Americans for Prosperity
- whose funding comes mainly from the Koch Industries
corporation- counter-argue that those corporations oppose a public-plan
, but some try to push for government actions that will unfairly benefit them, such as forcing private companies to buy health insurance for their employees. Journalist Ben Smith
has referred to mid-2009 as "The Summer of Astroturf" given the organizing and co-ordinating efforts made by various groups on both pro- and anti-reform sides.
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." Similarly, Franklin D. Roosevelt
advocated a right to medical care in his 1944 proposal for a Second Bill of Rights
.
Liberals were the primary advocates of both Social Security
and Medicare
, which are often targeted as significant expansions of government that has overwhelming satisfaction among beneficiaries. President Obama argued during a September 2009 joint session of Congress that the government has a moral responsibility to ensure quality healthcare is available to all citizens. He also referred to a letter from the late Senator Ted Kennedy
.
Economist and New York Times columnist Paul Krugman
has argued that Republican and conservative strategies in opposing healthcare are based on spite: "At this point, the guiding principle of one of our nation’s two great political parties is spite pure and simple. If Republicans think something might be good for the president, they’re against it — whether or not it’s good for America." He argued that Republican opposition to Medicare savings proposed by the President is "utterly at odds both with the party’s traditions and with what conservatives claim to believe. Think about just how bizarre it is for Republicans to position themselves as the defenders of unrestricted Medicare spending. First of all, the modern G.O.P. considers itself the party of Ronald Reagan — and Reagan was a fierce opponent of Medicare’s creation, warning that it would destroy American freedom. (Honest.) In the 1990s, Newt Gingrich tried to force drastic cuts in Medicare financing. And in recent years, Republicans have repeatedly decried the growth in entitlement spending — growth that is largely driven by rising health care costs." More recently he urged the House of representatives to pass the Senate's bill, which he called "centrist."
During the 2009 reform debate, Sen. Jim DeMint, R-S.C. opined in July, 2009:
Investigative reporter and columnist John Stossel
has remarked that "Insurance invites waste. That's a reason health care costs so much, and is often so consumer-unfriendly. In the few areas where there are free markets in health care -- such as cosmetic medicine and Lasik eye surgery -- customer service is great, and prices continue to drop." Republican Senator and medical doctor Tom Coburn
has stated that the healthcare system in Switzerland
should serve as a model for U.S. reform. He wrote for New York Sun
that reform should involve a market-based method transferring health care tax benefits to individuals rather than employers as well as giving individuals extra tax credits to afford more coverage.
Some critics of the bills passed in 2009 call them a "government take over of health care." FactCheck
called the phrase an unjustified "mantra." (Factcheck has also criticized a number of other assertions made during 2009 by advocates on both sides of the debate). CBS News
described it as a myth "mixed in with some real causes for concern." President Obama disputes the notion of a government takeover and says he no more wants government bureaucrats meddling than he wants insurance company bureaucrats doing so. However, other sources contend the bills do amount to either a government takeover or a corporate takeover, or both. This debate occurs in the context of a "revolution...transforming how medical care is delivered:" from 2002–2008, the percentage of medical practices owned by doctors fell from more than 70% to below 50%; in contrast to the traditional practice in which most doctors cared for patients in small, privately owned clinics, by 2008 most doctors had become employees of hospitals, nearly all of which are owned by corporations or government.
Republicans also argue the proposed excise tax on medical devices and drugs would increase the tax burden on vaccine makers.
Some conservatives argue that forcing people to buy private insurance
is unconstitutional
; legislators in 38 states have introduced bills opposing the new law, and 18 states have filed suit in federal court challenging the unfunded mandates on individuals and states.
Senator Judd Gregg
(R) said in an interview regarding the passage of healthcare reform: "Well, in my judgment we’re moving down a path towards...Europeanization of our nation. And our great uniqueness, what surrounds American exceptionalism, what really drives it is that entrepreneurial individualistic spirit which goes out and takes a risk when nobody else is willing to do it or comes up with an idea that nobody else comes up with and that all gets dampened down the larger and more intrusive government becomes, especially if you follow a European model."
After Massachusetts voters replaced a Senator who had voted for the Senate bill with a candidate who promised to vote against it, Senator Jim Webb
called on Senate leaders to suspend any further votes on the bill until the new Senator is sworn into office. In addition, members of the United States House of Representatives
reportedly "indicated they would not quickly pass the bill the Senate approved last month."
Republican Senator Olympia Snowe
, who had earlier voted for the Senate Finance Committee bill, in December 2009 announced she would oppose the revised bill: "Here we are today with a bill that's dramatically different and more expansive than the Finance Committee -- in fact it's 1,200 pages more -- it was placed on the floor just short of three weeks ago."
California
Governor Arnold Schwarzenegger
, whom the White House had brought much attention to as a Republican supporter, said in his State of the State address, "Health care reform, which started as noble and needed legislation, has become a trough of bribes, deals and loopholes." Schwarzenegger added, "California's congressional delegation should either vote against this bill that is a disaster for California or get in there and fight for the same sweetheart deal Senator [Ben] Nelson of Nebraska got for the Cornhusker State."
Polling data has been somewhat conflicting and results can depend on how the question is asked. Rasmussen Reports
in January 2010, found that 10% of the American public have withdrawn their support from leading Congressional proposals compared with June 2009, and reported a majority opposing them since November 2009. Other polls in December 2009 and January 2010 found opposition slightly higher at 57%. However, when asked generically whether Congress should vote for or against "a healthcare bill" (rather than the specific bills passed in each chamber), Gallup poll results show opinion has remained more evenly divided, fluctuating mostly within the margin of error since September 2009.
In 2010, 82% of Obama voters who voted for Brown in Massachusetts support the public option.
wrote that passing the bills "would be political suicide. It would be the act of a party so arrogant, elitist and contemptuous of popular wisdom that it would not deserve to govern."
New York Times columnist Bob Herbert
wrote, "No one in his or her right mind could have believed that a workable, efficient, cost-effective system could come out of the monstrously ugly plan that finally emerged from the Senate after long months of shady alliances, disgraceful back-room deals, outlandish payoffs and abject capitulation to the insurance companies and giant pharmaceutical outfits." Some "say the health care bill has been gutted to appease insurance companies;" for example, Howard Dean
called the Senate bill "an insurance company's dream" and said that "at this point, the bill does more harm than good."
Some advocates of single-payer healthcare, likewise argue against the current bills. Writing in the Huffington Post, Michael Moore
called the current bills a "massive government bailout for the insurance industry." Opposing the House bill, Democratic Representative Dennis Kucinich
called it "the wrong approach" and a subsidy rewarding "the wrong people" including the insurance companies. Dr. Marcia Angell
, past editor-in-chief of the New England Journal of Medicine
, wrote "Kucinich was right" to vote against the House bill, and warned that if it becomes law:
After voting to take up the Senate bill, Bernie Sanders
emphasized that his support for the final bill hinges on whether the Senate makes the measure "stronger and more effective for working families and taxpayers in Vermont and America."
Arianna Huffington
wrote, in recommending George Mason University
Professor Janine Wedel's The Shadow Elite, that "what may well have started out as a push for real reform ended up as an industry windfall. After all, the final Senate bill (which looks like it will be the base for the final bill sent to Obama), is essentially the same bill that was drawn up months ago in Max Baucus' office by Baucus staffers who used to be health care executives, and by health care lobbyists who used to be Baucus staffers." The Huffington Post
has published many articles saying the current proposals would be counterproductive.
(Randall Amster
, "The Road to Healthcare is Paved with Bad Intentions"
President Barack Obama
argued for passing healthcare reform in his State of the Union Address in January 2010: "[W]e are closer than ever to bringing more security to the lives of so many Americans. The approach we've taken would protect every American from the worst practices of the insurance industry. It would give small businesses and uninsured Americans a chance to choose an affordable health care plan in a competitive market. It would require every insurance plan to cover preventive care.... Our approach would preserve the right of Americans who have insurance to keep their doctor and their plan. It would reduce costs and premiums for millions of families and businesses. And according to the Congressional Budget Office -– the independent organization that both parties have cited as the official scorekeeper for Congress –- our approach would bring down the deficit by as much as $1 trillion over the next two decades."
Both the AARP
and the American Medical Association
have endorsed the House bill.
The Congressional Budget Office
reported in June 2008 that: In other words, all other federal spending categories (e.g., Social Security, Defense, Education, and Transportation) would require borrowing in order to be to be funded, which is not feasible.
President Obama stated in May 2009: "But we know that our families, our economy, and our nation itself will not succeed in the 21st century if we continue to be held down by the weight of rapidly rising health care costs and a broken health care system...Our businesses will not be able to compete; our families will not be able to save or spend; our budgets will remain unsustainable unless we get health care costs under control."
The Senate bill (without including amendments) would increase the share of GDP consumed by medical spending from the current 17% to 20.9% by 2019, compared to 20.8% under current law, according to the Department of Health and Human Services' Centers for Medicare and Medicaid Services
.
The final CBO cost estimates indicated that the ultimate passage of the Health Care and Education Reconciliation Act of 2010 would yield a net reduction in the federal deficit of $143 billion over the 2010–2019 period.
Both parties have introduced legislation to address the provision, yet they differ over how to pay for the $17 billion in revenue the provision was expected to raise. The most recent legislative action occurred on November 29, 2010, when the Senate voted on two amendments offered to S. 510, the Food Safety bill. S.A. 4702, offered by Senator Johanns, fully repeals the new 1099 requirement, and offsets the bill with unused stimulus funds. SA 4713, offered by Sen. Max Baucus of Montana, also fully repeals the new 1099 requirement and does not have an offset. Both amendments failed to pass. The Republican Party has expressly stated that the repeal of the 1099 Form provision will be a top healthcare legislative priority in the 112th Congress as they gain control of the House
United States presidential election, 2008
The United States presidential election of 2008 was the 56th quadrennial presidential election. It was held on November 4, 2008. Democrat Barack Obama, then the junior United States Senator from Illinois, defeated Republican John McCain, the senior U.S. Senator from Arizona. Obama received 365...
, who campaigned heavily on accomplishing health care reform, legislation was enacted in March 2010.
The U.S. has the highest healthcare costs relative to the size of the economy (GDP) in the world, with an estimated 50.2 million citizens (approximately 15.6% of the September 2011 estimated population of 312 million) without insurance coverage. Further, an estimated 77 million Baby Boomers are reaching retirement age, which combined with significant annual increases in healthcare costs per person will place enormous budgetary strain on U.S. state and federal governments. The long-term fiscal health of the U.S. federal government is primarily related to whether healthcare costs can be brought under control.
According to the Congressional Budget Office
Congressional Budget Office
The Congressional Budget Office is a federal agency within the legislative branch of the United States government that provides economic data to Congress....
, the primary House and Senate bills would reduce the total deficit during the 2010-2019 period by $138 billion and $132 billion, respectively. However, whether reforms will reduce costs remains a matter of contention by experts.
Various general and specific reform strategies are under debate in the Congress and media. Examples include comparative effectiveness research, independent review panels, doctor incentives (paying for quality rather than quantity of healthcare), tax reform, reducing defensive medicine, insurance regulation, prevention and wellness, incentives for more doctors and nurses, expanded use of technology, rationing of care, single-payer systems
Single-payer health care
Single-payer health care is medical care funded from a single insurance pool, run by the state. Under a single-payer system, universal health care for an entire population can be financed from a pool to which many parties employees, employers, and the state have contributed...
, etc.
Both advocates and critics of reform have mobilized citizens to support their views, with particularly visible demonstrations occurring as congressional leaders returned to their districts during August, 2009.
Quality of care
There is significant debate regarding the quality of the U.S. healthcare system relative to those of other countries. 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. The quality of health maintenance organizations and managed careManaged care
...intended to reduce unnecessary health care costs through a variety of mechanisms, including: economic incentives for physicians and patients to select less costly forms of care; programs for reviewing the medical necessity of specific services; increased beneficiary cost sharing; controls on...
have also been criticized by this same political advocacy group.
According to a 2000 study of the World Health Organization
World Health Organization
The World Health Organization is a specialized agency of the United Nations that acts as a coordinating authority on international public health. Established on 7 April 1948, with headquarters in Geneva, Switzerland, the agency inherited the mandate and resources of its predecessor, the Health...
, 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. However, conservative commentator David Gratzer
David Gratzer
David George Gratzer is a physician, columnist, author, Congressional expert witness, and a senior fellow at both the Manhattan Institute and the Montreal Economic Institute...
and the Cato Institute
Cato Institute
The Cato Institute is a libertarian think tank headquartered in Washington, D.C. It was founded in 1977 by Edward H. Crane, who remains president and CEO, and Charles Koch, chairman of the board and chief executive officer of the conglomerate Koch Industries, Inc., the largest privately held...
, a libertarian think tank, have both 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.
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
United States Department of Veterans Affairs
The United States Department of Veterans Affairs is a government-run military veteran benefit system with Cabinet-level status. It is the United States government’s second largest department, after the United States Department of Defense...
asked 236 elderly patients in two different managed care plans to rate their care, then examined care in medical records, as reported in Annals of Internal Medicine
Annals of Internal Medicine
Annals of Internal Medicine is an academic medical journal published by the American College of Physicians . It publishes research articles and reviews in the area of internal medicine. Its current editor is Christine Laine...
. 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.
There are health losses from insufficient health insurance. A 2009 Harvard study published in the American Journal of Public Health found more than 44,800 excess deaths annually in the United States due to Americans lacking health insurance. More broadly, estimates of 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.
Cost and efficiency
The United States spends a higher proportion of its GDP on health care (19.3% in ref cited, but now 16%, lagging other rich countries) than any other country in the world, except for East TimorEast Timor
The Democratic Republic of Timor-Leste, commonly known as East Timor , is a state in Southeast Asia. It comprises the eastern half of the island of Timor, the nearby islands of Atauro and Jaco, and Oecusse, an exclave on the northwestern side of the island, within Indonesian West Timor...
(Timor-Leste). 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 prices have risen 17%, according to a 2007 study by the Kaiser Family Foundation
Kaiser Family Foundation
The Henry J. Kaiser Family Foundation , or just Kaiser Family Foundation, is a U.S.-based non-profit, private operating foundation headquartered in Menlo Park, California. It focuses on the major health care issues facing the nation, as well as the U.S. role in global health policy...
.
Private insurance in the US varies greatly in its coverage; one study by the Commonwealth Fund
Commonwealth Fund
The Commonwealth Fund is a private U.S. foundation whose stated purpose is to promote a high-performing health care system that achieves better access, improved quality, and greater efficiency, especially for society's most vulnerable.-History:...
published in Health Affairs
Health Affairs
Health Affairs is a peer-reviewed healthcare journal established in 1981 by John K. Iglehart. It was described by The Washington Post as "the bible of health policy". Health Affairs is indexed and/or abstracted in PubMed, MEDLINE, EBSCO databases, ProQuest, LexisNexis, Current Contents/Health...
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.
However, a study published by the Kaiser Family Foundation
Kaiser Family Foundation
The Henry J. Kaiser Family Foundation , or just Kaiser Family Foundation, is a U.S.-based non-profit, private operating foundation headquartered in Menlo Park, California. It focuses on the major health care issues facing the nation, as well as the U.S. role in global health policy...
in 2008 found that the typical large employer Preferred provider organization
Preferred provider organization
In health insurance in the United States, a preferred provider organization is a managed care organization of medical doctors, hospitals, and other health care providers who have covenanted with an insurer or a third-party administrator to provide health care at reduced...
(PPO) plan in 2007 was more generous than either Medicare
Medicare (United States)
Medicare is a social insurance program administered by the United States government, providing health insurance coverage to people who are aged 65 and over; to those who are under 65 and are permanently physically disabled or who have a congenital physical disability; or to those who meet other...
or the Federal Employees Health Benefits Program Standard Option. 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, although other sources dispute this.
Proponents of health care reforms involving expansion of government involvement to achieve universal health care argue that the need to provide profits to investor
Investor
An investor is a party that makes an investment into one or more categories of assets --- equity, debt securities, real estate, currency, commodity, derivatives such as put and call options, etc...
s in a predominantly free market health system, and the additional administrative spending, tends to drive up costs, leading to more expensive health care provision.
According to economist and former US Secretary of Labor, Robert Reich
Robert Reich
Robert Bernard Reich is an American political economist, professor, author, and political commentator. He served in the administrations of Presidents Gerald Ford and Jimmy Carter and was Secretary of Labor under President Bill Clinton from 1993 to 1997....
, only a "big, national, public option" can force insurance companies to cooperate, share information, and reduce costs. Scattered, localized, "insurance cooperatives
Health insurance cooperative
A health insurance cooperative is a cooperative entity that has the goal of providing health insurance and is also owned by the people that the organization insures...
" are too small to do that and are "designed to fail" by the moneyed forces opposing Democratic health care reform.
Impact on U.S. economic productivity
On March 1, 2010, billionaire Warren BuffettWarren Buffett
Warren Edward Buffett is an American business magnate, investor, and philanthropist. He is widely regarded as one of the most successful investors in the world. Often introduced as "legendary investor, Warren Buffett", he is the primary shareholder, chairman and CEO of Berkshire Hathaway. He is...
(who is considered one of the world’s most savvy investors) 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.”
Proposed strategies for reform
During a June 2009 speech, President Barack ObamaBarack Obama
Barack Hussein Obama II is the 44th and current President of the United States. He is the first African American to hold the office. Obama previously served as a United States Senator from Illinois, from January 2005 until he resigned following his victory in the 2008 presidential election.Born in...
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
Bundled payment
Bundled payment, also known as episode-based payment, episode payment, episode-of-care payment, case rate, evidence-based case rate, global bundled payment, global payment, package pricing, or packaged pricing, is defined as the reimbursement of health care providers "on the basis of expected...
for treatment of conditions rather than specific services, better identifying and communicating the most cost-effective treatments, and reducing defensive medicine.
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.
OMB Director Peter Orszag
Peter Ország
Peter Ország is a Slovak ice hockey referee, who referees in the Slovak Extraliga.-Career:He has officiated many international tournaments including the Winter Olympics. He has been named Slovak referee of the year....
described aspects of the Obama administration's strategy during an interview in November 2009: "In order to help contain [Medicare and Medicaid] cost growth over the long term, we need a new health care system that has digitized information... in which that information is used to assess what’s working and what’s not more intelligently, and in which we’re paying for quality rather than quantity while also encouraging prevention and wellness." He also argued for bundling payments and accountable care organization
Accountable care organization
An accountable care organization is a type of payment and delivery reform model that seeks to tie provider reimbursements to quality metrics and reductions in the total cost of care for an assigned population of patients. A group of coordinated health care providers form an ACO, which then...
s, which reward doctors for teamwork and patient outcomes.
Mayo Clinic
Mayo Clinic
Mayo Clinic is a not-for-profit medical practice and medical research group specializing in treating difficult patients . Patients are referred to Mayo Clinic from across the U.S. and the world, and it is known for innovative and effective treatments. Mayo Clinic is known for being at the top of...
President and CEO Denis Cortese has advocated an overall strategy to guide reform efforts. He argued that the U.S. has an opportunity to redesign its healthcare system and that there is a wide consensus that reform is necessary. He articulated four "pillars" of such a strategy:
- Focus on value, which he defined as the ratio of quality of service provided relative to cost;
- Pay for and align incentives with value;
- Cover everyone;
- Establish mechanisms for improving the healthcare service delivery system over the long-term, which is the primary means through which value would be improved.
Writing in The New Yorker
The New Yorker
The New Yorker is an American magazine of reportage, commentary, criticism, essays, fiction, satire, cartoons and poetry published by Condé Nast...
, surgeon Atul Gawande
Atul Gawande
Atul Gawande is an American physician and journalist. He serves as a general and endocrine surgeon at Brigham and Women's Hospital in Boston, Massachusetts and associate director of their Center for Surgery and Public Health...
further distinguished between the delivery system, which refers to how medical services are provided to patients, and the payment system, which refers to how payments for services are processed. He argued that reform of the delivery system is critical to getting costs under control, but that payment system reform (e.g., whether the government or private insurers process payments) is considerably less important yet gathers a disproportionate share of attention. Gawande argued that dramatic improvements and savings in the delivery system will take "at least a decade." He recommended changes that address the overutilization
Overutilization
Overutilization refers to medical services that are provided with a higher volume or cost than is appropriate. In the United States, where health care costs are the highest as a percentage of GDP, overutilization is the predominant factor in its expense...
of healthcare; the refocusing of incentives on value rather than profits; and comparative analysis of the cost of treatment across various healthcare providers to identify best practices. He argued this would be an iterative, empirical process and should be administered by a "national institute for healthcare delivery" to analyze and communicate improvement opportunities.
Use of comparative effectiveness research
Several treatment alternatives may be available for a given medical condition, with significantly different costs yet no statistical difference in outcome. Such scenarios offer the opportunity to maintain or improve the quality of care, while significantly reducing costs, through comparative effectiveness research. Writing in the New York Times, David LeonhardtDavid Leonhardt
David Leonhardt is the Washington bureau chief of The New York Times. He joined The Times in 1999 and wrote the "Economics Scene" column, and for the Times Sunday Magazine. Before coming to The Times, he wrote for Business Week and The Washington Post...
described how the cost of treating the most common form of early-stage, slow-growing prostate
Prostate
The prostate is a compound tubuloalveolar exocrine gland of the male reproductive system in most mammals....
cancer ranges from an average of $2,400 (watchful waiting to see if the condition deteriorates) to as high as $100,000 (radiation beam therapy):
According to economist Peter A. Diamond
Peter A. Diamond
Peter Arthur Diamond is an American economist known for his analysis of U.S. Social Security policy and his work as an advisor to the Advisory Council on Social Security in the late 1980s and 1990s. He was awarded the Nobel Memorial Prize in Economic Sciences in 2010, along with Dale T. Mortensen...
and research cited by the Congressional Budget Office
Congressional Budget Office
The Congressional Budget Office is a federal agency within the legislative branch of the United States government that provides economic data to Congress....
(CBO), the cost of healthcare per person in the U.S. also varies significantly by geography and medical center, with little or no statistical difference in outcome.
Comparative effectiveness research has shown that significant cost reductions are possible. OMB Director Peter Orszag
Peter Ország
Peter Ország is a Slovak ice hockey referee, who referees in the Slovak Extraliga.-Career:He has officiated many international tournaments including the Winter Olympics. He has been named Slovak referee of the year....
stated: "Nearly thirty percent of Medicare's costs could be saved without negatively affecting health outcomes if spending in high- and medium-cost areas could be reduced to the level of low-cost areas."
Reform of doctor's incentives
Critics have argued that the healthcare system has several incentives that drive costly behavior. Two of these include:- Doctors are typically paid for services provided rather than with a salary. This provides a financial incentive to increase the costs of treatment provided.
- Patients that are fully insured have no financial incentive to minimize the cost when choosing from among alternatives. The overall effect is to increase insurance premiums for all.
Atul Gawande quoted one surgeon who stated: "We took a wrong turn when doctors stopped being doctors and became businessmen." Gawande identified various revenue-enhancing approaches and profit-based incentives that doctors were using in high-cost areas that may have caused the over-utilization of healthcare. He contrasted this with lower-cost areas that used salaried doctors and other techniques to reward value, referring to this as a "battle for the soul of American medicine."
Insurance reforms
The debate has involved certain insurance industry practices such as the placing of caps on coverage, the high level of co-pays even for essential services such as preventative procedures, the refusal of many insurers to cover pre-existing conditions or adding premium loading for these conditions, and practices which some people regard as egregious such as the additional loading of premiums for women, the regarding of having previously been assaulted by a partner as having a pre-existing condition, and even the cancellation of insurance policies on very flimsy grounds when a claimant who had paid in many premiums presents with a potentially expensive medical condition.Various legislative proposals under serious consideration propose fining larger employers who do not provide a minimum standard of health care insurance and mandating
Individual mandate
An individual mandate is a requirement by a government that certain individual citizens purchase or otherwise obtain a good or service.In the United States, the United States Congress has enacted two individual mandates, the first was never federally enforced, while the second is not scheduled to...
that people purchase private health care insurance. This is the first time that the Federal government has mandated people to buy insurance, although nearly all states in the union currently mandate the purchase of auto insurance. The legislation also taxes certain very high payout insurance policies (so-called "Cadillac policies") to help finance subsidies for poorer citizens. These will be offered on a sliding scale to people earning less than four times the federal poverty level to enable them to buy health insurance if they are not otherwise covered by their employer.
The issue of concentration of power by the insurance industry has also been a focus of debate as in many states very few large insurers dominate the market. Legislation which would provide a choice of a not-for-profit insurer modeled on Medicare but funded by insurance premiums has been a contentious issue. Much play has been made to changes to the Medicare Advantage scheme which will reduce public subsidies given to private insurance plans selling such plans by forcing insurers to compete and which it is estimated has increased the profitability of private insurance companies selling these products. No cuts are made to guaranteed coverage benefits in the bills before congress.
Certain proposals include a choice of a not-for-profit insurer modeled on Medicare (sometimes called the "government option"). Democratic legislators have largely supported the proposed reform efforts, while Republicans have criticized the government option or expanded regulation of healthcare.
The GAO
Gao
Gao is a town in eastern Mali on the River Niger lying ESE of Timbuktu. Situated on the left bank of the river at the junction with the Tilemsi valley, it is the capital of the Gao Region and had a population of 86,663 in 2009....
reported in 2002 (using 2000 data) that: "The median
Median
In probability theory and statistics, a median is described as the numerical value separating the higher half of a sample, a population, or a probability distribution, from the lower half. The median of a finite list of numbers can be found by arranging all the observations from lowest value to...
number of licensed carriers in the small group market per state was 28, with a range from 4 in Hawaii to 77 in Indiana. The median market share of the largest carrier was about 33 percent, with a range from about 14 percent in Texas to about 89 percent in North Dakota."
The GAO
Gao
Gao is a town in eastern Mali on the River Niger lying ESE of Timbuktu. Situated on the left bank of the river at the junction with the Tilemsi valley, it is the capital of the Gao Region and had a population of 86,663 in 2009....
reported in 2008 (using 2007 data for the most part) that: "The median number of licensed carriers in the small group market per state was 27. The median market share of the largest carrier in the small group market was about
47 percent, with a range from about 21 percent in Arizona to about 96 percent in Alabama. In 31 of the 39 states supplying market share information, the top carrier had a market share of a third or more. The five largest carriers in the small group market, when combined, represented three quarters or more of the market in 34 of the 39 states supplying this information, and they
represented 90 percent or more in 23 of these states....the median market share of all the BCBS carriers in 38 states reporting this information in 2008 was about 51 percent, compared to the 44 percent reported in 2005 and the 34 percent reported in 2002 for the 34 states supplying information in each of these years."
Tax reform
The Congressional Budget OfficeCongressional Budget Office
The Congressional Budget Office is a federal agency within the legislative branch of the United States government that provides economic data to Congress....
has also described how the tax treatment of insurance premiums may affect behavior:
In November 2009, The Economist
The Economist
The Economist is an English-language weekly news and international affairs publication owned by The Economist Newspaper Ltd. and edited in offices in the City of Westminster, London, England. Continuous publication began under founder James Wilson in September 1843...
estimated that taxing employer-provided health insurance (which is presently exempt from tax) would add $215 billion per year to federal tax revenue during the 2013-2014 periods. Peter Singer
Peter Singer
Peter Albert David Singer is an Australian philosopher who is the Ira W. DeCamp Professor of Bioethics at Princeton University and Laureate Professor at the Centre for Applied Philosophy and Public Ethics at the University of Melbourne...
wrote in the New York Times that the current exclusion of insurance premiums from compensation represents a $200 billion subsidy for the private insurance industry and that it would likely not exist without it. In other words, taxpayers might be more inclined to change behavior or the system itself if they were paying $200 billion more in taxes each year related to health insurance. To put this amount in perspective, the federal government collected $1,146 billion in income taxes in 2008, so $200 billion represents a 17.5% increase in the effective tax rate.
Independent advisory panels
President Obama has proposed an "Independent Medicare Advisory Panel" (IMAC) to make recommendations on Medicare reimbursement policy and other reforms. Comparative effectiveness research would be one of many tools used by the IMAC. The IMAC concept was endorsed in a letter from several prominent healthcare policy experts, as summarized by OMB Director Peter OrszagPeter Ország
Peter Ország is a Slovak ice hockey referee, who referees in the Slovak Extraliga.-Career:He has officiated many international tournaments including the Winter Olympics. He has been named Slovak referee of the year....
:
Both Mayo Clinic CEO Dr. Denis Cortese and Surgeon/Author Atul Gawande have argued that such panel(s) will be critical to reform of the delivery system and improving value. Washington Post columnist David Ignatius
David Ignatius
David R. Ignatius , is an American journalist and novelist. He is an associate editor and columnist for The Washington Post. He also co-hosts PostGlobal, an online discussion of international issues at Washingtonpost.com, with Newsweek 's Fareed Zakaria...
has also recommended that President Obama engage someone like Cortese to have a more active role in driving reform efforts.
Lowering obesity
Preventing obesity and overweight conditions presents a significant opportunity to reduce costs. The Centers for Disease Control reported that approximately 9% of healthcare costs in 1998 were attributable to overweight and obesity, or as much as $92.6 billion in 2002 dollars. Nearly half of these costs were paid for by the government via Medicare or Medicaid. However, by 2008 the CDC estimated these costs had nearly doubled to $147 billion. The CDC identified a series of expensive conditions more likely to occur due to obesity. The CDC released a series of strategies to prevent obesity and overweight, including: making healthy foods and beverages more available; supporting healthy food choices; encouraging kids to be more active; and creating safe communities to support physical activity. An estimated 25.6% of U.S. adults in 2007 were obese, versus 23.9% in 2005. State obesity rates ranged from 18.7% to 30%. Obesity rates were roughly equal among men and women. Some have proposed a so-called "fat taxFat tax
A fat tax is a tax or surcharge that is placed upon fattening foods, beverages or individuals. As an example of Pigovian taxation, a fat tax aims to discourage unhealthy diets and offset the economic costs of obesity....
" to provide incentives for healthier behavior, either by levying the tax on products (such as soft drinks) that are thought to contribute to obesity, or to individuals based on body measures, as is done in Japan.
Rationing of care
Healthcare rationingHealthcare rationing in the United States
Healthcare rationing in the United States exists in various forms. Access to private health insurance is rationed based on price and ability to pay. Those not able to afford a health insurance policy are unable to acquire one, and sometimes insurance companies pre-screen applicants for pre-existing...
may refer to the restriction of medical care service delivery based on any number of objective or subjective criteria. Republican Newt Gingrich
Newt Gingrich
Newton Leroy "Newt" Gingrich is a U.S. Republican Party politician who served as the House Minority Whip from 1989 to 1995 and as the 58th Speaker of the U.S. House of Representatives from 1995 to 1999....
argued that the reform plans supported by President Obama expand the control of government over healthcare decisions, which he referred to as a type of healthcare rationing. President Barack Obama
Barack Obama
Barack Hussein Obama II is the 44th and current President of the United States. He is the first African American to hold the office. Obama previously served as a United States Senator from Illinois, from January 2005 until he resigned following his victory in the 2008 presidential election.Born in...
has argued that U.S. healthcare is already rationed, based on income, type of employment, and medical pre-existing condition
Pre-existing condition
A pre-existing condition is a risk with extant causes that is not readily compensated by standard, affordable insurance premiums. Pre-existing condition exclusions by the insurance industry are meant to cope with adverse selection by potential customers. Such exclusions have become a topic in the...
s, with nearly 46 million uninsured. He argued that millions of Americans are denied coverage or face higher premiums as a result of medical pre-existing conditions.
Peter Singer
Peter Singer
Peter Albert David Singer is an Australian philosopher who is the Ira W. DeCamp Professor of Bioethics at Princeton University and Laureate Professor at the Centre for Applied Philosophy and Public Ethics at the University of Melbourne...
wrote in the New York Times in July 2009 that healthcare is rationed in the United States and argued for improved rationing processes:
According to PolitiFact, private health insurance companies already ration health care by income, by denying health insurance to those with pre-existing conditions and by caps on health insurance payments. Rationing exists now, and will continue to exist with or without health care reform. David Leonhardt
David Leonhardt
David Leonhardt is the Washington bureau chief of The New York Times. He joined The Times in 1999 and wrote the "Economics Scene" column, and for the Times Sunday Magazine. Before coming to The Times, he wrote for Business Week and The Washington Post...
also wrote in the New York Times in June 2009 that rationing is a part of economic reality: "The choice isn’t between rationing and not rationing. It’s between rationing well and rationing badly. Given that the United States devotes far more of its economy to health care than other rich countries, and gets worse results by many measures, it’s hard to argue that we are now rationing very rationally."
Palin's death panel
Death panel
"Death panel", , is a term that originated during a 2009 political debate regarding health care reform in the United States. The death panel claim portrayed the health care bills then pending before the U.S. Congress as encouraging euthanasia for the elderly and as rationing health care for the...
remarks were based on the ideas of Betsy McCaughey. During 2009, former Alaska Governor Sarah Palin
Sarah Palin
Sarah Louise Palin is an American politician, commentator and author. As the Republican Party nominee for Vice President in the 2008 presidential election, she was the first Alaskan on the national ticket of a major party and first Republican woman nominated for the vice-presidency.She was...
wrote against alleged rationing, referring to what by her interpretation was a "downright evil" "death panel" in current reform legislation known as H.R. 3200 Section 1233. However, Palin supported similar end of life discussion and advance directives for patients in 2008. Defenders of the plan indicated that the proposed legislation H.R. 3200 would allow Medicare for the first time to cover patient-doctor consultations about end-of-life planning, including discussions about drawing up a living will or planning hospice treatment. Patients could seek out such advice on their own, but would not be required to. The provision would limit Medicare coverage to one consultation every five years. Rep. Earl Blumenauer
Earl Blumenauer
Earl Blumenauer is the U.S. Representative for , serving since 1996. He is a member of the Democratic Party. The district includes most of Portland east of the Willamette River. A native of Portland, he previously spent over 20 years as a public official representing the city.-Early...
, D-Ore., who sponsored the H.R. 3200 end of life counseling provision, said the measure would block funds for counseling that presents suicide or assisted suicide as an option, and called references to death panels or euthanasia "mind-numbing". Republican Senator Johnny Isakson
Johnny Isakson
John Hardy "Johnny" Isakson is the junior United States Senator from Georgia and a member of the Republican Party. Previously, he represented in the House....
, who co-sponsored a 2007 end-of-life counseling provision, called the euthanasia claim "nuts". Analysts who examined the end-of-life provision Palin cited agree that Palin's claim is incorrect. According to TIME and ABC, Palin and Betsy McCaughey made false euthanasia claims.
The federal requirement that hospitals help patients with things like living wills
began when Republican George H. W. Bush
George H. W. Bush
George Herbert Walker Bush is an American politician who served as the 41st President of the United States . He had previously served as the 43rd Vice President of the United States , a congressman, an ambassador, and Director of Central Intelligence.Bush was born in Milton, Massachusetts, to...
was President. Section 1233 merely allows doctors to be paid for their time. However, an NBC poll indicates that as of August, 2009, 45% of Americans believed in the death panel story.
Slate
Slate (magazine)
Slate is a US-based English language online current affairs and culture magazine created in 1996 by former New Republic editor Michael Kinsley, initially under the ownership of Microsoft as part of MSN. On 21 December 2004 it was purchased by the Washington Post Company...
columnist Christopher Beam used the term "deathers" to refer to those who believed rationing and euthanasia would become likely for senior citizens. The Rachel Maddow
Rachel Maddow
Rachel Anne Maddow is an American television host and political commentator. Maddow hosts a nightly television show, The Rachel Maddow Show, on MSNBC. Her syndicated talk radio program, The Rachel Maddow Show, aired on Air America Radio...
Show aired a program called "Obama and the Deathers" in which Maddow discussed conspiracy theories that included "a secret plot to kill old people." Daily Kos
Daily Kos
Daily Kos is an American political blog that publishes news and opinions from a progressive point of view. It functions as a discussion forum and group blog for a variety of netroots activists, whose efforts are primarily directed toward influencing and strengthening the Democratic Party...
and other web sites had used the term for about a week before Hari Sevugan
Hari Sevugan
Hari Sevugan is the former national press secretary for the Democratic National Committee. He served as the senior spokesman for the Barack Obama presidential campaign. In June, 2011, Sevugal left his position with the DNC to become the Vice President of Communications for StudentsFirst, an...
, national spokesman for the Democratic National Committee
Democratic National Committee
The Democratic National Committee is the principal organization governing the United States Democratic Party on a day to day basis. While it is responsible for overseeing the process of writing a platform every four years, the DNC's central focus is on campaign and political activity in support...
, sent out an email with the subject line "Murkowski: Deathers 'Lying' 'Inciting Fear.'" The message included an article about a town hall
Town hall meeting
A town hall meeting is an American English term given to an informal public meeting. Everybody in a town community is invited to attend, not always to voice their opinions, but to hear the responses from public figures and elected officials about shared subjects of interest. Attendees rarely voted...
statement by Senator
United States Senate
The United States Senate is the upper house of the bicameral legislature of the United States, and together with the United States House of Representatives comprises the United States Congress. The composition and powers of the Senate are established in Article One of the U.S. Constitution. Each...
Lisa Murkowski
Lisa Murkowski
Lisa Ann Murkowski is the senior U.S. Senator from the State of Alaska and a member of the Republican Party. She was appointed to the Senate in 2002 by her father, Governor Frank Murkowski. After losing a Republican primary in 2010, she became the second person ever to win a U.S...
, a Republican
Republican Party (United States)
The Republican Party is one of the two major contemporary political parties in the United States, along with the Democratic Party. Founded by anti-slavery expansion activists in 1854, it is often called the GOP . The party's platform generally reflects American conservatism in the U.S...
from Alaska
Alaska
Alaska is the largest state in the United States by area. It is situated in the northwest extremity of the North American continent, with Canada to the east, the Arctic Ocean to the north, and the Pacific Ocean to the west and south, with Russia further west across the Bering Strait...
, that no version of health care reform included "death panels".
Sevugan explained the term "deathers" to Patricia Murphy, who writes a Politics Daily
Politics Daily
Politics Daily was an American political journalism web site launched by AOL News in April 2009. It described itself as a "political news magazine for the general reader."Melinda Henneberger, a former Newsweek and New York Times reporter,...
column called "The Capitolist":
By "deather," I mean an opponent of change who is knowingly spreading false information regarding the existence of an alleged "death panel" in health insurance reform plans despite the fact the claim has been repeatedly and unequivocally debunked by independent fact-checking organizations. Like "birthers," "deathers" are shamefully lying and trafficking in scurrilous rumors to incite fear and achieve their stated political objective of derailing the president of the United States.
Others, such as former Republican Secretary of Commerce Peter G. Peterson
Peter George Peterson
Peter G. Peterson is an American businessman, investment banker, fiscal conservative, author, and politician whose most prominent political position was as United States Secretary of Commerce from February 29, 1972, to February 1, 1973 under Richard Nixon. He is most well known currently as...
, have indicated that some form of rationing is inevitable and desirable considering the state of U.S. finances and the trillions of dollars of unfunded Medicare liabilities. He estimated that 25-33% of healthcare services are provided to those in the last months or year of life and advocated restrictions in cases where quality of life cannot be improved. He also recommended that a budget be established for government healthcare expenses, through establishing spending caps and pay-as-you-go rules that require tax increases for any incremental spending. He has indicated that a combination of tax increases and spending cuts will be required. All of these issues would be addressed under the aegis of a fiscal reform commission.
Medical malpractice costs and limits on redress (tort)
Critics have argued that medical malpracticeMedical malpractice
Medical malpractice is professional negligence by act or omission by a health care provider in which the treatment provided falls below the accepted standard of practice in the medical community and causes injury or death to the patient, with most cases involving medical error. Standards and...
costs are significant and should be addressed via tort reform
Tort reform
Tort reform refers to proposed changes in common law civil justice systems that would reduce tort litigation or damages. Tort actions are civil common law claims first created in the English commonwealth system as a non-legislative means for compensating wrongs and harm done by one party to...
. At the same time, a Hearst Newspapers investigation concluded that up to 200,000 people per year die from medical errors and infections in the United States. None of the three major bills under consideration lower recoverable damages in tort
Tort
A tort, in common law jurisdictions, is a wrong that involves a breach of a civil duty owed to someone else. It is differentiated from a crime, which involves a breach of a duty owed to society in general...
suits. Medical malpractice, such as doctor errors resulting in harm to patients, has several direct and indirect costs:
- jury awards to injured;
- workers' compensationWorkers' compensationWorkers' compensation is a form of insurance providing wage replacement and medical benefits to employees injured in the course of employment in exchange for mandatory relinquishment of the employee's right to sue his or her employer for the tort of negligence...
; - reduced worker productivity as a result of injury;
- pain and suffering of the injured;
How much these costs are is a matter of debate. Some have argued that malpractice
Malpractice
In law, malpractice is a type of negligence in, which the professional under a duty to act, fails to follow generally accepted professional standards, and that breach of duty is the proximate cause of injury to a plaintiff who suffers harm...
lawsuits are a major driver of medical costs. However, the direct cost of malpractice suits amounts to only about 0.5% of all healthcare spending, and a 2006 Harvard study showed that over 90% of the malpractice suits examined contained evidence of injury to the patient and that frivolous suits were generally readily dismissed
Involuntary dismissal
Involuntary dismissal is the termination of a court case despite the plaintiff's objection.In United States Federal courts, involuntary dismissal is governed by Federal Rules of Civil Procedure Rule 41....
by the courts. A 2005 study estimated the cost around 0.2%, and in 2009 insurer WellPoint Inc. said "liability wasn’t driving premiums." Counting both direct and indirect costs, other studies estimate the total cost of malpractice "is linked to" between 5% and 10% of total U.S. medical costs. A 2004 report by the Congressional Budget Office
Congressional Budget Office
The Congressional Budget Office is a federal agency within the legislative branch of the United States government that provides economic data to Congress....
put medical malpractice costs at 2% of U.S. health spending and "even significant reductions" would do little to reduce the growth of health-care expenses.
Conservative columnist Charles Krauthammer
Charles Krauthammer
Charles Krauthammer, MD is an American Pulitzer Prize–winning syndicated columnist, political commentator, and physician. His weekly column appears in The Washington Post and is syndicated to more than 275 newspapers and media outlets. He is a contributing editor to the Weekly Standard and The New...
argued that between $60–200 billion per year could be saved through tort reform. Physician and former Democratic National Committee Chairman Howard Dean
Howard Dean
Howard Brush Dean III is an American politician and physician from Vermont. He served six terms as the 79th Governor of Vermont and ran unsuccessfully for the 2004 Democratic presidential nomination. He was chairman of the Democratic National Committee from 2005 to 2009. Although his U.S...
explained why tort reform is not part of the bills under consideration: "When you go to pass a really enormous bill like that, the more stuff you put it in it, the more enemies you make, right?...And the reason tort reform is not on the bill is because the people who wrote it did not want to take on the trial lawyers in addition to everybody else they were taking on. That is the plain and simple truth."
However, even successful tort reform might not lead to lower aggregate liability: for example, medical commentators have argued that the current contingent fee system skews litigation towards high-value cases while ignoring meritorious small cases; aligning litigation more closely with merit might thus increase the number of small awards, offsetting any reduction in large awards. A New York study found that only 1.5% of hospital negligence led to claims; moreover, the CBO observed that "health care providers are generally not exposed to the financial cost of their own malpractice risk because they carry liability insurance, and the premiums for that insurance do not reflect the records or practice styles of individual providers but more-general factors such as location and medical specialty." Given that total liability is small relative to the amount doctors pay in malpractice insurance premiums, alternative mechanisms have been proposed to reform malpractice insurance.
Addressing the shortage of doctors, nurses and hospital capacity
The U.S. is facing shortages of doctors and nurses that are projected to grow worse as America ages, which may drive up the price of these services. Writing in the Washington Post, cardiologist Arthur Feldman cited various studies that indicate the U.S. is facing a "critical" shortage of doctors, including an estimated 1,300 general surgeons by 2010.The American Academy of Family Physicians predicts a shortage of 40,000 primary care doctors (including family practice, internal medicine, pediatrics and obstetrics/gynecology) by 2020. The number of medical students choosing the primary care specialty has dropped by 52% since 1997. Currently, only 2% of medical school graduates choose primary care as a career. An amendment to the Senate health bill includes $2 billion in funds over 10 years to create 2,000 new residency training slots geared toward primary care medicine and general surgery. Writing in Forbes, a physician argued that this is a "tiny band-aid at best," advocating full loan repayments and guaranteed positions upon graduation.
The U.S. had 2.3 doctors per 1,000 people in 2002, ranking 52nd. Germany and France had approximately 3.4 and ranked in the top 25. The OECD average in 2008 was 3.1 doctors per 1,000 people, while the U.S. had 2.4.
The American Association of Colleges of Nurses cited studies estimating that a shortage of registered nurses would reach 230,000 by 2025 as America ages, with over 135,000 open positions during 2007. An additional 30% more nurses would have to graduate annually to keep up with demand. A study by Price Waterhouse advanced several strategies for addressing the nursing shortage, including developing more public-private partnerships, federal and state-level grants for nursing students and educators, creating healthy work environments, using technology as a training tool, and designing more flexible roles for advanced practice nurses given their increased use as primary care providers.
In addition, the U.S. also does not measure favorably vs. OECD countries in terms of acute care hospital beds. Only four OECD countries have fewer acute care hospital beds per capita than the U.S, which has 2.7 per 1,000 population versus an OECD average of 3.8. Japan has 8.2 acute care beds per 1,000 population.
Addressing Medicare fraud
The Office of Management and Budget reported that $54 billion in "improper payments" were made to Medicare ($24B), Medicaid ($18B) and Medicaid Advantage ($12B) during FY 2009. This was 9.4% of the $573 billion spent in these categories. The Government Accountability OfficeGovernment Accountability Office
The Government Accountability Office is the audit, evaluation, and investigative arm of the United States Congress. It is located in the legislative branch of the United States government.-History:...
lists Medicare as a "high-risk" government program due to its vulnerability to improper payments. Fewer than 5% of Medicare claims are audited. Medicare fraud accounts for an estimated $60 billion in Medicare payments each year, and "has become one of, if not the most profitable, crimes in America." Criminals set up phony companies, then invoice Medicare for fraudulent services provided to valid Medicare patients who never receive the services. These costs appear on the Medicare statements provided to Medicare card holders. The program pays out over $430 billion per year via over 1 billion claims, making enforcement challenging. Its enforcement budget is "extremely limited" according to one Medicare official. U.S. Attorney General Eric Holder
Eric Holder
Eric Himpton Holder, Jr. is the 82nd and current Attorney General of the United States and the first African American to hold the position, serving under President Barack Obama....
said in an interview: "Clearly more auditing needs to be done and it needs to be done in real time." The Obama administration is providing Medicare with an additional $200 million to fight fraud as part of its stimulus package, and billions of dollars to computerize medical records and upgrade networks, which should assist Medicare in identifying fraudulent claims.
Single-payer payment system
Although studies indicate that Democrats tend to be more supportive of a single-payer health care system than are Republicans, none of the reform bills that were debated in the US Congress when it had a Democratic party majority from 2007 to 2010 included any proposals to implement a single payer health care system. In a single payer system the government or a government regulated non-profit agency channels health care payments to collect premiums and settle the bills of medical providers instead of for-profit insurance companies. Many countries use single-payer systems to cover all their citizens.The over 1,300 U.S. health insurance companies have different forms and processes for billing and reimbursement, requiring enormous costs on the part of service providers (mainly doctors and hospitals) to process payments. For example, the Cleveland Clinic, considered a low-cost, best-practices hospital system, has 1,400 billing clerks to support 2,000 doctors. Further, the insurance companies have their own overhead functions and profit margins, much of which could be eliminated with a single payer system. Economist Paul Krugman estimated in 2005 that converting from the current private insurance system to a single-payer system would enable $200 billion per year in cost savings, primarily via insurance company overhead. One advocacy group estimated savings as high as $400 billion annually for 2009 and beyond.
The US system is often compared with that of its northern neighbor, Canada (see Canadian and American health care systems compared
Canadian and American health care systems compared
Comparison of the health care systems in Canada and the United States are often made by government, public health and public policy analysts. The two countries had similar health care systems before Canada reformed its system in the 1960s and 1970s. The United States spends much more money on...
). Canada's system is largely publicly funded. In 2006, Americans spent an estimated US$6,714 per capita on health care, while Canadians spent US$3,678. This amounted to 15.3% of US GDP in that year, while Canada spent 10.0% of GDP on health care. A study by Harvard Medical School and the Canadian Institute for Health Information determined that some 31% of US health care dollars, or more than $1,000 per person per year, went to health care administrative costs.
Advocates argue that shifting the US to a single-payer health care system would provide universal coverage, give patients free choice of providers and hospitals, and guarantee comprehensive coverage and equal access for all medically necessary procedures, without increasing overall spending. Shifting to a single-payer system would also eliminate oversight by managed care reviewers, restoring the traditional doctor-patient relationship.
Advocates argue that the largest obstacle to single-payer, universal system in the U.S. is a lack of political will.
Privatize Medicare with a voucher system
Rep. Paul RyanPaul Ryan (politician)
Paul Davis Ryan is the U.S. Representative for , serving since 1999. He is a member of the Republican Party and has been ranked among the party's most influential voices on economic policy....
(R) has proposed the Roadmap for America's Future, which is a series of budgetary reforms. His January 2010 version of the plan includes the transition of Medicare to a voucher system, meaning individuals would receive a voucher which could be used to purchase health insurance in the private market. This would not affect those near retirement or currently enrolled. A series of graphs and charts summarizing the impact of the plan are included. Economists have both praised and criticized particular features of the plan. The CBO also partially scored the bill.
Congressional Proposals for Health Care Reform
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
Affordable Health Care for America Act
The Affordable Health Care for America Act was a bill that was crafted by the United States House of Representatives in November 2009. At the encouragement of the Obama administration, the 111th Congress devoted much of its time to enacting reform of the United States' health care system...
, 220-215.
On December 24, 2009 the Senate passed the Patient Protection and Affordable Care Act
Patient Protection and Affordable Care Act
The Patient Protection and Affordable Care Act is a United States federal statute signed into law by President Barack Obama on March 23, 2010. The law is the principal health care reform legislation of the 111th United States Congress...
.
Republicans continue to claim that they had a workable bill to extend coverage to all Americans and not cost the taxpayer a singe penny. The Empowering Patients First Act
Empowering Patients First Act
The Empowering Patients First Act of 2009 is legislation proposed in the United States Congress during the 1st Session of the 111th Congress as a Republican alternative to the America's Affordable Health Choices Act of 2009 The Empowering Patients First Act of 2009 (H.R. 3400, introduced July 30,...
which was proposed as a replacing amendment to the Senate Bill during the bill mark-up. However, this alternative bill was rejected by the Senate Finance Committee. The Congressional Budget Office said that it would not reduce the percentage of working age people who do not have insurance over the next 10 years, and that it estimated it would encourage health insurers to reduce rather than increase insurance coverage as it would remove mandated coverage rules that currently apply in some states. This bill would have given the insurance industry greater access to government funds through new insurance subsidies. It does not have any taxation provisions and though it would reduce the deficit over 10 years by $18 billion, this is a considerably smaller deficit reduction than either the House or the Senate bills.
| Financing | Places a 5.4% surtax Surtax A surtax may be a tax levied upon a tax, or a tax levied upon income.-United Kingdom:In 1929, Supertax was renamed Sur-tax... on incomes over $500,000 for individuals and $1,000,000 for families. |
Increases the Medicare payroll tax from 1.45% to 2.35% on incomes over $200,000 for individuals and $250,000 for families. | ||
|---|---|---|---|---|
| Abortion | Insurance companies that accept federal subsidies will not be allowed to cover abortion. | Insurance companies that participate in the newly-created exchanges will be permitted to include abortion coverage, but a separate check must be written to the participating insurance company. Each state will have the option to prevent federal money from funding abortions in their insurance exchanges. | ||
| Public Option Public health insurance option The public health insurance option is a proposed government-run health insurance agency which competes with other health insurance companies. It is not the same as Publicly-funded health care. Called the public insurance option or public option, for short, it was a proposed health insurance plan... |
yes | 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. | ||
| 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. | Each state will create its own insurance exchange under federal guidelines. | ||
| Medicaid Eligibility | Expanded to 150% of the federal poverty level | Expanded to 133% of the federal poverty level | ||
| 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 Congressional Budget Office The Congressional Budget Office is a federal agency within the legislative branch of the United States government that provides economic data to Congress.... Cost Estimate |
$1,050 billion dollars over 10 years. Deficit would be reduced a total of $138 billion 2010-2019 after tax receipts and cost reductions. | $871 billion dollars over 10 years. Deficit would be reduced a total of $132 billion 2010-2019 after tax receipts and cost reductions. | ||
| Takes effect | 2013 | 2014 |
Similarities between the House and Senate Bills
The two bills are similar in a number of ways. In particular, both bills:- Mandate minimum health insurance benefits for most Americans
- Remove insurer set annual and lifetime caps on coverage and limit co-pay amounts
- Remove co-pays on certain services such as health screenings and some vaccinations
- Impose a new excise tax on medical devices and drugs, including vaccines (the federal government began taxing vaccines in 1987).
- Establish health insurance exchangeHealth insurance exchangeA health insurance exchange is a set of state-regulated and standardized health care plans in the United States, from which individuals may purchase health insurance that is eligible for Federal subsidies...
s making easier price and coverage comparisons and purchasing for people and small businesses buying health care coverage - Prevent insurers selling in the exchange insurance policies that do not meet minimum coverage standards
- Prevent insurers from denying coverage to people with pre-existing health conditions
- Prevent sex discrimination by insurers (especially the current discrimination against women) in setting premiums
- Limit age discrimination by insurers when setting policy premiums
- Restrict the ability of insurers to rescind policies they have been collecting premiums on
- Require insurers to cover adult children up to their mid twenties as part of family coverage
- Expand Medicaid eligibility up the income ladder (to 133% of the poverty line in the Senate bill and 150% in the House bill)
- 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 have health insurance (except American Indians (currently covered by the Indian Health Service), people with religious objections and people who can show financial hardship)
- Provide health insurance assistance subsidies for those earning up to 400% of the federal poverty level that must buy insurance for themselves
- Offer a new voluntary long-term care insurance program
- Pay for new spending, in part, through cutting over-generous funding (under existing law) given to private insurers that sell privatised health care plans to seniors (so called Medicare Advantage plans), slowing the growth of Medicare provider payments , reducing Medicare and Medicaid drug prices , cutting other Medicare and Medicaid spending through better reward structures, and raising taxes on very generous health care packages (typically offered to senior executives) and penalties on larger firms not providing their employees with health care coverage and certain persons who do not buy health insurance.
- Impose a $2,500 limit on contributions to a flexible spending account (FSAs), pre-tax health benefits, to pay for health care reform costs.
Differences in the House and Senate Bills
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 'CadillacCadillac insurance plan
A Cadillac plan is an informal term for any unusually expensive health insurance plan, usually arising in discussions of medical-cost control measures in the United States. The term derives from the Cadillac automobile, which has represented American luxury since its introduction in 1902, and as a...
' insurance plans, as well as an increase in the Medicare payroll tax for high earners.
Most 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. In contrast, the House bill's insurance mandate
Health insurance mandate
A health insurance mandate is either an employer or individual mandate to obtain private health insurance, instead of a National Health Service or National Health Insurance.-United States:...
has been described as "an economic assault on the young" by, for example, Robert J. Samuelson
Robert J. Samuelson
Robert Jacob Samuelson is a contributing editor of Newsweek and The Washington Post where he has written about business and economic issues since 1977. His columns appear in both publications. His articles also appear in the Los Angeles Times, The Boston Globe, and other influential newspapers...
for The Washington Post
The Washington Post
The Washington Post is Washington, D.C.'s largest newspaper and its oldest still-existing paper, founded in 1877. Located in the capital of the United States, The Post has a particular emphasis on national politics. D.C., Maryland, and Virginia editions are printed for daily circulation...
.
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.
Services marketed as preventive care are a subject of continuing debate. Years of study
Evidence-based medicine
Evidence-based medicine or evidence-based practice aims to apply the best available evidence gained from the scientific method to clinical decision making. It seeks to assess the strength of evidence of the risks and benefits of treatments and diagnostic tests...
have shown that most common services provide no benefit to patients. The House and Senate bills would mandate the purchase of policies that pay 100% of the cost of certain services, with no co-pay; when the Senate bill was amended to mandate paying for tests that a federal panel
U.S. Preventive Services Task Force
The U.S. Preventive Services Task Force is "an independent panel of experts in primary care and prevention that systematically reviews the evidence of effectiveness and develops recommendations for clinical preventive services." The task force, a panel of primary care physicians and...
and U.S. News & World Report
U.S. News & World Report
U.S. News & World Report is an American news magazine published from Washington, D.C. Along with Time and Newsweek it was for many years a leading news weekly, focusing more than its counterparts on political, economic, health and education stories...
said "do more harm than good," The New York Times
The New York Times
The New York Times is an American daily newspaper founded and continuously published in New York City since 1851. The New York Times has won 106 Pulitzer Prizes, the most of any news organization...
wrote, "This sorry episode does not bode well for reform efforts to rein in spending on other procedures based on sound scientific evidence of their potential benefits and risks for patients."
Differences in how each chamber determines subsidies
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
Kaiser Family Foundation
The Henry J. Kaiser Family Foundation , or just Kaiser Family Foundation, is a U.S.-based non-profit, private operating foundation headquartered in Menlo Park, California. It focuses on the major health care issues facing the nation, as well as the U.S. role in global health policy...
'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 a family 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 bill would differ, somewhat, in their overall impact. The Senate bill would cover an additional 31 million people, at a federal budget cost of nearly $850 billion (not counting unfunded mandates) 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.
Commentary on the cost analysis
It is worth noting that both bills rely on a number of "gimmicks" to get their favorable deficit reduction numbers. For example, both institute a public long-term care insurance known as the CLASS Act - because this insurance has a 5-year vesting period, it will appear to raise revenue in the first decade, even though all the money will need to be paid back. If the CLASS Act is subtracted from the bills, the Senate bill would reduce the deficit by $57 billion over ten years, and the House by $37 billion. In addition to the CLASS Act, neither bill accounts for the costs of updating Medicare physician payments, even though the House did so on a deficit-financed basis shortly after passing their health care bill.The Senate bill also begins most provisions a year later than the House bill in order to make costs seem smaller:
Surgeon Atul Gawande
Atul Gawande
Atul Gawande is an American physician and journalist. He serves as a general and endocrine surgeon at Brigham and Women's Hospital in Boston, Massachusetts and associate director of their Center for Surgery and Public Health...
wrote in The New Yorker
The New Yorker
The New Yorker is an American magazine of reportage, commentary, criticism, essays, fiction, satire, cartoons and poetry published by Condé Nast...
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.
Lobbying
The health and insurance sectors gave nearly $170 million to House and Senate members in 2007 and 2008, with 54% going to Democrats, according to data compiled by the Center for Responsive PoliticsCenter for Responsive Politics
The Center for Responsive Politics is a non-profit, nonpartisan research group based in Washington, D.C. that tracks money in politics and the effect of money and lobbying activity on elections and public policy and maintains a public online database of its information.Their database...
. The shift in parties was even more pronounced during the first three months of 2009, when Democrats collected 60% of the $5.4 million donated by health-care companies and their employees, the data show. Lawmakers that chair key committees have been leading recipients, some of whom received over $1.0 million in contributions.
Matt Taibbi
Matt Taibbi
Matthew C. "Matt" Taibbi is an American author and journalist reporting on politics, media, finance, and sports for Rolling Stone and Men's Journal, often in a polemical style. He has also edited and written for The eXile, the New York Press, and The Beast.- Early years :Taibbi grew up in the...
wrote in Rolling Stone
Rolling Stone
Rolling Stone is a US-based magazine devoted to music, liberal politics, and popular culture that is published every two weeks. Rolling Stone was founded in San Francisco in 1967 by Jann Wenner and music critic Ralph J...
that President Obama and key senators who have advocated single-payer systems in the past are unwilling to face the insurance companies and their powerful lobbying efforts. Key politicians on the Senate Finance Committee involved in crafting legislation have received over $2 million in campaign contributions from the healthcare industry. Several of the firms invited to testify at the hearings sent lobbyists that had formerly worked for Senator Max Baucus
Max Baucus
Max Sieben Baucus is the senior United States Senator from Montana and a member of the Democratic Party. First elected to the Senate in 1978, as of 2010 he is the longest-serving Senator from Montana, and the fifth longest-serving U.S...
, the chair of the committee. Mr. Baucus stated in February 2009 that: "There may come a time when we can push for single-payer. At this time, it's not going to get to first base in Congress."
George McGovern
George McGovern
George Stanley McGovern is an historian, author, and former U.S. Representative, U.S. Senator, and the Democratic Party nominee in the 1972 presidential election....
wrote that significant campaign funds were given to the chairman and ranking minority member of the Senate Finance Committee, which has jurisdiction over health-care legislation: "Chairman Max Baucus of Montana, a Democrat, and his political action committee have received nearly $4 million from the health-care lobby since 2003. The ranking Republican, Charles Grassley of Iowa, has received more than $2 million. It's a mistake for one politician to judge the personal motives of another. But Sens. Baucus and Grassley are firm opponents of the single-payer system, as are other highly placed members of Congress who have been generously rewarded by the insurance lobby."
Debate about political organizing methods
Much of the coverage of the debate has involved how the different sides are competing to express their views, rather than the specific reform proposals. The health care reform debate in the United States has been influenced by the Tea Party protest phenomenon, with reporters and politicians spending time reacting to it. Supporters of a greater government role in healthcare, such as former insurance PRPublic relations
Public relations is the actions of a corporation, store, government, individual, etc., in promoting goodwill between itself and the public, the community, employees, customers, etc....
executive Wendell Potter
Wendell Potter
Wendell Potter is former Vice President of corporate communications at CIGNA, one of the United States' largest health insurance companies. In June 2009, he testified against the HMO industry in the U.S. Senate as a whistleblower....
of the Center for Media and Democracy
Center for Media and Democracy
The Center for Media and Democracy is a non-profit investigative reporting group. The CMD gives analysis and opinion on policies such as the economy, environment and national security...
- whose funding comes from groups such as the Tides Foundation- argue that the hyperbole generated by this phenomenon is a form of corporate astroturfing
Astroturfing
Astroturfing is a form of advocacy in support of a political, organizational, or corporate agenda, designed to give the appearance of a "grassroots" movement. The goal of such campaigns is to disguise the efforts of a political and/or commercial entity as an independent public reaction to some...
, which he says that he used to write for CIGNA
CIGNA
Cigna , headquartered in Bloomfield, Connecticut, is a global health services company, owing to its expanding international footprint and the fact that it provides administrative services only to approximately 80 percent of its clients...
. Opponents of more government involvement, such as Phil Kerpen of Americans for Prosperity
Americans for Prosperity
Americans for Prosperity is a Washington, D.C.–based political advocacy group. According to their literature, they promote economic policy that supports business, and restrains regulation by government...
- whose funding comes mainly from the Koch Industries
Koch Industries
Koch Industries, Inc. , is an American private energy conglomerate based in Wichita, Kansas, with subsidiaries involved in manufacturing, trading and investments. Koch also owns Invista, Georgia-Pacific, Flint Hills Resources, Koch Pipeline, Koch Fertilizer, Koch Minerals and Matador Cattle Company...
corporation- counter-argue that those corporations oppose a public-plan
Publicly-funded health care
Publicly funded health care is a form of health care financing designed to meet the cost of all or most health care needs from a publicly managed fund. Usually this is under some form of democratic accountability, the right of access to which are set down in rules applying to the whole population...
, but some try to push for government actions that will unfairly benefit them, such as forcing private companies to buy health insurance for their employees. Journalist Ben Smith
Ben Smith (journalist)
Ben Smith is an American political journalist and blogger for the news outlet Politico, which was frequently cited during the 2008 presidential election. He formerly wrote for the Wall Street Journal Europe, the New York Sun, the New York Observer and wrote a political column for the New York Daily...
has referred to mid-2009 as "The Summer of Astroturf" given the organizing and co-ordinating efforts made by various groups on both pro- and anti-reform sides.
Liberal arguments
Some have argued that health care is a fundamental human right. Article 25 of the Universal Declaration of Human RightsUniversal Declaration of Human Rights
The Universal Declaration of Human Rights is a declaration adopted by the United Nations General Assembly . The Declaration arose directly from the experience of the Second World War and represents the first global expression of rights to which all human beings are inherently entitled...
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." Similarly, Franklin D. Roosevelt
Franklin D. Roosevelt
Franklin Delano Roosevelt , also known by his initials, FDR, was the 32nd President of the United States and a central figure in world events during the mid-20th century, leading the United States during a time of worldwide economic crisis and world war...
advocated a right to medical care in his 1944 proposal for a Second Bill of Rights
Second Bill of Rights
The Second Bill of Rights was a list of rights proposed by Franklin D. Roosevelt, the then President of the United States, during his State of the Union Address on January 11, 1944. In his address Roosevelt suggested that the nation had come to recognize, and should now implement, a second "bill...
.
Liberals were the primary advocates of both Social Security
Social Security (United States)
In the United States, Social Security refers to the federal Old-Age, Survivors, and Disability Insurance program.The original Social Security Act and the current version of the Act, as amended encompass several social welfare and social insurance programs...
and Medicare
Medicare (United States)
Medicare is a social insurance program administered by the United States government, providing health insurance coverage to people who are aged 65 and over; to those who are under 65 and are permanently physically disabled or who have a congenital physical disability; or to those who meet other...
, which are often targeted as significant expansions of government that has overwhelming satisfaction among beneficiaries. President Obama argued during a September 2009 joint session of Congress that the government has a moral responsibility to ensure quality healthcare is available to all citizens. He also referred to a letter from the late Senator Ted Kennedy
Ted Kennedy
Edward Moore "Ted" Kennedy was a United States Senator from Massachusetts and a member of the Democratic Party. Serving almost 47 years, he was the second most senior member of the Senate when he died and is the fourth-longest-serving senator in United States history...
.
Economist and New York Times columnist Paul Krugman
Paul Krugman
Paul Robin Krugman is an American economist, professor of Economics and International Affairs at the Woodrow Wilson School of Public and International Affairs at Princeton University, Centenary Professor at the London School of Economics, and an op-ed columnist for The New York Times...
has argued that Republican and conservative strategies in opposing healthcare are based on spite: "At this point, the guiding principle of one of our nation’s two great political parties is spite pure and simple. If Republicans think something might be good for the president, they’re against it — whether or not it’s good for America." He argued that Republican opposition to Medicare savings proposed by the President is "utterly at odds both with the party’s traditions and with what conservatives claim to believe. Think about just how bizarre it is for Republicans to position themselves as the defenders of unrestricted Medicare spending. First of all, the modern G.O.P. considers itself the party of Ronald Reagan — and Reagan was a fierce opponent of Medicare’s creation, warning that it would destroy American freedom. (Honest.) In the 1990s, Newt Gingrich tried to force drastic cuts in Medicare financing. And in recent years, Republicans have repeatedly decried the growth in entitlement spending — growth that is largely driven by rising health care costs." More recently he urged the House of representatives to pass the Senate's bill, which he called "centrist."
Conservative arguments
Conservatives have historically argued for a lesser role of government in healthcare. For example, Conservative GOP columnist Bill Kristol advocated several free-market reforms instead of the Clinton plan during the 1993-1994 period. He also argued that the results of the debate would have important ideological and political ramifications:- "...[T]he long-term political effects of a successful... health care bill will be even worse — much worse... It will revive the reputation of... Democrats as the generous protector of middle-class interests. And it will at the same time strike a punishing blow against Republican claims to defend the middle class..."
During the 2009 reform debate, Sen. Jim DeMint, R-S.C. opined in July, 2009:
- "If we're able to stop Obama on this, it will be his Waterloo. It will break him."
Investigative reporter and columnist John Stossel
John Stossel
John F. Stossel is an American consumer reporter, investigative journalist, author and libertarian columnist. In October 2009 Stossel left his long time home on ABC News to join the Fox Business Channel and Fox News Channel, both owned and operated by News Corp...
has remarked that "Insurance invites waste. That's a reason health care costs so much, and is often so consumer-unfriendly. In the few areas where there are free markets in health care -- such as cosmetic medicine and Lasik eye surgery -- customer service is great, and prices continue to drop." Republican Senator and medical doctor Tom Coburn
Tom Coburn
Thomas Allen "Tom" Coburn, M.D. , is an American politician, medical doctor, and Southern Baptist deacon. A member of the Republican Party, he currently serves as the junior U.S. Senator from Oklahoma. In the Senate, he is known as "Dr. No" for his tendency to place holds on and vote against bills...
has stated that the healthcare system in Switzerland
Switzerland
Switzerland name of one of the Swiss cantons. ; ; ; or ), in its full name the Swiss Confederation , is a federal republic consisting of 26 cantons, with Bern as the seat of the federal authorities. The country is situated in Western Europe,Or Central Europe depending on the definition....
should serve as a model for U.S. reform. He wrote for New York Sun
New York Sun
The New York Sun was a weekday daily newspaper published in New York City from 2002 to 2008. When it debuted on April 16, 2002, adopting the name, motto, and masthead of an otherwise unrelated earlier New York paper, The Sun , it became the first general-interest broadsheet newspaper to be started...
that reform should involve a market-based method transferring health care tax benefits to individuals rather than employers as well as giving individuals extra tax credits to afford more coverage.
Some critics of the bills passed in 2009 call them a "government take over of health care." FactCheck
FactCheck
FactCheck.org is a non-partisan, nonprofit website that describes itself as a consumer advocate' for voters that aims to reduce the level of deception and confusion in U.S. politics." It is a project of the Annenberg Public Policy Center of the Annenberg School for Communication at the University...
called the phrase an unjustified "mantra." (Factcheck has also criticized a number of other assertions made during 2009 by advocates on both sides of the debate). CBS News
CBS News
CBS News is the news division of American television and radio network CBS. The current chairman is Jeff Fager who is also the executive producer of 60 Minutes, while the current president of CBS News is David Rhodes. CBS News' flagship program is the CBS Evening News, hosted by the network's main...
described it as a myth "mixed in with some real causes for concern." President Obama disputes the notion of a government takeover and says he no more wants government bureaucrats meddling than he wants insurance company bureaucrats doing so. However, other sources contend the bills do amount to either a government takeover or a corporate takeover, or both. This debate occurs in the context of a "revolution...transforming how medical care is delivered:" from 2002–2008, the percentage of medical practices owned by doctors fell from more than 70% to below 50%; in contrast to the traditional practice in which most doctors cared for patients in small, privately owned clinics, by 2008 most doctors had become employees of hospitals, nearly all of which are owned by corporations or government.
Republicans also argue the proposed excise tax on medical devices and drugs would increase the tax burden on vaccine makers.
Some conservatives argue that forcing people to buy private insurance
Insurance
In law and economics, insurance is a form of risk management primarily used to hedge against the risk of a contingent, uncertain loss. Insurance is defined as the equitable transfer of the risk of a loss, from one entity to another, in exchange for payment. An insurer is a company selling the...
is unconstitutional
United States Constitution
The Constitution of the United States is the supreme law of the United States of America. It is the framework for the organization of the United States government and for the relationship of the federal government with the states, citizens, and all people within the United States.The first three...
; legislators in 38 states have introduced bills opposing the new law, and 18 states have filed suit in federal court challenging the unfunded mandates on individuals and states.
Senator Judd Gregg
Judd Gregg
Judd Alan Gregg is a former Governor of New Hampshire and former United States Senator from New Hampshire, who served as chairman of the Senate Budget Committee. He is a member of the Republican Party and was a businessman and attorney in Nashua before entering politics...
(R) said in an interview regarding the passage of healthcare reform: "Well, in my judgment we’re moving down a path towards...Europeanization of our nation. And our great uniqueness, what surrounds American exceptionalism, what really drives it is that entrepreneurial individualistic spirit which goes out and takes a risk when nobody else is willing to do it or comes up with an idea that nobody else comes up with and that all gets dampened down the larger and more intrusive government becomes, especially if you follow a European model."
Changes in Support and Opposition to the current leading proposals
Though in 2008 then-Senators Obama and Biden campaigned against requiring adults to buy insurance, in July 2009 President Obama reportedly changed his mind and announced that he was "now in favor of some sort of individual mandate as long as there's a hardship exemption." Also, in contrast to earlier advocacy of a publicly-funded health care program, in August 2009 Obama administration officials announced they would support a health insurance cooperative, reportedly in response to deep political unrest amongst Congressional Republicans and Democrats, and citizens in town hall meetings held across America. Public approval of President Obama's handling of healthcare dropped from 57% to 49% between April and July 2009, and fell to 36% by January 2010.After Massachusetts voters replaced a Senator who had voted for the Senate bill with a candidate who promised to vote against it, Senator Jim Webb
Jim Webb
James Henry "Jim" Webb, Jr. is the senior United States Senator from Virginia. He is also an author and a former Secretary of the Navy. He is a member of the Democratic Party....
called on Senate leaders to suspend any further votes on the bill until the new Senator is sworn into office. In addition, members of the United States House of Representatives
United States House of Representatives
The United States House of Representatives is one of the two Houses of the United States Congress, the bicameral legislature which also includes the Senate.The composition and powers of the House are established in Article One of the Constitution...
reportedly "indicated they would not quickly pass the bill the Senate approved last month."
Republican Senator Olympia Snowe
Olympia Snowe
Olympia Jean Snowe , née Bouchles, is the senior United States Senator from Maine and a member of the Republican Party. Snowe has become widely known for her ability to influence the outcome of close votes, including whether to end filibusters. She and her fellow Senator from Maine, Susan Collins,...
, who had earlier voted for the Senate Finance Committee bill, in December 2009 announced she would oppose the revised bill: "Here we are today with a bill that's dramatically different and more expansive than the Finance Committee -- in fact it's 1,200 pages more -- it was placed on the floor just short of three weeks ago."
California
California
California is a state located on the West Coast of the United States. It is by far the most populous U.S. state, and the third-largest by land area...
Governor Arnold Schwarzenegger
Arnold Schwarzenegger
Arnold Alois Schwarzenegger is an Austrian-American former professional bodybuilder, actor, businessman, investor, and politician. Schwarzenegger served as the 38th Governor of California from 2003 until 2011....
, whom the White House had brought much attention to as a Republican supporter, said in his State of the State address, "Health care reform, which started as noble and needed legislation, has become a trough of bribes, deals and loopholes." Schwarzenegger added, "California's congressional delegation should either vote against this bill that is a disaster for California or get in there and fight for the same sweetheart deal Senator [Ben] Nelson of Nebraska got for the Cornhusker State."
Polling data has been somewhat conflicting and results can depend on how the question is asked. Rasmussen Reports
Rasmussen Reports
Rasmussen Reports is an American media company that publishes and distributes information based on public opinion polling. Founded by pollster Scott Rasmussen in 2003, the company updates daily indexes including the President's job approval rating, and provides public opinion data, analysis, and...
in January 2010, found that 10% of the American public have withdrawn their support from leading Congressional proposals compared with June 2009, and reported a majority opposing them since November 2009. Other polls in December 2009 and January 2010 found opposition slightly higher at 57%. However, when asked generically whether Congress should vote for or against "a healthcare bill" (rather than the specific bills passed in each chamber), Gallup poll results show opinion has remained more evenly divided, fluctuating mostly within the margin of error since September 2009.
In 2010, 82% of Obama voters who voted for Brown in Massachusetts support the public option.
Debate after passage of Senate and House bills
The Senate bill was passed with 60 senators voting in favor during December 2009. The House bill was passed in November 2009 by a vote of 220-215. The next legislative step is for a reconciled bill to be voted on in both chambers, or either chamber could pass the other's bill as-is.Arguments against passing the current bills
New York Times columnist David BrooksDavid Brooks (journalist)
David Brooks is a Canadian-born political and cultural commentator who considers himself a moderate and writes for the New York Times...
wrote that passing the bills "would be political suicide. It would be the act of a party so arrogant, elitist and contemptuous of popular wisdom that it would not deserve to govern."
New York Times columnist Bob Herbert
Bob Herbert
Robert “Bob” Herbert is an American journalist op-ed columnist who wrote for The New York Times. His column was syndicated to other newspapers around the country. Herbert frequently writes on poverty, the Iraq war, racism and American political apathy towards race issues...
wrote, "No one in his or her right mind could have believed that a workable, efficient, cost-effective system could come out of the monstrously ugly plan that finally emerged from the Senate after long months of shady alliances, disgraceful back-room deals, outlandish payoffs and abject capitulation to the insurance companies and giant pharmaceutical outfits." Some "say the health care bill has been gutted to appease insurance companies;" for example, Howard Dean
Howard Dean
Howard Brush Dean III is an American politician and physician from Vermont. He served six terms as the 79th Governor of Vermont and ran unsuccessfully for the 2004 Democratic presidential nomination. He was chairman of the Democratic National Committee from 2005 to 2009. Although his U.S...
called the Senate bill "an insurance company's dream" and said that "at this point, the bill does more harm than good."
Some advocates of single-payer healthcare, likewise argue against the current bills. Writing in the Huffington Post, Michael Moore
Michael Moore
Michael Francis Moore is an American filmmaker, author, social critic and activist. He is the director and producer of Fahrenheit 9/11, which is the highest-grossing documentary of all time. His films Bowling for Columbine and Sicko also place in the top ten highest-grossing documentaries...
called the current bills a "massive government bailout for the insurance industry." Opposing the House bill, Democratic Representative Dennis Kucinich
Dennis Kucinich
Dennis John Kucinich is the U.S. Representative for , serving since 1997. He was furthermore a candidate for the Democratic nomination for President of the United States in the 2004 and 2008 presidential elections....
called it "the wrong approach" and a subsidy rewarding "the wrong people" including the insurance companies. Dr. Marcia Angell
Marcia Angell
Marcia Angell, M.D. is an American physician, author, and the first woman to serve as editor-in-chief of the New England Journal of Medicine...
, past editor-in-chief of the New England Journal of Medicine
New England Journal of Medicine
The New England Journal of Medicine is an English-language peer-reviewed medical journal published by the Massachusetts Medical Society. It describes itself as the oldest continuously published medical journal in the world.-History:...
, wrote "Kucinich was right" to vote against the House bill, and warned that if it becomes law:
- "First, health costs will continue to skyrocket, even faster than they are now, as taxpayer dollars are pumped into the private sector. The response of payers -- government and employers -- will be to shrink benefits and increase deductibles and co-payments...people will conclude that we've tried health reform and it didn't work. But the real problem will be that we didn't really try it. I would rather see us do nothing now, and have a better chance of trying again later and then doing it right."
After voting to take up the Senate bill, Bernie Sanders
Bernie Sanders
Bernard "Bernie" Sanders is the junior United States Senator from Vermont. He previously represented Vermont's at-large district in the United States House of Representatives...
emphasized that his support for the final bill hinges on whether the Senate makes the measure "stronger and more effective for working families and taxpayers in Vermont and America."
Arianna Huffington
Arianna Huffington
Arianna Huffington is a Greek American author and syndicated columnist. She is best known as co-founder of the news website The Huffington Post. A popular conservative commentator in the mid-1990s, she adopted more liberal political beliefs in the late 1990s...
wrote, in recommending George Mason University
George Mason University
George Mason University is a public university based in unincorporated Fairfax County, Virginia, United States, south of and adjacent to the city of Fairfax. Additional campuses are located nearby in Arlington County, Prince William County, and Loudoun County...
Professor Janine Wedel's The Shadow Elite, that "what may well have started out as a push for real reform ended up as an industry windfall. After all, the final Senate bill (which looks like it will be the base for the final bill sent to Obama), is essentially the same bill that was drawn up months ago in Max Baucus' office by Baucus staffers who used to be health care executives, and by health care lobbyists who used to be Baucus staffers." The Huffington Post
The Huffington Post
The Huffington Post is an American news website and content-aggregating blog founded by Arianna Huffington, Kenneth Lerer, and Jonah Peretti, featuring liberal minded columnists and various news sources. The site offers coverage of politics, theology, media, business, entertainment, living, style,...
has published many articles saying the current proposals would be counterproductive.
(Randall Amster
Randall Amster
Randall Amster is an author, activist, and educator in areas including peace, ecology, homelessness, and anarchism. Born in Brooklyn, New York in 1966, Amster has worked as an attorney, judicial clerk, professor, and academic administrator during his professional career...
, "The Road to Healthcare is Paved with Bad Intentions"
Arguments for passing the current bills
A letter from 47 health policy experts from various universities and think tanks was sent to Congressional leaders on January 22, 2010 arguing that the House should pass the Senate bill as-is. Thereafter, only Presidential signature would be required.President Barack Obama
Barack Obama
Barack Hussein Obama II is the 44th and current President of the United States. He is the first African American to hold the office. Obama previously served as a United States Senator from Illinois, from January 2005 until he resigned following his victory in the 2008 presidential election.Born in...
argued for passing healthcare reform in his State of the Union Address in January 2010: "[W]e are closer than ever to bringing more security to the lives of so many Americans. The approach we've taken would protect every American from the worst practices of the insurance industry. It would give small businesses and uninsured Americans a chance to choose an affordable health care plan in a competitive market. It would require every insurance plan to cover preventive care.... Our approach would preserve the right of Americans who have insurance to keep their doctor and their plan. It would reduce costs and premiums for millions of families and businesses. And according to the Congressional Budget Office -– the independent organization that both parties have cited as the official scorekeeper for Congress –- our approach would bring down the deficit by as much as $1 trillion over the next two decades."
Both the AARP
AARP
AARP, formerly the American Association of Retired Persons, is the United States-based non-governmental organization and interest group, founded in 1958 by Ethel Percy Andrus, PhD, a retired educator from California, and based in Washington, D.C. According to its mission statement, it is "a...
and the American Medical Association
American Medical Association
The American Medical Association , founded in 1847 and incorporated in 1897, is the largest association of medical doctors and medical students in the United States.-Scope and operations:...
have endorsed the House bill.
Consequences of not controlling healthcare costs
Congressional Budget Office
The Congressional Budget Office is a federal agency within the legislative branch of the United States government that provides economic data to Congress....
reported in June 2008 that: In other words, all other federal spending categories (e.g., Social Security, Defense, Education, and Transportation) would require borrowing in order to be to be funded, which is not feasible.
President Obama stated in May 2009: "But we know that our families, our economy, and our nation itself will not succeed in the 21st century if we continue to be held down by the weight of rapidly rising health care costs and a broken health care system...Our businesses will not be able to compete; our families will not be able to save or spend; our budgets will remain unsustainable unless we get health care costs under control."
The Senate bill (without including amendments) would increase the share of GDP consumed by medical spending from the current 17% to 20.9% by 2019, compared to 20.8% under current law, according to the Department of Health and Human Services' Centers for Medicare and Medicaid Services
Centers for Medicare and Medicaid Services
The Centers for Medicare & Medicaid Services , previously known as the Health Care Financing Administration , is a federal agency within the United States Department of Health and Human Services that administers the Medicare program and works in partnership with state governments to administer...
.
The final CBO cost estimates indicated that the ultimate passage of the Health Care and Education Reconciliation Act of 2010 would yield a net reduction in the federal deficit of $143 billion over the 2010–2019 period.
Elements of the reform signed in March 2010
A Reuters article summarized the key reforms that were later passed in March 2010; the following list is taken nearly verbatim from that article.Within one year of enactment (2010-2011)
- Insurance companies barred from dropping people from coverage when they get sick. Lifetime coverage limits eliminated and annual limits restricted.
- Insurers barred from excluding children for coverage because of pre-existing conditions.
- Young adults able to stay on their parents' health plans until age 26. Many health plans currently drop dependents from coverage when they turn 19 or finish college.
- Uninsured adults with a pre-existing conditions will be able to obtain health coverage through a new program that will expire once new insurance exchanges begin operating in 2014.
- A temporary reinsurance program is created to help companies maintain health coverage for early retirees between the ages of 55 and 64. This also expires in 2014.
- Medicare drug beneficiaries who fall into the "doughnut hole" coverage gap will get a $250 rebate. The bill eventually closes that gap which currently begins after $2,700 is spent on drugs. Coverage starts again after $6,154 is spent.
- A tax credit becomes available for some small businesses to help provide coverage for workers.
- A 10% tax on indoor tanning services that use ultraviolet lamps goes into effect on July 1.
During 2011
- Medicare provides 10% bonus payments to primary care physicians and general surgeons.
- Medicare beneficiaries will be able to get a free annual wellness visit and personalized prevention plan service. New health plans will be required to cover preventive services with little or no cost to patients.
- A new program under the Medicaid plan for the poor goes into effect in October that allows states to offer home and community based care for the disabled that might otherwise require institutional care.
- Payments to insurers offering Medicare Advantage services are frozen at 2010 levels. These payments are to be gradually reduced to bring them more in line with traditional Medicare.
- Employers are required to disclose the value of health benefits on employees' W-2 tax forms.
- An annual fee is imposed on pharmaceutical companies according to market share. The fee does not apply to companies with sales of $5 million or less.
During 2012
- Physician payment reforms are implemented in Medicare to enhance primary care services and encourage doctors to form "accountable care organizationAccountable care organizationAn accountable care organization is a type of payment and delivery reform model that seeks to tie provider reimbursements to quality metrics and reductions in the total cost of care for an assigned population of patients. A group of coordinated health care providers form an ACO, which then...
s" to improve quality and efficiency of care. - An incentive program is established in Medicare for acute care hospitals to improve quality outcomes.
- The Centers for Medicare and Medicaid Services, which oversees the government programs, begin tracking hospital readmission rates and puts in place financial incentives to reduce preventable readmissions.
During 2013
- A national pilot program is established for Medicare on payment bundling to encourage doctors, hospitals and other care providers to better coordinate patient care.
- The threshold for claiming medical expenses on itemized tax returns is raised to 10% from 7.5% of income. The threshold remains at 7.5% for the elderly through 2016.
- The Medicare payroll tax is raised to 2.35% from 1.45% for individuals earning more than $200,000 and married couples with incomes over $250,000. At a rate of 3.8%, the tax is imposed on some investment income for that income group.
- A 2.9% excise tax is imposed on the sale of medical devices. Anything generally purchased at the retail level by the public is excluded from the tax.
During 2014
- State health insurance exchangeHealth insurance exchangeA health insurance exchange is a set of state-regulated and standardized health care plans in the United States, from which individuals may purchase health insurance that is eligible for Federal subsidies...
s for small businesses and individuals open. - Individuals with income up to 133% of the federal poverty level qualify for MedicaidMedicaidMedicaid is the United States health program for certain people and families with low incomes and resources. It is a means-tested program that is jointly funded by the state and federal governments, and is managed by the states. People served by Medicaid are U.S. citizens or legal permanent...
coverage. - Healthcare tax credits become available to help people with incomes up to 400 percent of poverty purchase coverage on the exchange.
- Premium cap for maximum "out-of-pocket" pay will be established for people with incomes up to 400 percent of FPL. Section 1401 of PPACAPatient Protection and Affordable Care ActThe Patient Protection and Affordable Care Act is a United States federal statute signed into law by President Barack Obama on March 23, 2010. The law is the principal health care reform legislation of the 111th United States Congress...
explains that the subsidy will be provided as an advanceble, refundable tax credit and gives a formula for it calculation. Refundable tax credit is a way to provide government benefit to people even with no tax liability(example: Child Tax Credit). According to White House and Congressional Budget Office the maximum share of income that enrollees would have to pay for the "silver" healthcare plan would vary depending on their income relative to the federal poverty level, as follows: for families with income 133–150% of FPL will be 4-4.7% of income, for families with income 150–200% of FPL will be 4.7-6.5% of income, for families with income 200–250% of FPL will be 6.5-8.4% of income, for families with income 250-300% of FPL will be 8.4-10.2% of income, for families with income from 300-400% of FPL will be 10.2% of income. In 2016,the FPL is projected to equal about $11,800 for a single person and about $24,000 for family of four. See Subsidy Calculator for specific dollar amount. - Most people required to obtain health insurance coverage or pay a fine if they don't.
- Health plans no longer can exclude people from coverage due to pre-existing conditions.
- Employers with 50 or more workers who do not offer coverage face a fine of $2,000 for each employee if any worker receives subsidized insurance on the exchange. The first 30 employees aren't counted for the fine.
- Health insurance companies begin paying a fee based on their market share.
During 2015
- Medicare creates a physician payment program aimed at rewarding quality of care rather than volume of services.
During 2018
- An excise tax on high cost employer-provided plans is imposed. The first $27,500 of a family plan and $10,200 for individual coverage is exempt from the tax. Higher levels are set for plans covering retirees and people in high risk professions.
Debate since passage of The Patient Protection and Affordable Care Act (PPACA)
Since the passage of the Patient Protection and Affordable Care Act (PPACA), debate has surrounded a particular provision within the bill regarding new tax reporting requirements. Known as the 1099 provision, it requires businesses to file 1099 forms for every transaction (both goods and services) of $600 and above. Several business groups have come out in strong opposition to the provision, including the small business lobby organization the National Federation of Independent Business, which states that the provision creates a new paperwork compliance burden for small business. The group details several reasons how small business owners will be affected. Another prominent business group, the Chamber of Commerce has also expressed opposition to the provision, and advocates for full repeal. Since the election, Republicans and Democrats have acknowledged that the provision will prove to be costly and burdensome for small businesses, and President Obama has publicly expressed willingness to roll back the new tax reporting requirements.Both parties have introduced legislation to address the provision, yet they differ over how to pay for the $17 billion in revenue the provision was expected to raise. The most recent legislative action occurred on November 29, 2010, when the Senate voted on two amendments offered to S. 510, the Food Safety bill. S.A. 4702, offered by Senator Johanns, fully repeals the new 1099 requirement, and offsets the bill with unused stimulus funds. SA 4713, offered by Sen. Max Baucus of Montana, also fully repeals the new 1099 requirement and does not have an offset. Both amendments failed to pass. The Republican Party has expressly stated that the repeal of the 1099 Form provision will be a top healthcare legislative priority in the 112th Congress as they gain control of the House
See also
- Health care compared - tabular comparisons of the US, Canada, and other countries.
- Health care politicsHealth care politicsHealth policy can be defined as the "decisions, plans, and actions that are undertaken to achieve specific health care goals within a society." According to the World Health Organization, an explicit health policy can achieve several things: it defines a vision for the future; it outlines...
- Health care reformHealth care reformHealth care reform is a general rubric used for discussing major health policy creation or changes—for the most part, governmental policy that affects health care delivery in a given place...
- Health economicsHealth economicsHealth economics is a branch of economics concerned with issues related to efficiency, effectiveness, value and behavior in the production and consumption of health and health care...
- Health insurance cooperativeHealth insurance cooperativeA health insurance cooperative is a cooperative entity that has the goal of providing health insurance and is also owned by the people that the organization insures...
- Health insurance exchangeHealth insurance exchangeA health insurance exchange is a set of state-regulated and standardized health care plans in the United States, from which individuals may purchase health insurance that is eligible for Federal subsidies...
- Health policy analysis
- History of health care reform in the United StatesHistory of health care reform in the United StatesThe issue of health insurance reform in the United States has been the subject of political debate since the early part of the 20th century. Recent reforms remains an active political issue...
- List of healthcare reform advocacy groups in the United States
- Public opinion on health care reform in the United StatesPublic opinion on health care reform in the United StatesPublic opinion on health care reform in the United States is mixed. Many Americans express a desire for health care reform because they see health care as too expensive and because they perceive that insurance companies avoid meeting health costs through coverage exclusions, caps, and co-pays...
- Uninsured in the United StatesUninsured in the United StatesThe number of persons without health insurance coverage in the United States is one of the primary concerns raised by advocates of health care reform. According to the United States Census Bureau, in 2009 there were 50.7 million people in the US who were without health insurance...
External links
- PBS Special Report:Healthcare Reform NOW on PBS
- Malhotra, Umang, Solving the American Healthcare Crisis, iUniverse, 2010. ISBN 978-1-4401-8018-7