INSURANCE

The debate over health care reform in the United States centers around questions of access, efficiency, quality, and sustainability. The mixed public-private health care system in the US is the most expensive in the world, with the US spending more on health care per capita than any other nation, and a greater portion of gross domestic product (GDP) than any other United Nations member state except for the Marshall Islands. Current estimates put US health care spending at approximately 16% of GDP. In 2007, the U.S. spent a projected $2.26 trillion on health care, or $7,439 per person. Health care costs are rising faster than wages or inflation, and the health share of GDP is expected to continue its historical upward trend, reaching 19.5 percent of GDP by 2017.

The United States is the only wealthy, industrialized nation that does not have a universal health care system, according to the Institute of Medicine of the National Academy of Sciences and others. US citizens and noncitizens without health insurance coverage at some time during 2007 totaled 15.3% of the population, or 45.7 million people, down from 15.8% and 47 million in 2006. This decrease is due to increased publicly sponsored coverage and includes about 300,000 people in Massachusetts, which implemented the Massachusetts health care reform law in 2007. It is projected that the current economic downturn and rising unemployment rate likely will cause the number of uninsured to grow by at least 2 million in 2008.

International comparisons that could lead to conclusions about the quality of the health care received by Americans are inconclusive and subject to debate. The US lags other wealthy nations in such measures as infant mortality and life expectancy, but it is unclear whether these statistics have anything to do with the structure of the health care system. Other comparisons indicate that the US system performs better on some measures, such as responsiveness and higher cure rates for serious illnesses such as cancer.

Whether a government-mandated system of universal health care should be implemented in the U.S. remains a hotly debated political topic, with Americans divided along party lines in their views of the US health system and what should be done to improve it. Those in favor of universal health care argue that the large number of uninsured Americans creates direct and hidden costs shared by all, and that extending coverage to all would lower costs and improve quality. Opponents of government mandates or programs for universal health care argue that people should be free to opt out of health insurance and that government programs would require higher taxes, increase utilization, and reduce health care quality. Opponents also claim that the current level of government involvement in US health care contributes to higher costs, and point to free-market solutions to increase efficiency, stimulate innovation, and make consumers rather than third parties more responsible for cost decisions. Both sides of the political spectrum have also looked to more philosophical arguments, debating whether people have a fundamental right to have health care provided to them by their government.

The cost and quality of care in the United States are frequently the two major issues of discussion. The US performs worse than the average developed country in health measures such as infant mortality, maternal death, and life expectancy, but the causes of these disparities are subject to debate. For example, the US CDC suggests that higher rates of infant mortality in the US are "due in large part to disparities which continue to exist among various racial and ethnic groups in this country, particularly African Americans". Some studies claim the data collected regarding infant mortality and life expectancy do not lend themselves to fair comparison.

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

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

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

Various health care analysts have asserted that market failure occurs in health care markets, but some have suggested that it is a result of too much government involvement rather than too little. Consumers want unfettered access to medical services; they also prefer to pay through insurance or tax rather than out of pocket. These two needs create cost-efficiency challenges for health care. Some studies have found no consistent and systematic relationship between the type of financing of health care and cost containment.

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

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

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

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

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

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

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

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

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

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

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

In January 2007 Rep. John Conyers, Jr. (D-MI) has introduced The United States National Health Insurance Act (HR 676) in the House of Representatives. As of October 2008, HR 676 has 93 co-sponsors. Also in January 2007, Senator Ron Wyden introduced the Healthy Americans Act (S. 334) in the Senate. As of October 2008, S. 334 had 17 cosponsors.

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

Economists Katherine Baicker and Amitabh Chandra argue that five "myths" about the US health care system hinder reform efforts. While each has a "kernel of truth," they oversimplify complicated issues to the point where they are "false or misleading."

The myths they identify are:

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

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

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

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

THE CASE FOR PUBLICLY FUNDED HEALTH CARE

Supporters of publicly funded health care argue that it has several advantages over the free market. It has been suggested that the largest obstacle is a lack of political will.

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

Converting to a single-payer system is seen by proponents as a solution to the flaws in the current system. The US health care system is the most expensive in the world. Despite this expenditure, the current US system fails to provide universal coverage. Almost 46 million Americans, more than 15 percent of the population, lacked health insurance in 2007. The lack of universal coverage contributes to another flaw in the current US health care system: on most dimensions of performance, it underperforms relative to other industrialized countries. In a 2007 comparison by the Commonwealth Fund of health care in the U.S. with that of Germany, Britain, Australia, New Zealand, and Canada, the US ranked last on measures of quality, access, efficiency, equity, and outcomes.

For example, the US ranks 22nd in infant mortality, between Taiwan and Croatia, 46th in life expectancy, between Saint Helena and Cyprus, and 37th in health system performance, between Costa Rica and Slovenia. None of these rankings however were claimed to be related to the US health care system.

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

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

Proponents of health care reform argue that moving to a single-payer system would reallocate the money currently spent on the administrative overhead required to run the hundreds of insurance companies in the US to provide universal care. An often-cited study by Harvard Medical School and the Canadian Institute for Health Information determined that some 31 percent of US health care dollars, or more than $1,000 per person per year, went to health care administrative costs.

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

QUALITY OF CARE

One political advocacy group has claimed that a free market solution to health care provides a lower quality of care, with higher mortality rates, than publicly funded systems. The quality of health maintenance organizations and managed care 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, commentators have criticized the WHO's comparison method for being biased; the WHO study marked down countries for having private or fee-paying health treatment and rated countries by comparison to their expected health care performance, rather than objectively comparing quality of care.

While most Americans are generally satisfied with the quality of their own health 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 at 2 managed care plans to rate their care, then examined care in medical records, as reported in Annals of Internal Medicine. There was no correlation. "Patient ratings of health care are easy to obtain and report, but do not accurately measure the technical quality of medical care," said John T. Chang, UCLA, lead author.

COST AND EFFICIENCY

Proponents of publicly funded health care point out that the United States, which has a partly free market health care system, spends a higher proportion of its GDP on health care (15.2%) than any other country in the world, except for the tiny Marshall Islands. The number of employers who offer health insurance is declining. Costs for employer-paid health insurance are rising rapidly: since 2001, premiums for family coverage have increased 78%, while wages have risen 19% and inflation has risen 17%, according to a 2007 study by the Kaiser Family Foundation. 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. 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 investors in a predominantly free market health system, and the additional administrative spending, tends to drive up costs, leading to more expensive health care provision.

THE CASE AGAINST PUBLICLY FUNDED HEALTH CARE

Those who oppose publicly funded health care, predominantly on the political right, have pointed out a number of flaws in publicly funded health care systems, such as those which operate in Canada, the United Kingdom and Germany. Public health care systems have been criticized for poor quality of care, long waiting lists, and slow access to new drugs. For example, according to a 1998 medical study, financial considerations prevented 500-600% more Canadian and British citizens from getting lifesaving dialysis medical care than happened with Americans.

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

Supporters of the free market medicine would contend that the high level of administrative costs cited by advocates of publicly funded care arise out of the substantial level of government regulation that exists in the United States's health care sector. According to a Cato Institute study, this regulation provides benefits in the amount of $170 billion but costs the public up to $340 billion.

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

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

QUALITY OF CARE

International comparisons of health care quality are difficult and have yielded mixed results. For example, an international comparison of health systems in six countries by the Commonwealth Fund ranked the UK's publicly funded system first overall and first in quality of care. Systems in the United States and Canada tied for the lowest overall ranking and toward the bottom for quality of care.

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

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

INNOVATION AND DEVELOPMENT OF NEW TREATMENTS

Free market advocates say that the largely free market system of health care in the United States has led to the faster development of more advanced medical treatment and new drugs, and that cancer patients in the United States for many forms of cancer, including those of the breast, thyroid and lung, have higher survival rates than their counterparts in publicly-funded health systems in Europe. Some analysts have pointed out the difficulty of comparing international health statistics. In particular, the mortality rates for cancer in the United States is at about the same level as many other countries, suggesting that the higher survival rates are a function of the way cancer is diagnosed. Market advocates say that public care systems, in which there is more bureaucratic government involvement and less financial incentive in the health care industry, lead to less motivation for medical innovation and invention.

By some criteria, the United States, with its partly free-market health care system, is the world leader in medical innovation. According to economist Tyler Cohen quoted in The New York Times, the American system leads in converting new ideas into workable commercial technologies, and the research environment in the United States, compared with Europe, is richer, more competitive, more meritocratic and less tolerant of waste. Cohen argues that the American government could use its size to bargain down health care prices, but in the longer run it would cost lives because of the reduced innovation. Cohen argues that one reason America's leadership in innovation does not translate into relatively higher life expectancy is that other wealthy countries also benefit from US medical innovations. Economist Arnold Kling says that America's role in medical innovation is crucial not just for Americans, but for the entire world. In June 2008 the Financial Times reported that leading pharmaceutical companies, including Pfizer, Roche and Merck-Serono, were reducing the amount of clinical research they performed in the United Kingdom. The companies say that the policies of the National Institute for Health and Clinical Excellence (NICE) result in too few UK patients receiving "gold standard" care to provide the comparison group needed for clinical trials.

IMPACT ON PHYSICIANS

Some commentators have pointed out that in publicly funded systems, health care workers' pay is often unrelated to quality or speed of care. There is also less financial motivation for the most able people to enter health care professions. For example, in Canada, which has a publicly funded health system, the average physician earns roughly half the annual salary earned by counterparts in the United States, according to 1996 health data collected by the OECD. This difference in physician income reflects Canada's more limited spending on health care overall; in 2004, combined public and private spending on health care consumed 15.4% of U.S. annual GDP; in Canada, 9.8% of GDP. By limiting the amount of money in the health care system through political mechanisms, shortages of health care resources (such as physicians, nurses, medical equipment, medical devices, pharmaceuticals, and hospitals) are more likely to occur, sometimes resulting in longer waits for care.

COMMON ARGUMENTS FOR AND AGAINST A NATIONAL HEALTH CARE SYSTEM

DEBATE IN THE 2008 U.S. PRESIDENTIAL ELECTION

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

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

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

The Philadelphia Inquirer reports that the two plans have different philosophical focuses. They describe the purpose of the McCain plan is to "make insurance more affordable," while the purpose of the Obama plan is for "more people to have health insurance." The Des Moines Register characterizes the plans similarly. The Commonwealth Fund concludes that, compared with McCain's approach, Obama's plan could provide more people with affordable health insurance that covers essential services, achieve greater equity in access to care, realize efficiencies and cost savings in the provision of coverage and delivery of care, and redirect incentives to improve quality.

Critics of McCain's plan argue that it would not significantly reduce the number of uninsured Americans, would increase costs, reduce consumer protections and lead to less generous benefit packages. Critics of Obama's plan argue that it would increase federal regulation of private health insurance without addressing the underlying incentives behind rising health care spending. Mark Pauly has suggested that a combination of the two approaches would work better than either one alone.

Various analyses of the two candidates' plans have come to widely varying predictions of their costs and effects. A comparison by The Tax Policy Center, a project of the Brookings Institution and the Urban Institute estimated that Obama's proposals could cost $1.6 trillion over 10 years, while the tax-related provisions of McCain's proposals could cost $1.3 trillion over the same period. A comparison by The Lewin Group published in October 2008 found that the McCain plan would reduce the number of uninsured by 21.1 million and cost $2.05 trillion over 10 years, while the Obama plan would reduce the uninsured by 26.6 million and increase federal spending by $1.17 trillion over the same period. Estimates prepared by HSI Networks found that the McCain plan would reduce the uninsured by 27.5 million at an annual cost of $287 billion, and the Obama plan would reduce the uninsured by 25.5 million at an annual cost of $452 billion.

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

JOHN MCCAIN

McCain is against publicly funded health care, universal health care, or health coverage mandates. Instead, he favors tax credits of up to $5,000 for families to get health insurance. His plan focuses on enhancing competition in the health care industry as a way to lower costs. To that end, McCain would allow citizens to purchase health insurance nationwide instead of limiting them to in-state companies, and to buy insurance through any organization or association they choose as well as through their employers or buying direct from an insurance company. In an October 2007 statement, McCain said: "In health care, we believe in enhancing the freedom of individuals to receive necessary and desired care. We do not believe in coercion and the use of state power to mandate care, coverage or costs."

On April 29, 2008, McCain detailed his health care plan in the context of his campaign for President. His plan focused on open-market competition rather than government funding or control. At the heart of his plan are tax credits: $2,500 for individuals and $5,000 for families who do not subscribe to or do not have access to health care through their employer. He says the money could be used to purchase insurance and force insurance companies to be competitive with their costs in order to attract consumers. McCain would pay for the tax credits by eliminating the tax break currently offered to employers for providing health insurance to employees. A critique of McCain's health care plan published in Health Affairs projected that the loss of tax benefits would cause businesses to drop 20 million people from employer-sponsored coverage, while the individual insurance market would grow to 21 million people. To help people who are denied coverage by insurance companies due to pre-existing conditions, McCain would work with states to create what he calls a "Guaranteed Access Plan". He did not provide details, but pointed to states such as Florida and North Carolina where such systems are in place. His health care plan has an estimated annual cost of $7 billion, according to McCain's health-policy experts. His campaign has acknowledged that the health plan he had outlined would have the effect of increasing tax payments for some workers, primarily those with high incomes and expensive health plans.

BARACK OBAMA

On January 24, 2007, Obama spoke about his position on health care at Families USA, a health care advocacy group. Obama said, "The time has come for universal health care in America [...] I am absolutely determined that by the end of the first term of the next president, we should have universal health care in this country." Obama went on to say that he believed that it was wrong that forty-seven million Americans are uninsured, noting that taxpayers already pay over $15 billion annually to care for the uninsured. Obama cites cost as the reason so many Americans are without health insurance. Obama's health care plan includes implementing guaranteed eligibility for affordable health care for all Americans, paid for by insurance reform, reducing costs, removing patent protection for pharmaceuticals, and requiring employers to either furnish meaningful coverage or contribute to a new public plan. He would provide for mandatory health care insurance for children.

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

For those not insured through employment, Obama proposes a National Health Insurance Exchange that would include both private insurance plans and a Medicare-like, government-run option. Coverage would be guaranteed regardless of health status, and premiums would not vary based on health status either. The campaign estimates the cost of the program at $60 billion annually. According to the Associated Press, the program will need to attract young, healthy people into buying coverage to work, but at the state level guaranteed issue requirements have "often had the opposite effect." The plan requires that parents cover their children, but does not require adults to buy insurance. A critique of Obama's health care plan published in Health Affairs concludes that it does not address the core economic causes of rising health care spending, but would "greatly increase" federal regulation of health coverage.

USE OF THE TERM "SOCIALIZED MEDICINE"

The issue of health care in the 2008 U.S. presidential election has caused a resurgence in use of the term by Republicans. For example, in a July 2007 campaign speech, Republican presidential candidate Rudy Giuliani made a direct connection between socialized medicine and socialism. Giuliani also quoted statistics from his health care advisor, Canadian psychiatrist David Gratzer, to support his claim that he had a better chance of surviving prostate cancer in the U.S. than he would have had in England. According to cancer experts cited in fact check articles by the Annenberg Public Policy Center's FactCheck.org, the St. Petersburg Times and its PolitiFact.com, The New York Times, The Washington Post, and The Times, Giuliani's statistics were "false" and very "misleading" and his conclusions were complete "nonsense".

In response, Canadian psychiatrist and Giuliani health care advisor David Gratzer said: "The mayor is right."

Krugman and others have compared statistical apples to oranges. My 44% figure, replicated by economist John Goodman and others, looks at a snapshot in time, based on decade-old OECD data; Krugman's 74% is a five-year relative survival rate from government sources today.

Annenberg's FactCheck.org found no merit in Gratzer's response:

Marie Diener-West, professor of biostatistics at Johns Hopkins Bloomberg School of Public Health, said Gratzer's attempts to calculate cancer survival rates were "inappropriate" and "very misleading."

Peter Albertsen, professor and chief of urology at the University of Connecticut Health Center, called Gratzer's calculations a "very dangerous thing to do" and "complete nonsense."

Nor did The Washington Post, which awarded Giuliani and Gratzer's response the same "Four Pinocchios" rating (reserved for "whoppers") it awarded Giuliani and Gratzer's original claim.

A few states have taken serious steps toward universal health care coverage, most notably Minnesota and Massachusetts, with a recent example being the Massachusetts 2006 Health Reform Statute. Other states, while not attempting to insure all of their residents, cover large numbers of people by reimbursing hospitals and other health care providers using what is generally characterized as a charity care scheme; New Jersey is perhaps the best example of a state that employs the latter strategy. It is typical for most forms of general liability insurance sold in the U.S., such as home, automobile, or business insurance to have a significant premium allocation for medical damages. In the event that a third party is responsible for injury or illness (e.g., the responsible driver in an automobile accident), action can be taken in the U.S. court system to prove liability and collect the money for medical bills from the responsible party's liability insurances.

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

The state legislature of California has twice passed SB 840, The Health Care for All Californians Act, a single-payer health care system. Both times, Governor Arnold Schwarzenegger (R) vetoed the bill, once in 2006 and again in 2008.

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

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

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

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

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

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

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

A poll published in early 2008 had similar findings. Republicans are significantly less likely to give the current system poor reviews, are more likely to report satisfaction with their own care, and less likely to express concern about losing coverage. Differing levels of satisfaction with the current system result in differences in the preferred policy solutions of Democrats and Republicans. Democrats are more likely to believe that the primary responsibility for ensuring access to health care should fall on government, while Republicans are more likely to see health care as an individual responsibility, and are more likely to believe that private industry is more effective in providing coverage and controlling cost than government. Democrats are more likely to support higher taxes to expand coverage, and more likely to require everyone to purchase coverage.

A poll released in March 2008 by the Harvard School of Public Health and Harris Interactive found that Americans are divided in their views of the US health system, and that there are significant differences by political affiliation. When asked whether the US has the best health care system or if other countries have better systems, 45% said that the US system was best and 39% said that other countries' systems are better. Belief that the US system is best was highest among Republicans (68%), lower among independents (40%), and lowest among Democrats (32%). Over half of Democrats (56%) said they would be more likely to support a presidential candidate who advocates making the US system more like those of other countries; 37% of independents and 19% of Republicans said they would be more likely to support such a candidate. 45% of Republicans said that they would be less likely to support such a candidate, compared to 17% of independents and 7% of Democrats.

Another poll released in February 2008, conducted by the Harvard School of Public Health and Harris Interactive, indicated that Americans are also divided in their opinions of "socialized medicine," and this split too correlates strongly with their political party affiliation. Two-thirds of those polled said they understood the term "socialized medicine" very well or somewhat well. When offered descriptions of what such a system could mean, strong majorities believed that it means "the government makes sure everyone has health insurance" (79%) and "the government pays most of the cost of health care" (73%). One-third (32%) felt that socialized medicine is a system where "the government tells doctors what to do". The poll showed "striking differences" by party affiliation. Among Republicans polled, 70% said that socialized medicine would be worse than the current system. The same percentage of Democrats (70%) said that a socialized medical system would be better than the current system. Independents were more evenly split, with 43% saying socialized medicine would be better and 38% worse.

Physicians' opinions on a national health insurance program have evolved. A 2008 survey of doctors, published in Annals of Internal Medicine, shows that physicians support universal health care and national health insurance by almost 2 to 1.

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

Polling data from June 2008 show that Americans who are currently covered at work are hesitant about moving away from the employment-based system. Majorities say that it would make it harder to find a plan that meets their needs, make it harder to keep up with administration issues, harder to find and keep coverage, and harder to get health insurance at a good price.

In August 2008, the Chicago Tribune reported that health care was falling behind in the polls as an issue in the presidential election, having been superseded by the economy, the Iraq War and the price of gasoline. A September 2008 poll of registered voters by the Kaiser Family Foundation somewhat disputes this conclusion, ranking health care as the third most important issue, superseded only by the economy and only slightly by the Iraq War.

During the 1990s, the price of prescription drugs became a major issue in American politics as the prices of many new drugs increased exponentially, and many citizens discovered that neither the government nor their insurer would cover the cost of such drugs. In absolute currency, the U.S. spends the most on pharmaceuticals per capita in the world. However, national expenditures on pharmaceuticals accounted for only 12.9% of total health care costs, compared to an OECD average of 17.7% (2003 figures). Some 25% of out-of-pocket spending by individuals is for prescription drugs.

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