National Health Insurance - Is There A Middle Ground?

The debate over national health insurance extends well beyond the issues of economics and political ideology. Rising costs, rising numbers of uninsured citizens, negative impact on families and businesses, and poor outcomes make the debate over healthcare reform one of the most important issues on the nation's agenda.

Medical care costs in the United States represent $2.4 trillion annually or $7,868 per capita. The cost of medical care has risen 75% over the past 8 years, outstripping inflation and per capita income increases by several multiples. Even though the United States spends almost 20% of its GDP on healthcare, millions of Americans are either uninsured or underinsured. 47 million Americans have no health insurance coverage at all. 25 million adults are underinsured, up 60% from 2003.

The United States is unusual among industrialized countries; it is the only wealthy industrialized nation that does not ensure health coverage for all of its citizens. As the United States loses jobs, workers become increasingly uninsured or underinsured, leading to huge personal financial problems. According to a study by Harvard University, 50% of all individual/family bankruptcies in 2001 were the result of medical bills.

Although the United States spends the most money on healthcare per capita, global indicators of health such as mortality, infant mortality and incidence of various diseases remain strikingly lower than many other industrialized and emerging economy countries. Taken together, the following indicators suggest that the U.S. healthcare system is in chaos - too expensive and not effective enough.

(1) The 2007 U.S. infant mortality rate of 6.4 deaths per 1000 live births is comparable to Croatia, Lithuania and Cuba. Most analysts currently rank the United States 28th in the world in infant mortality, far behind other industrialized nations such as Sweden, France, Japan and Germany.

(2) Life expectancy is currently 78 years. According to NationMaster data, the U.S. is ranked 44th in life expectancy compared with the 220 countries in its database.

(3) Even in the area of heart disease the United States' rate of 106.5 deaths per 100,000 population is higher than almost half of the other 26 countries for which data was available.

The U.S. healthcare system is a competitive marketplace, paid for by a combination of private insurance and several national or quasi-national healthcare insurance programs. 68% of Americans are insured by private healthcare insurers, either as individuals or individual families or in a group plan through an employer or association. 8.2% of Americans, mostly those aged 65 and over participate in the Medicare program, a national health insurance program that pays for most but not all medical costs. 14% of Americans are insured by Medicaid, state/federal health insurance programs that provide coverage for families who meet guidelines for low income. Many healthcare providers simply refuse Medicaid insurance,rendering them effectively uninsured. 3% of Americans receive veterans' medical benefits and lastly 15.6% of Americans are uninsured. The percentages add up to more than 100% because some people are counted in more than one category.

One of the areas of confusion in the national health insurance debate is the difference between national health insurance and socialized medicine. Both systems are in operation in the U.S. today. Medicare and Medicaid represent forms of national health insurance, albeit limited to specific populations of people. The Veterans Administration's separate medical care system represents the socialized medicine approach where the government owns and operates all medical facilities. The current national healthcare insurance debate does not include discussion of government-owned facilities. Instead the debate centers on whether there should be a single governmental payor for care, such as an expansion of Medicare or modifying the current private insurance system.

The national health insurance debate is, at its roots, a debate about the role of government in people's lives and money. Proponents supporting NHI present the following arguments:

(1) Government should play a role in safeguarding the health and safety of Americans.

(2) Every American has a right to a basic level of quality healthcare. Access to a minimum level of healthcare IS a right that every American should be able to count on; it's a cost of being a part of our great society.

(3) Reductions in the enormous administrative burden caused by many different insurance programs combined with an emphasis on long term preventive care will more than pay for the increase in coverage costs. NHI will save at least $200 billion annually (more than enough to cover all of the uninsured) by eliminating the high overhead and profits of the private, investor-owned insurance industry and reducing spending for marketing and other satellite services. Global evidence shows that every country that offers some kind of national health insurance experiences lower costs and better outcomes than the United States.

(4) NHI would create a healthier America which in turn will create greater productivity and ability to compete in the world marketplace including helping corporations by equalizing the burden of healthcare across businesses and allowing US corporations to become more competitive in the global economy.

(5) NHI would reduce clinicians' fears of the corporate dominance of medical care,

(6) NHI would make it possible to set and enforce overall spending limits for the health care system, slowing cost growth over the long run.

(7) One of the factors that drives healthcare costs is the plight of the uninsured. These Americans typically do not receive preventive care and avoid seeking medical care until the need is acute. As a result, the cost of providing care for the uninsured is much higher than it needs to be.

(8) NHI would increase choice, highly valued by Americans, as opposed to HMOs which limit choice.

(9) A NHI program will invest in longer term prevention that will improve outcomes across populations.

Those who oppose national health insurance believe:

(1) Healthcare, like any other commodity to be purchased, will be made most effective and efficient by being subjected to the marketplace where competition will drive innovation and quality and efficiency.

(2) They further believe in limiting the role that government plays in people's lives, preferring to provide money directly to citizens so they can make independent choices about healthcare, according to their own needs. The U.S. system acknowledges the American belief that every person has a right to make their own decisions such as purchasing the amount of healthcare they need at a price they can afford. Distributing healthcare creates entitlements that are subject to abuse.

(3) The current government system of Medicare and Medicaid imposes a huge burden of rules to follow and justifications required for reimbursement. This massive bureaucratic overlay would not disappear under NHI. The U.S. has an extremely poor track record of government being able to manage large scale programs effectively; in contrast, corporations have an excellent management track record.

(4) Choice will continue to be eroded under a NHI. Medicare, the model for NHI, uses HMOs as a cost containment strategy.

(5) Many corporations use medical insurance programs as a recruiting and retention tool; NHI would marginalize that competitive advantage.

(6) The U.S. government has shown that when it manages medical care, it reduces costs by making broad cuts across the Board, forcing physicians to be unwilling to accept government programs such as Medicaid.

(7) Most national health insurance programs in other countries create rationing for necessary procedures. "Research has indicated that Medicare and Medicaid patients face obstacles in getting the care they need, such as required prior approval for certain drugs, limits on prescriptions and co-payments that they can't afford." Similar obstacles to care exist in most countries, implemented with the goal of reducing unnecessary costs.

(8) Even though there are many uninsured American citizens, they still receive healthcare when needed.

(9) NHI will establish healthcare as a right. That status will make it very difficult to dial back the system if costs become unmanageable, like the social security situation.

(10) There is only so much money available for healthcare. This money is best used to support public health programs to limit environmental health hazards and the spread of infectious and communicable diseases.

(11) Healthy, responsible people should not be penalized by subsidizing people who choose not to take care of themselves by smoking or overeating. Similarly, young working people should not need to subsidize the elderly.

Is there any middle ground? Although many of the arguments represent polar opposite beliefs, there are some areas of middle ground where a discussion can begin.

(1) The fundamental competitive system of hospitals, physicians and other providers can remain intact, providing choice and driving innovation. NHI is merely a payment mechanism.

(2) It's possible to review and slash some of the administrative burdens and make those a high priority.

(3) Both sides are interested in some government role in matters of health. Although there are analysts who argue against an incremental approach, it may be possible to add another group to the Medicare program, people aged 55 and older, the age where chronic diseases begin to appear.

(4) It would be very useful to increase programs of consumer-directed spending through health savings accounts within the current Medicare and Medicaid systems.

While there may be middle ground, the debate over national health insurance will likely be fought on issues of ideology and finance.