In his State of the Union address on January 23, 2007, U.S. President George W. Bush presented a plan for reforming the U.S. health care system, asserting that “a future of hope and opportunity requires that all our citizens have affordable and available health care.” (Parish, 128) Bush’s proposal will face an uphill battle in Congress, as the Democrats that now control both chambers typically favor more government involvement in health care than the Bush plan offers. But the president’s attention to the health care issue reflects a growing consensus among lawmakers that the current U.S. health care system is failing, leaving millions of Americans without access to affordable medical treatment.
Two Democratic presidential hopefuls former Senator John Edwards and Senator Barack Obama have already made detailed policy statements about their plans for health care reform, further showing that health care is at the top of the national political agenda. Most lawmakers, while disagreeing about the means, would agree that some nationwide solution to the health care problem needs to be found. (Daschle, 174) But in the absence of such a solution, a growing number of states have stepped in, passing laws that expand health care coverage for their residents. Bush’s address came just days after two governors Arnold Schwarzenegger (R) of California, and Ed Rendell (D) of Pennsylvania announced initiatives to provide universal health care to state residents. Three other states Maine, Vermont and Massachusetts have passed universal health care laws within the last four years, joining Hawaii, which until 2003 was the only state that attempted to provide universal health care. (Parish, 132) Illinois and Pennsylvania have passed laws extending health coverage to all children within the state. The results of these initiatives are being closely monitored, with many observers viewing the states as testing grounds for potential nationwide reform.
Background of a System in Crisis
The all too gradual rise of health care as a key campaign issue came out of the context of stark problems in large scale policy design and implementation over the past decade. (Gardner, 333) This is ongoing failure has led to a system of growing complexity and dysfunction. The U.S. is the only developed country in the world that does not provide health care to all of its residents through a government-funded health system. Instead, most U.S. residents either pay privately for insurance or receive it as a benefit from their employers. The U.S. government does subsidize health insurance for those over the age of 65, through Medicare, and in partnership with state governments for those with very low incomes, through Medicaid. (Dent, 65) But many Americans do not have access to health insurance from any of these sources they do not receive health insurance through their jobs and cannot afford to pay the monthly premiums for private insurance, but do not have low enough incomes to qualify for Medicaid. According to the U.S. Census Bureau, 15.9% of Americans, or about 1 in 6, did not have health insurance in 2005. The actual number was about 46,577,000. Of U.S. children, 11.2% are uninsured, or about 8,310,000. (Kronenfeld, 228) Uninsured families often avoid getting necessary treatment because of the out of pocket expense, and they can face financial ruin if confronted with a serious medical problem requiring expensive care.
The problems currently facing the U.S. health care system are often traced to the 1970s and 1980s, when a combination of expensive improvements in medical technology and an aging U.S. population requiring more long-term care contributed to a precipitous rise in health care costs. Private health insurers raised their premiums in response to the rising costs, and many employers felt they could no longer afford to provide health insurance as a benefit to their employees. (Kronenfeld, 225) This increased the number of working families in the difficult position of making too much money in wages or salary to qualify for Medicaid, but too little to afford to pay for their own health insurance, especially as premiums were rising.
The Bush Plan: Reforming the Tax Code for Equal Access to Health Care
Bush’s plan focuses on changing the tax code in order to make private health insurance policies more affordable to individuals. In the current system, health insurance provided as a benefit from employers is not treated as income subject to income or payroll taxes. So someone who purchases her own insurance is at a disadvantage because she has to pay taxes on any income she chooses to put toward health insurance, whereas an employer-insured individual, even though she might be paid less, receives health insurance tax-free. (Moreira, 352) Bush’s proposal would make employer-provided health benefits taxable in order to “level the playing field for those who do not get health insurance through their job.” (Kronenfeld, 220) At the same time, Bush’s plan would provide anyone who carried health insurance, either privately or through their employer, with a new tax break.
Effectively, any health care policy would be tax-free up to a certain amount ($7,500 for individuals and $15,000 for families). (Hann,125) But plans that exceeded that amount would be taxed, either directly through the new income and payroll taxes on employer-provided health insurance, or indirectly by taxes on the income that would be put toward private insurance. That all matters more than usual because a decade after the failure of Bill Clinton’s health care reform proposals, it’s looking more and more like national health care is going to be back on the political-and therefore the journalistic-agenda over the next few years. CEOS are increasingly antsy about rising insurance premiums, the ranks of the uninsured continue to grow, medical costs are plainly out of control, and more and more people are starting to realize that tying health care to employment makes little sense in an era where the average worker changes jobs every seven years. (Drum, 2008)
Bush and his supporters argue that this plan would equalize access to health care coverage by neutralizing the advantage those with employer-provided health benefits now have, and that it would help the poorest Americans by taxing those with the most expensive health insurance. (Petch, 39) Opponents, however, argue that the plan would destabilize the entire U.S. health care system, which is grounded in the concept of employer-provided insurance. They also question how many people it would actually help, noting that of those Americans with no health insurance, 53% earn so little that they owe no federal taxes and therefore would not benefit from the tax relief. The plan was viewed as very unlikely to succeed in the Democratic-controlled 110th Congress. (Daschle, 186)
Campaign 2008 and Health Care Reform
Senator Barack Obama (Illinois), one of the top candidates for the 2008 Democratic presidential nomination, May 29 unveiled a plan to extend health insurance coverage to the 45 million uninsured people in the U.S., and lower health care costs for all. Speaking in Iowa City, Iowa, Obama said, “It’s time to bring together businesses, the medical community and members of both parties around a comprehensive solution to this crisis, and it’s time to let the drug and insurance industries know that while they’ll get a seat at the table, they don’t get to buy every chair.” (Obama, 2008) Polls showed that health care ranked as voters’ top domestic concern. Under Obama’s plan, the federal government would require employers to either provide health insurance to their employees or pay a tax to fund government insurance plans. To keep costs down, he would also have the government reimburse employers for costs incurred when their workers suffered catastrophic illnesses. (Jonathan, 2007)
“The Obama plan will create a National Health Insurance Exchange to help individuals who wish to purchase a private insurance plan. The Exchange will act as a watchdog group and help reform the private insurance market by creating rules and standards for participating insurance plans to ensure fairness and to make individual coverage more affordable and accessible”. (Obama, 2008)
Obama said he would pay for his plan by allowing the expiration in 2010 of income-tax cuts for people who earned more than $250,000 a year. He said a family of four would save $2,500 per year under his plan. Obama said he would mandate that all children have insurance, but not all adults. (Obama, 2008) The rival campaigns of Senator Hillary Rodham Clinton (New York) and former Senator John Edwards (North Carolina) faulted Obama’s plan for not making health insurance a universal requirement. Edwards had introduced his own health care plan in February. Obama’s resembled it in many respects. The health care plan was Obama’s biggest domestic policy proposal so far. He had faced criticism in recent weeks for speaking in broad terms about the need for optimism and hope, but not offering specific policies.
“Edwards’ plan differs from Clinton’s, however, in requiring all health insurers to spend at least 85 percent of premiums on patient care benefits. It would also change Medicare reimbursement rules to emphasize primary care with the intention of moving the healthcare system toward medical homes. One proposed requirement that could well lead to controversy: mandating that all Americans see a physician regularly for a preventive care checkup.” (Margaret, 2008)
John McCain believes health care reform should tackle the rising costs that intimidate families’ budgets, business competitiveness, and government programs by building the entire system reactive to the needs of American families. Families should get quality, liable care at lesser costs by controlling market competition. John McCain believes that insurance reforms should raise the diversity and affordability of insurance coverage accessible to American families by the development of competition and advancement. “As President, John McCain will work to advance federal research into autism, promote early screening, and identify better treatment options, while providing support for children with autism so that they may reach their full potential”. (McCain, 2008)
Senator Hillary Rodham Clinton (New York), the national front-runner for the 2008 Democratic presidential nomination, September 17 unveiled her plan to provide health insurance for everyone in the U.S., in a speech in Des Moines, Iowa. Clinton emphasized that her plan incorporated lessons she had learned from the failure of a universal health care proposal that she had championed in 1993, during the administration of her husband, President Bill Clinton. “Every man, woman and child should have quality, affordable health care in America. I intend to be the president who accomplishes that goal–finally–for our country,” she said. (Clinton, 2008)
Health care ranked as the top domestic issue of the presidential race. Both of Clinton’s leading Democratic rivals, Senator Barack Obama (Illinois) and former Senator John Edwards (North Carolina), had already proposed similar plans. Clinton said her new plan would extend health insurance to the 47 million people who lacked it, and require everyone in the U.S. to obtain insurance, although she did not say how that requirement would be enforced.
However, she said the plan was designed to avoid the creation of unwieldy new bureaucracies. She also stressed that it would not force change on people content with their current insurance coverage.
“This is not government-run. There will be no new bureaucracy,” she said. (Clinton, 2008)
Instead, she promised that her plan would give people more “choice,” allowing them to obtain coverage either from private insurers or from federal programs. Critics had attacked her 1990s plan as too coercive and bureaucratic, and her advocacy for it as first lady had often been confrontational. Clinton now said that her experience as a senator gave her a better understanding of the compromises that would be necessary to get the legislation passed by Congress.
Clinton Outlines Cost-Cutting Plan
Clinton, known as the architect of a failed 1994 health care overhaul proposed by her husband, President Bill Clinton, May 24 outlined a plan for cutting health care costs by $120 billion, in a speech at George Washington University in Washington, D.C. She said she would present a plan for covering the uninsured later in the year. To cut costs, Clinton called for more focus on preventive health care to cut increasing rates of diabetes, heart disease and asthma. She said she would bar insurers from denying coverage or charging higher premiums for people in poor health.
She also proposed allowing imports of foreign drugs and requiring Medicare, the federal insurance program for the elderly and disabled, to negotiate lower prices with drugmakers. She criticized the drug industry for promoting expensive new drugs that she said were often no more effective than cheaper generic versions. (Clinton, 2008)
Proposes Tax Credits
Clinton called for tax credits to help people afford insurance premiums. She also proposed tax credits for small businesses that offered insurance to employees. But bigger businesses would be required either to provide insurance to their employees, as most already did, or else pay into a government fund to finance such coverage.
The plan would require insurance companies to offer coverage to anyone who applied for it. Clinton vowed to succeed in “eliminating discrimination” by insurers that refused to cover people with preexisting health problems. Clinton said she would finance the cost of the plan, estimated at $110 billion per year, by repealing President George W. Bush’s tax cuts for people with incomes of more than $250,000 a year. She also counted on finding $35 billion in savings from increased efficiency in the health care system.
Republicans Blast Plan
Former Massachusetts Governor Mitt Romney, a top Republican presidential candidate, September 17 blasted Clinton’s health care plan, calling it “European-style socialized medicine.” Romney August 24 had laid out his own plan to expand access to health insurance, relying mainly on tax breaks, as well as incentives that would be offered by the federal government to states if they took steps to reduce the cost of insurance.
Unlike Clinton’s plan–and unlike a health care reform that Romney had pushed through in Massachusetts in 2006–his federal proposal would not mandate that individuals or companies obtain or provide insurance. Conservatives opposed such mandates as a government intrusion on the free market. Former New York City Mayor Rudolph (Rudy) Giuliani, who led the Republican presidential race in national polls, July 31 had outlined his own health care proposal, which envisioned a move away from the existing system of employer-provided coverage. He denounced the plans offered by the Democratic candidates as “socialist.” (Veach, 2008)
Giuliani called for tax exemptions of up to $15,000 per family for people to buy their own insurance. He also said he would propose additional vouchers and tax refunds to help people who could not otherwise afford to buy individual insurance policies.
Although there seems to be agreement that changes in the U.S. health care system are required, disagreement about what to change it to threatens to preclude any major reform. Even among those that agree that health care coverage needs to be expanded, there is still the fundamental question of how responsibility for expanding coverage is to be distributed among businesses, states, the federal government and the uninsured themselves. Another major debate is over how much coverage individuals should receive under any health care reform plan. Bush and his supporters argue that comprehensive coverage is prohibitively costly, while supporters of more inclusive insurance plans argue that consumers have a right to medical treatment for all of their health problems, regardless of expense. Coverage for undocumented immigrants is another major sticking point. Supporters argue that it is inhumane to deny vital medical coverage to any person and that illegal immigrants are often in the lowest economic brackets and therefore unable to pay out of pocket. Opponents argue that taxpayers should not have to pay for the health care of people who enter the country illegally.
Still, the force of so many varied groups agreeing on one fact that the number of uninsured Americans is too high is likely to be a powerful motivator for legislators to work toward a solution. And as the discussion of a national solution continues, many eyes will be on states like Vermont, Maine and Massachusetts, states that observers are already referring to as “laboratories” for health care reform.
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