See also: Health care reform debate in the United States, Health care in the United States, Uninsured in the United States, and History of health care reform in the United States
The debate over health care reform in the United States centers on questions about whether there is a fundamental right to health care, on who should have access to health care and under what circumstances, on the quality achieved for the high sums spent, and on the sustainability of expenditures that have been rising faster than the level of general inflation and the growth in the economy. The leading cause of personal bankruptcy in the United States is medical debt which is almost unknown in other countries in the developed world. The United States spends a greater portion of total yearly income in the nation on health care than any United Nations member state except for East Timor (Timor-Leste), although the actual use of health care services in the U.S., by most measures of health services use, is below the median among the world's developed countries.
According to the Institute of Medicine of the National Academy of Sciences, the United States is the "only wealthy, industrialized nation that does not ensure that all citizens have coverage". Americans are divided along party lines in their views regarding the role of government in the health economy and especially whether a new public health plan should be created and administered by the federal government. 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 laws requiring people to have health insurance argue that this impinges on their personal freedom. Both sides of the political spectrum have also looked to more philosophical arguments, debating whether people have a fundamental right to have health care which needs to be protected by their government.
The focus is currently on the recently passed Affordable Health Care for America Act in the House of Representatives, which has yet to be acted on by the Senate, and the Patient Protection and Affordable Care Act, up for debate in the Senate.
Costs
Current figures estimate that spending on health care in the U.S. is about 16% of its GDP. In 2007, an estimated $2.26 trillion was spent on health care in the United States, or $7,439 per capita. Health care costs are rising faster than wages or inflation, and the health share of GDP is expected to continue its upward trend, reaching 19.5 percent of GDP by 2017. In fact, government health care spending in the United States is consistently greater, as a portion of GDP, than in Canada, Italy, the United Kingdom and Japan (countries that have predominantly public health care). And an even larger portion is paid by private insurance and individuals themselves. A recent study found that medical expenditure was a significant contributing factor in 62% of personal bankruptcies in the United States during 2007. "Unless you're Warren Buffett, your family is just one serious illness away from bankruptcy...for middle-class Americans, health insurance offers little protection...," said Dr. David Himmelstein of Harvard University, who helped compile the study.
The U.S. 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 U.S. spent $6,102 per capita on health care, 92.7% more than any other G7 country, and 19.9% more than Luxembourg, which, after the U.S., had the highest spending in the Organisation for Economic Co-operation and Development (OECD). Although the U.S. Medicare coverage of prescription drugs began in 2006, most patented prescription drugs are more costly in the U.S. 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 monopsony purchasing power seen in national single-payer systems. Some U.S. citizens obtain their medications, directly or indirectly, from foreign sources, to take advantage of lower prices.
A study of international health care spending levels in the year 2000, published in the health policy journal Health Affairs , found that while the U.S. spends more on health care than other countries in the Organisation for Economic Co-operation and Development (OECD), the use of health care services in the U.S. is below the OECD median. The authors of the study concluded that the prices paid for health care services are much higher in the U.S.
The U.S. system already has substantial public components. The federal Medicare program covers nearly 45 million elderly and some 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; Native Americans are covered both on the reservation (by tribal hospital), and in the urban setting (by hospitals maintained by the Indian Health Service); merchant seamen are covered by the Public Health System; and retired railway workers and military veterans are also covered by the government.
The Congressional Budget Office has argued that the Medicare program as currently structured is unsustainable without significant reform, as tax revenues dedicated to the program are not sufficient to cover its rapidly increasing expenditures. Further, the CBO also projects that "total federal Medicare and Medicaid outlays will rise from 4 percent of GDP in 2007 to 12 percent in 2050 and 19 percent in 2082—which, as a share of the economy, is roughly equivalent to the total amount that the federal government spends today. The bulk of that projected increase in health care spending reflects higher costs per beneficiary rather than an increase in the number of beneficiaries associated with an aging population." The Government Accountability Office reported that the unfunded liability facing Medicare as of January 2007 was $32.1 trillion, which is the present value of the program deficits expected for the next 75 years in the absence of reform. According to the Centers for Medicare and Medicaid Services, spending on Medicare will grow from approximately $500 billion during 2009 to $930 billion by 2018. Without changes, the system is guaranteed “to basically break the federal budget,” President Obama said at a White House news conference July 22.
Uninsured
Main article: Uninsured in the United StatesAccording to the U.S. Census Bureau, people in the U.S. without health insurance coverage at some time during 2007 totaled 15.3% of the population, or 45.7 million people. According to the Census Bureau, this number decreased slightly from 47 million in 2006 due to increased publicly sponsored coverage in addition to the fact that about 300,000 more people were covered in Massachusetts under the Massachusetts health care reform law in 2007. In 2009, the Census Bureau estimated that there are 47 million Americans who do not have any health insurance at all. Other studies, which complement the Census Bureau and include data from the Agency for Healthcare Research and Quality, have placed the number of uninsured for all or part of the years 2007-2008 as high as 86.7 million, about 29% of the U.S. population, or about one-in-three among those under 65 years of age.
It is estimated that the current economic downturn and rising unemployment rate likely will have caused the number of uninsured to grow by at least 2 million in 2008. Fareed Zakaria wrote that only 38% of small businesses provide health insurance for their employees during 2009, versus 61% in 1993, due to rising costs.
During September 2009, Senator Dick Durbin (D-IL) stated that the average family pays an additional $1,000 per year in insurance premiums to cover the uninsured. President Obama, in his September 9 remarks to a joint session of Congress on health care, called the cost of uninsured Americans "a hidden and growing tax." However, CBO found that while broadening insurance coverage might lead to less cost shifting, "that effect would probably be relatively small and would not directly produce net savings in national or federal spending on health care." The Pacific Research Institute, a conservative think-tank, argues that the uninsured subsidize the insured, do not drive up the cost of health care, and use fewer services than the insured. A 2004 editorial in USA Today asserted that United States Department of Health and Human Services (HHS) data show the uninsured are unfairly billed for services at rates far higher—on average 305% at urban hospitals in California—than are the insured; USA Today concluded that "millions of are forced to subsidize insured patients." According to the editorial:
"Many hospitals say they have to charge the uninsured high 'sticker prices' or risk violating a federal ban on charging Medicare patients more than other customers. Hospitals also must try to collect what patients owe, or they could lose Medicare reimbursement for bad debts, notes a 2003 study by the Commonwealth Fund, a health-policy-research foundation."
Citing data from the Urban Institute and the experience of Massachusetts, the Cato Institute, a conservative libertarian think-tank, argues that without the uninsured, "The insured would pay more, not less."
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