All questions about healthcare reform in the United States eventually boil down to cost:
Should healthcare be a right extended to all American citizens, such as education, police protection or fire protection? Or should Americans be responsible for funding their own healthcare, like they pay for their own food and shelter?
Should the government be responsible for footing part of the bill, or the entire cost of healthcare? Should we be considering a universal health system which could be a cooperative system of public and private payer systems? Or a universal system that would rely on a single payer?
Or should the government step out completely and not participate in healthcare at all?
Is it important that everyone have coverage? Why is it in our best interests that everyone have access to healthcare?
Our current system is a mixed bag of access and coverage, as follows:
- Citizens age 65 and older have access to Medicare, a federal government program that covers the basics of their healthcare needs at no direct out-of-pocket cost to them. Medicare does not pay for all drugs, nor all medical services. These older citizens may purchase additional coverage from private insurers for those services not covered by Medicare.
- Private health insurance through employers is available to employees of businesses that offer health insurance as a benefit. This is the major source of healthcare payment for most people under age 65. Employees may be able to choose from a number of private plans, or the company or organization they work for may be large enough that it insures its employees itself. Employees generally pay for part of the coverage cost themselves in the form of premiums, which are monthly amounts paid into the system.
- Americans under age 65 who cannot afford to purchase health insurance, either because they are disabled, or because they don't earn enough income (each state sets a maximum earning limit) may participate in state-run programs that provide payment for basic health services. These state-run services are supplemented for children through a federal program called SCHIP (State Childrens Health Insurance Program.)
There are an estimated 47 million Americans who are not covered for healthcare services for a variety of reasons, as discussed in the Coverage section of this Healthcare Reform overview. Further, there are an estimated 25 million Americans who are underinsured. If a family member suffered a health problem of any magnitude, they would learn that their insurance would not be adequate. In fact, the journal Health Affairs cites one study that estimated that half the bankruptcy filings in the United States stem from medical problems, despite the fact that more than 75% of the bankruptcy filers had health insurance.
In another study reported in the journal Health Affairs in late 2007, this lack of insurance was also shown to affect mortality. An estimated 101,000 people die each year because they do not have health coverage.
One big sticking point in conversations about how payment should shift when the American healthcare system is reformed is the principle of cost transparency. The current system covers up costs; insurance companies and government programs hide the pricing they have negotiated with providers and drug and device makers, so patients have no idea of the real costs of care.
Healthcare reform experts take a variety of stances on the issue of payment:
Some believe the best answers lie in consumer-directed or consumer-driven healthcare models where patient-consumers are given more control over the choices they make for the care they will receive, based on cost. These experts point out that the free market system works in most other aspects of American consumerism, and healthcare should be no different. Patient-consumers can control their costs through high deductible insurance and health savings accounts. The problem with this system is that healthcare doesn't seem to follow other consumerism models because patients don't really understand how healthcare works. Further the same cost transparency issue mentioned above means patient-consumers do not have the information they need to make those wise choices.
Other experts believe we should have a combination of private and public universal system, one in which everyone who wants coverage, or everyone in general would be covered for healthcare. This is an extended version of what now exists in the United States, and would ensure those who have previously been denied coverage for pre-existing conditions, or those who have not been able to afford it, would have access to the basic care they need.
Still other experts suggest we move to a single payer universal system in which the government would take over all payment for healthcare, subsidized through taxes.
All payment reform discussions must center on who is covered, what services they are covered for, and rationing. Regardless of what our reformed system evolves to, there is little doubt it will frustrate those who come down on the opposite side of the payment argument.
