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Health Care Debates

By: Kerry Dooley Young

Pub. Date: October 18, 2019 Access Date: November 10, 2022

Source URL: https://library.cqpress.com/cqresearcher/cqresrre2019101800

https://library.cqpress.com/cqresearcher/cqresrre2019101800

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Table of Contents

Introduction

Overview

Background

Current Situation

Outlook

Pro/Con

Chronology

Short Features

Bibliography

The Next Step

Contacts

Footnotes

About the Author

Page 2 of 32 Health Care Debates CQ Researcher

Introduction Concerns about how Americans pay for medical care likely will be a dominant theme in the 2020 elections and beyond. While the federal Medicare program provides coverage for those age 65 and older, other Americans worry they will be unable to afford treatment for serious illnesses, even if they have private insurance. As stories spread about high medical costs bankrupting families, lawmakers and policy experts are debating whether the federal government, already the nation's largest purchaser of health care, should expand its role. There is bipartisan interest in finding ways to lower prescription drug costs and protect patients against unexpectedly high hospital charges. But the two parties divide over proposals by Democratic presidential candidates for increased government control, such as Sen. Bernie Sanders' call to replace private insurance with a single- payer plan. Some Democrats suggest more limited approaches, such as creating a public option to compete with private insurers. Republicans defend private insurance, saying it is the most effective way to manage costs.

Laura Marston of Washington, D.C., holds a vial of Humalog, a type of insulin that she takes for her Type 1 diabetes. In the two decades since she received her diagnosis, Humalog's price has risen from $21 per vial to a minimum of $137.35. Soaring drug prices are fueling demands for greater government involvement in health care. (Getty Images/The Washington Post/Jorge Ribas)

Overview A mix of devastating medical bills and draining bureaucratic runarounds led Rebecca Wood of Massachusetts to become an activist, lobbying for a comprehensive nationwide health plan.

After Wood's daughter was born prematurely in 2012, her family's medical expenses quickly exceeded the limit of the insurance coverage provided through her husband's employer. They wound up in need of assistance from Medicaid, the government program that helps those with lower incomes pay for health care. Wood says she had to forgo her own dental care, leading to an infection so severe that all her teeth had to be extracted.

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#top

An audience member holds a sign promoting Sen. Bernie Sanders' Medicare- for-All proposal as Sanders discusses his plan in 2017. Several other Democratic presidential candidates have endorsed some version of the proposal, which calls for the creation of a government-funded single-payer health care system. (AFP/Getty Images/Jim Watson)

In addition to the stress of mounting medical bills, Wood experienced time-consuming runarounds. She told the House Ways and Means Committee at a June hearing about a two-month bureaucratic battle to get her insurer to admit it was obliged to cover a doctor-ordered baby formula that cost $28 a day.

“This is health coverage I paid for. This is a service that they were supposed to provide,” Wood said. “Coverage does not equal access, which is probably one of the most frustrating lessons I've learned.”

Experiences like Wood's are creating growing frustration among consumers that may force lawmakers in Washington to address health care costs, says Frederick Isasi, executive director of Families USA, which supports government actions to lower health costs. Many people fear being unable to afford medical care if they face a serious illness, even if they have paid for health insurance, he says.

“American families are really starting to become completely overwhelmed with the dysfunction in the health care system and the exorbitant prices that are being charged,” Isasi says. “Many of them are forgoing care.”

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Even as the number of Americans without health insurance fell until recently, the ranks of what analysts describe as the underinsured — adults whose out-of-pocket health care costs consume a significant chunk of their income even after paying insurers such as United Healthcare and Blue Cross for coverage — are rising. About 23 percent of adults under age 65 were underinsured in 2018, up from 9 percent in 2005, according to the Commonwealth Fund, a New York group that researches health care issues.

These pressures have created opportunities for limited legislative action on health care, even in a politically divided Congress.

One opportunity may exist in the area of “surprise billing” — cases in which patients are hit with unexpectedly high charges for hospital care after unknowingly seeing a doctor who did not have a contract with their insurer. There is strong bipartisan interest in this issue, as well as in considering ways to lower prescription drug costs.

“While our American health care system does have problems, we should focus on improving what's working and to fix what's broken,” said Rep. Kevin Brady of Texas, the ranking Republican on the House Ways and Means Committee, which has jurisdiction over health care issues.

But lawmakers quickly part company when it comes to more ambitious proposals, such as the “Medicare for All” plan advanced by Sen. Bernie Sanders, I-Vt., and some other candidates for the 2020 Democratic presidential nomination. Sanders calls for a single-payer approach that would provide all Americans with access to care through a government-funded system. Other Democrats, while opposing a single-payer plan, have proposed moderate expansions of the 2010 Affordable Care Act (ACA), such as a so-called public option, that would increase the federal role in health care.

Republicans oppose expanding government involvement, and instead advocate undoing some of the regulations imposed by the ACA, former Democratic President Barack Obama's health care law. The Trump administration in 2018 cleared the way for extended use of so-called short-term insurance plans, allowing consumers to keep such coverage for 36 continuous months. These less expensive plans do not have to meet ACA requirements such as covering prescription drugs, maternity care or pre-existing medical conditions. Republicans also have advocated transferring responsibility for helping people obtain insurance to the states.

These divisions reflect a split between Republicans and many Democrats on a fundamental question.

Insurance agent Rudy Figueora (right) speaks with Marvin Mojica as Mojica shops for health insurance through the Affordable Care Act (ACA) in Miami in 2017. The ACA created health insurance exchanges that now enroll more than 10 million people in private plans. (Getty Images/Joe Raedle)

Republicans defend the role of private insurers, often citing the design of Medicare's Part D pharmacy program as an example. Insurers compete for Part D customers based on what their plans cover and cost, said Senate Finance Chairman Chuck Grassley, R-Iowa, one of the program's creators. In 2003, Grassley fought Democratic calls to design Part D with Medicare serving as the direct negotiator on drug prices.

Republicans argue Medicare for All would result in rationing of care and lower quality. “We have all heard horror stories from abroad about bureaucrats making decisions instead of citizens and long waits for treatment,” said Senate Majority Leader Mitch McConnell, R-Ky.

Democrats say rationing already occurs in the United States. High prices force many Americans to skip doses of needed drugs such as insulin and even forgo cancer treatment. Rationing happens even among the roughly 300 million people who have some form of insurance, either obtained privately or from the government through Medicare or Medicaid.

“Seniors are being forced to choose between paying for groceries and paying for their medicine,” said Sen. Tina Smith, D-Minn. “In the wealthiest country in the world, this is unacceptable.”

The costs of these coverage gaps extend beyond hits to a family's finances, said Sen. Elizabeth Warren, D-Mass., who is seeking her party's 2020 presidential nomination.

Page 5 of 32 Health Care Debates CQ Researcher

“Families pay every time an insurance company says, ‘Sorry, you can't see that specialist.’ Every time an insurance company says, ‘Sorry, that doctor is out of network.’ ‘Sorry, we are not covering that prescription,’” Warren said during a Sept. 12 candidate debate.

Warren and other advocates for expanding Medicare argue the federal government is squandering the leverage it should have in dictating the costs of health care. In the United States, the government's buying power is diluted, because insurers and various states and federal health programs each strike their own deals.

Administrative expenses contribute to the higher costs of health care in the United States, compared with those in the United Kingdom, Canada, Germany and France. Another contributor is more-generous pay for physicians and other medical professionals in the United States than in Europe.

The United States spent about twice as much as other rich nations on medical services and products between 2013 and 2016, but had worse results on markers for good health such as life expectancy and infant mortality, according to a study in the Journal of the American Medical Association.

The current debate often is framed as a choice between government dominance or a robust free market. In fact, the U.S. health care system is a complex mix of private and public initiatives that would be challenging to separate.

For example, more than a third of the 61 million people covered by Medicare have opted to join insurer-run versions of the program.

Medicare pays both publicly traded companies such as Humana and UnitedHealth and ostensibly not-for-profit organizations such as Kaiser Permanente to run so-called Advantage plans, in which coverage is provided through an insurer rather than the government.

Many of these same insurers help states implement their Medicaid programs. In 2012, about 89 percent of those eligible for full Medicaid benefits were enrolled in insurer-managed forms of the program, up from 63 percent in 1999.

The health insurance exchanges created by the ACA represent another public-private partnership. About 10.6 million people are now enrolled in private insurance plans sold through these government exchanges.

At the same time, the federal government provides a large and growing subsidy in the form of a tax deduction for the insurance plans that employers buy to cover some 159 million Americans. This tax break cost the U.S. Treasury $280 billion in 2018, making it the federal government's third-largest investment in health care, according to the Tax Policy Center. It lags only the $583 billion tab for Medicare and the $399 billion in combined funds for the state-federal Medicaid and Children's Health Insurance programs.

Many economists across the political spectrum long have argued that the tax break on employer-sponsored plans is a key contributor to what they call a broken health care system.

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The individuals and families covered by employer-sponsored plans have limited say in selecting them. Brokers who serve as middlemen in the sales of health policies to companies sometimes receive payments from both insurers and employers. Critics have described this arrangement as being akin to a real estate agent representing both the buyer and seller.

Consumers also have little insight into behind-the-scenes agreements between hospitals and insurers. And they have been subject to surprise billing, with many physicians opting out of insurers' networks to demand higher prices. Sen. Lamar Alexander, R-Tenn., chairman of the Senate's Committee on Health, Education, Labor and Pensions (HELP), said the “black box” surrounding costs is one of the reasons health care is so expensive in the United States.

“Patients just don't know how much a particular test and procedure will cost,” Alexander said. “That makes it nearly impossible to adequately plan for future health care expenses, and because of that, the health care system does not operate with the discipline and the cost-saving benefits of a real market.”

Annual health costs incurred by families covered by employers with 1,000 or more employees, including premium contributions and out-of-pocket spending, rose 67 percent, from $4,617 to $7,726, between 2008 and 2018, according to the Peterson-Kaiser Health System Tracker, a partnership of two nonprofit groups, the Peterson Center on Healthcare and the Kaiser Family Foundation.

Average annual premium contributions from employers for family coverage increased 51 percent, from $10,008 to $15,159, in the same period, Peterson-Kaiser found.

Yet despite these significant investments in insurance, Americans often struggle with medical costs. About a quarter of U.S. adults either had trouble paying a medical bill within the past year or share a home with someone who has, the nonprofit Kaiser Family Foundation said.

“People have this sense there's a looming high-cost emergency or illness that could strike at any time, and that they could really be hurt financially because of that,” says Sara R. Collins, an economist who is the vice president for health care coverage and access at the Commonwealth Fund. “It's a valid fear.”

Medical costs contributed to about 67 percent of all U.S. personal bankruptcies in recent years, according to a study led by David Himmelstein, a founder of Physicians for a National Health Program, which supports a single-payer system. Himmelstein describes private health insurance as “a defective product, akin to an umbrella that melts in the rain.”

Even one of the staunchest opponents of expanding Medicare, Rep. Greg Walden, R-Ore., has a negative view of private plans.

“The fact of the matter is that for too many Americans, health insurance coverage exists solely on paper because health care costs and high deductibles are putting family budgets in peril,” said Walden, who is the top Republican on the House Energy and Commerce Committee.

As policymakers, health providers and consumers consider how to meet the challenges of improving the U.S. health care system, here are some of the key issues they are discussing:

Would a government-funded health care system limit access to care?

Critics of Sen. Sanders' Medicare-for-All bill predict that a switch to a single-payer plan would end up denying health care to many people.

“Medicare for All could increase wait times to see your doctor, and be slower to cover lifesaving, innovative treatments than the coverage that Americans use today,” said Sen. Alexander.

Even a limited expansion of Medicare would raise costs for those with private insurance and cause some hospitals to reduce services, according to two powerful lobbying groups.

The American Hospital Association and the Federation of American Hospitals in August released an assessment of the “Medicare X” bill proposed by Sen. Michael Bennet, D-Colo., a long shot presidential candidate. Like former Vice President Joseph Biden, another candidate, Bennet wants a public option to compete with private insurers.

Bennet's plan would phase in a government-run, Medicare-like health plan that would compete with private insurers on the state and federal health exchanges. Because Medicare pays lower rates to doctors and hospitals than private insurers do, hospitals would lose more than $800 billion in revenue over a decade, the report said. Some hospitals would reduce services, and others would seek to raise prices for patients covered by private insurance, leaving many consumers with fewer health care options, the groups said.

The head of the federal Centers for Medicare and Medicaid Services (CMS), Seema Verma, says she sees ample evidence already of how government plans limit patients' access to health treatments. In addition to running the two largest federal health programs, CMS oversees the operations of the ACA-created exchanges.

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Seema Verma, administrator of the U.S. Centers for Medicare and Medicaid Services, speaks at a conference in April. Verma argues that government regulations can limit access to health treatment. (Getty Images/Bloomberg/Kyle Grillot)

“We spend our days trying to unravel government regulations that have led to a lot of the problems in our health care system,” Verma says.

For example, newer medical products, especially if they do not fit neatly into the program's existing categories for payment, often face delays receiving coverage approval, Verma says. CMS then may need to run a process to assess the value of new products, seeking feedback from the public, including makers of rival treatments.

Verma cites as an example the difference in how private insurers and Medicare approached insulin pumps.

Some people with diabetes found themselves in a difficult position as they turned 65 and aged into eligibility for Medicare, she says. The private insurers had been quicker to pay for these small, computerized devices that are intended to mimic how the body naturally produces insulin. But Medicare for many years did not.

If the government served as the single or even an increasingly dominant payer for health care, researchers would face significant delays and hurdles in trying to get new treatments to people in need of them, Verma says. “If you have this huge quagmire even just to provide treatment to people, it's going to slow down innovation and slow down access to more innovative lifesaving treatments,” she says.

But Donald Berwick, who served as CMS administrator in the Obama administration, says a Medicare-for-All approach could dramatically improve the quality of health care.

“I had the honor to help lead ‘Medicare for Some,’ and the successes and potential of that program have given me confidence that a wise choice for this nation would be Medicare for All,” Berwick said.

In Berwick's view, a single-payer plan would eliminate inefficiencies, freeing up money to address urgent needs.

A Medicare-for-All approach could better address rising levels of opioid addiction and maternal mortality rates, Berwick said. This approach also would help remove barriers preventing many people from getting adequate health care, especially preventive care, he said.

“Right now, health care is a repair shop. We wait for people to get sick and then they come into the system,” Berwick said. “There are things we need to do to make sure that no matter what your income or your race is, you can have access to the same quality care.”

Sanders said his plan would fulfill a wish of many Americans by stripping away hurdles insurers put between doctors and patients.

“They want a health care system which guarantees health care to all Americans as a right,” Sanders said. “They want a health care system which will lower health care costs and save them money. They want a health care system which will guarantee them freedom of choice as to which doctor or hospital they can go to.”

Medicare for All would help people younger than 65 if they face debilitating disease, said Rep. Jamie Raskin, D-Md. He cited his own experience undergoing radiation, chemotherapy and surgery for advanced colon cancer. He had what he considered great insurance at the time, but it made him worry about people who face serious illness without such generous coverage.

Page 8 of 32 Health Care Debates CQ Researcher

“If you experience such a misfortune and you get such a diagnosis and you can't get health care, because you love the wrong person or you lost your job or you're not working or you're too poor, that's not a misfortune,” Raskin said. “That's an injustice because we can do something about that.”

Would a single-payer approach overwhelm the federal budget?

Sen. Sanders showed unusual interest in a 2018 report from a right-leaning think tank, the Mercatus Center, whose board of directors includes philanthropist and conservative activist Charles Koch. Sanders long has been a critic of Koch and his late brother, David Koch, for their efforts to reduce taxes and regulations.

Charles Blahous, a former Republican congressional and White House staffer now working at Mercatus, had sought to emphasize how Sanders' bill would increase the federal budget. The bill would have led to a cumulative federal spending increase of about $32.6 trillion during its first decade of full implementation, Blahous said in his report.

But what caught Sanders' attention was another calculation in the report. It showed a cumulative drop of $2 trillion in total national spending on health care in the same decade. Most of the expected savings — $1.57 trillion — could come from a drop in administrative costs, and not to any reduced services for Americans.

In a July 2018 video, Sanders thanked the Koch brothers, “of all people,” for funding the Mercatus Center that produced this savings estimate.

“A Medicare for All health care system would save the average family significant sums of money,” Sanders said. “It will do that by substantially reducing the administrative costs now taking place as a result of the billing, bureaucracy and insatiable greed within the insurance industry.”

Sanders and fellow Medicare-for-All advocates say their approach would stop the flow of money to the insurance companies. This would direct more spending to actual medical services, eliminating private insurers' administrative expenses and the bite they take in premiums to pay shareholders' dividends. The federal government also would have new bargaining power to rein in costs by providers.

Economists from the University of Massachusetts, Amherst, in 2018 said Medicare for All could reduce total annual national health care spending to $2.93 trillion from the current level of $3.24 trillion. In reviewing this estimate, Columbia University economist Jeffrey Sachs said the Medicare-for-All approach “promises a system that is fairer, more efficient and vastly less expensive than America's bloated, monopolized, overpriced and underperforming private health insurance system.”

But Blahous was skeptical of Sanders' predicted cost reductions.

Actual spending on health care likely would be “substantially greater” than the estimates in the report, as physicians, hospitals and other providers of medical care would defeat a bid to cut their payments, Blahous wrote.

Charles Blahous, then a public trustee of the Social Security and Medicare programs, speaks at a 2014 news conference. In a 2018 study, Blahous found that a Medicare-for-All program would increase federal spending by $32.6 trillion over a decade — but also could cut total national spending on health care by $2 trillion over the same period. (AP Photo/Susan Walsh)

Blahous has deep expertise in Medicare, having served from 2010 to 2015 on the program's board of trustees. He warned that Congress would face intense lobbying if it sought to carry out Sanders' cost reductions.

“To lend credibility to the $2 trillion savings number, one would have to argue that we can cut payments to providers by about 40 percent at the same time as increasing demand by about 11 percent,” Blahous said.

Page 9 of 32 Health Care Debates CQ Researcher

These kind of political questions complicate efforts to estimate what a new federal health plan might cost, says Cori Uccello, an actuary and the senior health fellow at the American Academy of Actuaries.

Cutting or slowing Medicare spending has proven difficult, as industry trade groups can pressure members of Congress to try to block payment reductions, she says. Uccello previously served as a member of an influential congressional research board, the Medicare Payment Advisory Commission. In this role, Uccello saw how industry groups rallied to fight proposals meant to reduce their Medicare payments. These groups likely would respond the same way under a government-run system, she said.

Several other researchers have tried to estimate what the federal government would spend on a single-payer program.

The Committee for a Responsible Federal Budget, which advocates fiscal restraint, has cited estimates of roughly $28 trillion over a decade. Ken Thorpe, an Emory University health care expert and a former adviser to Democratic President Bill Clinton, pegged the decadelong costs at $24.7 trillion, plus an additional $3 trillion for long-term care benefits. The liberal-leaning Urban Institute estimates it at $32 trillion while the conservative American Action Forum has a $36 trillion estimate.

The Congressional Budget Office (CBO), which advises Congress on fiscal issues, has so far not produced a cost estimate on a Medicare-for-All plan. Instead, CBO in May released a report outlining the issues lawmakers would need to consider in designing a plan. The report provided fodder for both sides in the debate. For example, single-payer systems are more prone to have waiting lists, CBO said.

But, as Sanders emphasizes, Medicare diverts less of its money to administration, the report concluded. CBO said the federal government's 2017 cost of administering Medicare accounted for 1.4 percent of total program expenses. That figure rose to 6 percent when the costs of the insurer- run parts of Medicare, the Advantage program and prescription drug plans, were included, CBO said. But private insurers' administrative costs averaged 12 percent.

For many consumers, the key question is how expanding the federal role in health care would affect their own finances.

New taxes on both employers and wage earners would be needed to cover the costs of a more expansive federal plan.

But that means the government would collect the revenue for health care from taxpayers and use it to pay doctors and hospitals, said Dean Baker, an economist with the liberal Center for Economic and Policy Research. In doing so, the federal government would replace employers who now pay insurers with money they would otherwise pay to workers. Employers in 2018 paid more than $900 billion to insurers, which keep a slice of these funds as payments for administering health plans.

“Employers don't provide insurance as a gift, and premiums for insurance come out of workers' wages in the same way that a tax would come out of those wages,” Baker said. “Most workers would probably not object if their employers paid this money to the government for universal coverage as opposed to an insurance company.”

Sanders said he expects companies to redirect to their workers the funds now spent on buying private insurance if Medicare for All is enacted. Biden, who has been critical of the single-payer approach, depicted this as naive during a September presidential debate.

“For a socialist, you've got a lot more confidence in corporate America than I do,” Biden told Sanders.

Would Americans accept the end of the private health insurance system?

The American Medical Association (AMA) long has been a powerful and effective opponent of a single-payer system. It is largely credited with derailing Democratic President Harry S. Truman's 1945 bid for a “universal” national health insurance program. Tapping into the era's fears about communism, the AMA attacked Truman's idea as “socialized medicine.”

Yet, in June, the AMA's policymaking arm nearly reversed its position. Its House of Delegates only narrowly defeated a resolution that would have overturned the organization's opposition to single-payer, with 47 percent voting for the measure. People took notice.

“Bottom-line: there is a large segment of the House of Delegates who support single payer (or don't want AMA to oppose them) or public option approaches, as well as AMA's new policies to close coverage gaps” in the ACA, tweeted Robert Doherty, senior vice president for government affairs and public policy at the American College of Physicians. “This would have been unimaginable in years past.”

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Backers of a single-payer plan point to Americans' dissatisfaction with the current system as evidence the public will embrace major change.

“I have never met one person who loves their insurance company. I have met many people who do love their doctors and their nurses, who have very good experiences in their hospitals,” Sen. Sanders said. “And what we do is to say, you can go to those doctors, you can go to those hospitals, but you're not going to have to any more deal with rip-off insurance companies.”

But support for Sanders' plan wanes as people learn more about it, according to polling done by the Kaiser Family Foundation. About 51 percent of those polled in October said they supported a single-payer approach. But that approval rate dropped to 26 percent when people were told about potential delays in medical treatments under a national Medicare-for-All plan.

A leading expert on private and public insurance, Gail Wilensky, says it would be difficult to persuade people to drop employer-sponsored insurance. Wilensky oversaw Medicare in the George H.W. Bush administration and then served as chair of the Medicare Payment Advisory Commission. She also has been on the board of directors of the nation's largest private insurer, UnitedHealth, since 1993.

“Even when people have complained, they are hesitant to give up something they know for something that's unknown,” Wilensky says.

And some of Sanders' presidential rivals doubt that Americans are ready for a change on the scale he has proposed.

A single-payer plan would force millions of people to quickly transfer into a newly established government plan, said Sen. Amy Klobuchar of Minnesota. “I don't think that's a bold idea, I think it's a bad idea,” she said.

Klobuchar instead favors creating a government-backed insurance plan that would compete with private ones, the public option approach.

Another candidate, Pete Buttigieg, the mayor of South Bend, Ind., said the main problem with Sanders' plan is that “it doesn't trust the American people. I trust you to choose what makes the most sense for you. Not my way or the highway.”

A significant number of people would likely opt for some form of public plan if one were available, says Billy Wynne, who served as an adviser to then-Senate Finance Chairman Max Baucus, D-Mont., from 2006 to 2008.

Congress is unlikely to create a single-payer plan, which would eliminate most or all private coverage, Wynne says. But he sees a chance for creation of a public option, which consumers might see as more likely to protect them against high health care costs.

“There is an appetite there, but there isn't an appetite to have insurance taken away from people,” he says.

At least one industry group has predicted significant interest in a public option. The report done for the American Hospital Association and the Federation of American Hospitals sees a rapid adoption of Sen. Bennet's Medicare-X plan if it were enacted. Under this plan, consumers would have the option of buying a plan modeled on Medicare, with their premiums set to cover the full cost of the plan, including administrative expenses.

“Medicare-X Choice would result in significant changes in the health insurance landscape, with 36.5 million people leaving private coverage for the new government-run public option, and 5.5 million individuals without insurance gaining coverage,” said the report.

Bennet's plan would be sold on the ACA's existing exchanges that are operated by the federal and state governments. It would be introduced first in areas where the exchanges offer few options, as is the case in rural Colorado. Bennet's bill proposes that by 2024, Medicare-X would expand to every ZIP code in the country.

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As of early October, polls showed Bennet was trailing in the crowded Democratic presidential field. But three stronger contenders — Klobuchar, Sen. Kamala Harris of California and Sen. Cory Booker of New Jersey — were among the 11 co-sponsors of his bill. Separately, Biden also has proposed creating a public option.

The Democratic proposals fail to address consumers' chief concern about health care, says David Merritt, executive vice president of public affairs for the trade group America's Health Insurance Plans.

“It doesn't matter if you are Republican, a Democrat or an independent, everybody is worried about cost,” Merritt says. “Many of the solutions that are being proposed don't address cost at all.”

Democrats will not want to pay more for health care, whether they are sending their money to insurers or a federal plan, Merritt says. He says lawmakers should instead focus on such issues as surprise billings and the high cost of prescription drugs.

Background Early Insurance

In 1798, President John Adams signed a bill establishing the first federal health program. The Act for the Relief of Sick and Disabled Seamen created a marine hospital service to treat injured and ailing sailors employed by private shippers. The law called for a monthly deduction of 20 cents from the pay of merchant seamen for a hospital tax, the first prepaid medical care plan in the United States.

Commercial health insurance plans also have a long history in the United States. The Massachusetts-based Franklin Health Assurance Co. may have sold the first such policy in 1850. For a 15-cent premium, the policy paid $200 if its holder was injured in a railway or steamboat accident. By 1899, 47 insurers wrote 463,000 policies that would pay in case of accidents.

The mining, railway and lumber industries established insurance plans during the 1870s and 1880s that foreshadowed the rise of health maintenance organizations (HMOs). Workers in these industries faced serious health risks and often were sent to remote locations where care was not available. So companies established clinics that prepaid doctors fixed monthly fees to provide care to their workers.

Germany took a different tack in 1883, when it created the first national health care financing system. Under the change, citizens contributed to a common fund that offered populationwide health care benefits.

By the early 20th century, health care in the United States was becoming increasingly linked to employment. In 1910, the catalog store Montgomery Ward and Co. set up a group plan to pay as much as half of an ill or injured employee's weekly salary. Throughout the century, presidents from both parties called for major changes in health insurance, but made only piecemeal progress in changing federal laws. At the same time, private insurance grew in new ways.

In 1912, Theodore Roosevelt's “Bull Moose” party made national health insurance a main plank in its platform. Presidential candidate Roosevelt called on employers, employees and society at large to use insurance to safeguard Americans from “the hazards of sickness, accident, invalidism, involuntary unemployment and old age.”

In 1929, the Dallas school system established sickness insurance to protect teachers against impoverishment.

The federal government took two steps during World War II that fostered the creation of private insurance plans. In 1942, Congress passed a bill limiting wage increases, which made health insurance an alternative way to draw and retain workers. The following year, the IRS ruled that employees would not have to pay taxes on company-provided health insurance.

In 1945, physician Sidney Garfield and industrialist Henry J. Kaiser expanded on the concept of prepaid medical care for workers in dangerous industries by introducing their Permanente Health Plan. Within about a decade, the plan's enrollment topped 300,000, due largely to the support of two labor groups, the International Longshoremen's and Warehousemen's Union and the Retail Clerks Union.

Government Plans

Also in 1945, President Truman issued a call for a national health insurance system. “In a nation as rich as ours, it is a shocking fact that tens of millions lack adequate medical care,” Truman said. But the AMA fought the plan, and Truman eventually dropped it.

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President Lyndon B. Johnson displays the bill creating the Medicare program to provide health insurance for those ages 65 and older in 1965, while former President Harry S. Truman holds up the pens Johnson used to sign it. Truman first proposed a universal national health care plan 20 years earlier. (Getty Images/Bettmann)

Truman's idea persisted, however. In homage to his Democratic predecessor, President Lyndon B. Johnson chose Truman's hometown of Independence, Mo., for a 1965 signing ceremony for the century's most sweeping U.S. health legislation. While smaller in scope than Truman's vision, the law created Medicare for people ages 65 and older and Medicaid for those living in or near poverty. Medicaid also covered long-term care for older Americans who could not otherwise afford it. “No longer will older Americans be denied the healing miracle of modern medicine,” Johnson said. (By 2019, Medicare and Medicaid together would pay for the health care of more than 100 million people, or almost one in three Americans.)

Other developed nations with democratic traditions opted in the mid-20th century to cover their entire populations through government plans. In 1948, the United Kingdom created the National Health Service, which provided care based on need rather than ability to pay. Canada's federal government in 1966 moved to provide publicly funded medical care insurance plans, splitting costs with the nation's provinces and territories.

In the early 1970s, Republican President Richard M. Nixon advocated creating a comprehensive health insurance program. In his 1974 State of the Union address, he proposed a plan to provide health insurance for “millions of Americans who cannot now obtain it or afford it.” Although Nixon's proposal drew serious attention in Congress, it fell by the wayside as the Watergate scandal engulfed his presidency.

Nixon left a more lasting mark when he signed into law a 1973 bill that required businesses with more than 25 employees to offer at least one HMO plan. These were intended to offer more coordinated and comprehensive coverage than unstructured fee-for-service health insurance. In 1982, Republican President Ronald Reagan expanded the role of HMOs in Medicare by signing a law that made these programs more attractive for insurers.

Notable Stumbles

But Reagan suffered a major setback with another health law, the Medicare Catastrophic Coverage Act of 1988, which was repealed the following year amid widespread protests. The law shielded senior citizens from potentially devastating hospital bills and created a Medicare drug benefit. But affluent seniors objected to being taxed to pay for the extended benefits.

An angry crowd greeted House Ways and Means Chairman Dan Rostenkowski, who had organized an event in his Illinois district to explain the law. One senior citizen jumped on his car's hood and others shouted “coward,” “recall,” and “impeach.” “These people don't understand what the government is trying to do for them,'' Rostenkowski complained as he tried to outpace his pursuers.

President Clinton's proposal for a broad health care overhaul had even less success than Reagan's and Rostenkowski's.

With first lady Hillary Clinton serving as a key adviser, Clinton in 1993 unveiled a plan in which most Americans would get their coverage through large regional purchasing groups called health alliances. Employers would be required to pay 80 percent of their employees' premiums.

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First lady Hillary Rodham Clinton displays a copy of President Bill Clinton's health care plan at an event in Baltimore to promote it in 1993. She served as a key adviser in drafting the plan, which failed to win congressional approval. (AP Photo/Joe Marquette)

Opponents ranging from talk-radio hosts to conservative Republican lawmakers portrayed the plan as a bureaucratic takeover by welfare-state liberals.

Insurers also fought the plan, saying it would hurt their profitability. An influential television ad, part of a campaign by the Health Insurance Association of America, helped torpedo the plan. Featuring a fictitious couple, Harry and Louise, the ad stoked public anxieties. Would health care decisions be left to government bureaucrats?

Clinton's proposal never even came up for a floor vote. But in 1997, Clinton signed into law a bipartisan budget deal that created the state-federal Children's Health Insurance Program (CHIP). The program was intended to secure medical care for children in families with too much income to qualify for Medicaid but too little to afford private insurance. (As of July 2019, 6.6 million were enrolled in CHIP.)

Public-Private Combinations

Spiraling drug prices put pressure on Congress in the early 2000s to revisit a Medicare drug benefit.

In the debate over this benefit, many Democrats fought to have Medicare directly negotiate with pharmaceutical companies to pay for these medicines. Their goal was an expansion of the traditional Medicare program.

But Senate Finance Chairman John Breaux, D-La., worked with Republican leaders to create a drug benefit that private insurers would administer. Their 2003 Medicare Modernization Act also was designed with a planned interruption in coverage, known as a “donut hole.” Senior citizens' drug coverage would lapse at a set threshold and resume only if they faced very high pharmacy bills. Republicans described this feature as giving consumers “skin in the game,” encouraging controlling spending by seeking generic drugs where possible.

Democrats were angered that the drug plan, known as Medicare Part D, broke with tradition and charged higher premiums for wealthier senior citizens. (In 2019, the extra premium applied to Medicare enrollees with annual incomes topping $85,000, or $170,000 for couples.) In a 2003 speech, House Ways and Means Chairman Bill Thomas, R-Calif., argued this approach was needed to address Medicare's rising costs.

“No one wants to place a financial burden on those unable to pay,” Thomas said. “But, my friends, it is overdue to ask those who are financially well-off enough to share.”

Confusion and disappointment surrounded the 2006 introduction of Medicare's drug benefit. Many seniors expected a more straightforward addition of drug coverage to their traditional Medicare benefits. Instead, they were asked to choose among competing insurer-run drug plans.

In 2006, Massachusetts enacted a law proposed by Republican Gov. Mitt Romney that set the stage for creation of the federal Affordable Care Act.

The Massachusetts plan, soon dubbed “Romneycare,” expanded Medicaid coverage to the working poor, with the federal and state governments sharing the cost. Romneycare rested on an underlying principle of shared responsibility, through its use of an individual mandate — residents were required to obtain health coverage if an affordable plan was available or face a financial penalty. Businesses that employed 11 or more workers were held financially accountable if they failed to make a “fair and reasonable” contribution to their employees' health coverage.

Although Romneycare was a model for the Affordable Care Act, the ACA passed without any Republican support in Congress. It expanded Medicaid and included an insurance mandate. It also created subsidies to help Americans with low incomes buy private health insurance plans. President Obama signed the ACA — soon called “Obamacare” — into law in 2010.

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The ACA's suite of health initiatives still fell short of many Democrats' goals, in that it lacked a public option. Democrats initially sought to attract some GOP support by including ideas that some Republicans had supported in the past, such as the mandate for people to have health insurance.

While this gambit failed to gain any Republican votes for the bill, it won the support of the insurance industry.

The ACA also provided significant federal assistance for states to raise their income limits for Medicaid. This Medicaid expansion aided many people who work but still cannot afford health insurance. But the Medicaid provision suffered a blow in one of the first legal challenges to the ACA.

The U.S. Supreme Court in 2012 essentially upheld the law's constitutionality, characterizing the insurance mandate's financial penalty as a tax. But in this decision, National Federation of Independent Business v. Sebelius, the court also limited the federal government's power to compel states to expand their Medicaid programs.

As of September, 36 states and the District of Columbia had opted to take federal aid to expand their Medicaid programs. The holdouts include states with the highest rates of poverty, such as Mississippi and Alabama, and some with the largest numbers of uninsured residents, such as Texas and Oklahoma.

Congress has repeatedly changed the ACA since its enactment. It passed bipartisan bills that have delayed or undone cost-saving measures included in the law, such as its tax on employer-sponsored health plans deemed too generous. Democrats have joined Republicans in passing legislation that delayed the start of this “Cadillac” tax. And this July, the House passed a bill repealing the tax in a 419-6 vote.

Under President Trump, congressional Republicans repeatedly tried without success to repeal the ACA. But in December 2017, a new tax law eliminated the penalty on individuals who do not buy health insurance.

Republican state attorneys general and governors then challenged the ACA's legality, arguing that ending the penalty makes the entire law invalid. In 2018, federal Judge Reed O'Connor in the Northern District of Texas agreed, setting up the potential for yet another Supreme Court decision on the validity of all or major parts of the law.

Current Situation Debates Continue

Amid signs the ACA's coverage gains may be receding, health care remains a dominant issue in Congress and the states. In 2018, 8.5 percent of Americans of all ages, or 27.5 million, did not have health insurance at any point during the year, an increase from 7.9 percent, or 25.6 million people, the previous year. (Still, before the law took effect, about 51 million Americans were uninsured.)

On the campaign trail, Democratic presidential candidates continue to debate how much more deeply the federal government should become involved in the nation's health care. Sens. Sanders and Warren remain committed to a single-payer plan, while their rivals explore a more piecemeal expansion.

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Sen. Booker, for example, is a co-sponsor of five pending Senate bills that would expand the federal government's role in health care. He supports Sanders' single-payer proposal. Booker also backs a bill from Sen. Brian Schatz, a Hawaii Democrat, that would create a state-based public option and allow people to buy into Medicaid programs regardless of income.

And Booker supports three different Democratic Medicare expansion bills, including Sen. Bennet's Medicare-X. Sen. Jeff Merkley, D-Ore., has a similar proposal, seeking to add a Medicare option to the state and federal insurance exchanges.

Buttigieg in September put forward a plan he called “Medicare for all who want it.” He envisions having a public option compete with private insurers. His approach, he said, would help address the root causes of rising health care costs.

“I really do believe the public alternative will be better. It could well be the glide path that leads to a Medicare-for-All environment,” Buttigieg said. “I just don't think it's a good idea to command Americans to adopt Medicare for All whether they want it or not.”

Still, analysts doubt Congress will act anytime soon. Instead, states may take the lead in these efforts.

Democratic presidential candidates Pete Buttigieg, Bernie Sanders, Joe Biden, Elizabeth Warren and Kamala Harris (left to right) appear at a debate in Houston in September. The candidates' differing approaches to health care coverage formed a major focus of the debate. (Getty Images/Win McNamee)

In Washington state, a new law will allow the state to contract with private insurers to offer lower-cost, tightly regulated plans on an insurance exchange by 2021. The law sets payment rates for physicians and other medical professionals at no more than an average of 160 percent of Medicare rates. The plan, known as Cascade Care, is a hybrid public-private system in which the state will contract with other insurers to administer its operations while retaining control of costs. Democratic Gov. Jay Inslee calls this plan the nation's first “public guarantee” of health insurance access.

President Trump in October praised the Medicare Advantage plans offered by private insurers and asked the Department of Health and Human Services to develop proposals to allow the plans to offer more services and to embrace long-distance “telehealth” services. Trump portrayed his order as an alternative to Democratic proposals to expand Medicare.

In Congress, members of both parties are digging into the issue of surprise medical billing, while awaiting a federal appeals court ruling on the Texas judge's decision invalidating the ACA.

Sen. Patty Murray of Washington, the ranking Democrat on the HELP Committee, noted the dual challenges for Congress at a June markup of several bipartisan bills.

The committee is heading efforts to address cases where Americans routinely receive six-figure bills from hospitals due to limits in the coverage provided by their health insurance. The panel's Lower Health Care Costs Act would require patients to pay only in-network cost-sharing amounts for out-of-network emergency care.

“While all of these steps are good, they are absolutely not enough,” Murray said. “The biggest threat to families' health care continues to be sabotage from President Trump.”

The Justice Department originally said it would appeal the Texas ruling in the ACA case, but later said it backed invalidation of the law, breaking with the department's tradition of defending federal laws in the courts.

“Decisions not to defend federal law are exceedingly rare,” said Katie Keith, a lawyer who advises nonprofits and foundations on health care. “It seems even rarer to change the government's position mid-appeal in such a high-profile lawsuit that risks disrupting the entire health care system and health insurance coverage for millions of Americans.”

The Justice Department argued in its brief that Judge O'Connor was correct in his conclusion that eliminating the financial penalty for not buying insurance effectively invalidated the rest of the law.

Some congressional Republicans worry about what will happen if the ACA is struck down.

“Whatever happens, we don't want millions of people to lose their health insurance,” said Rep. Larry Bucshon, R-Ind., who is a physician. “If the Supreme Court ultimately decides the ACA is unconstitutional, Congress will need to act very quickly to make sure that no one loses their health coverage.”

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Many Republicans now embrace the ACA's highly popular guarantee of coverage for people with previously diagnosed medical conditions, such as diabetes and cancer. Walden of the Energy and Commerce Committee advocates giving lawmakers the chance to vote on a measure narrowly written to affirm the ACA's pre-existing conditions provision in light of the continuing legal challenge.

“That would be an easy vote,” Walden said. “We could all vote for it.”

Democrats are unlikely to allow Republicans to score such an easy political win while the GOP is seeking to roll back other parts of the ACA such as the Medicaid expansion. But Walden and other Republicans are continuing to work with Democrats on a popular cause: addressing surprise medical bills, particularly because of the role played by private equity firms. These firms often have financial stakes in businesses that staff emergency rooms.

“We have evidence where they buy the practice, take the physicians out of network and raise the rates by 96 percent,” Walden said. “Guess who is paying that? It's people like you and me and our constituents.”

In some cases, physicians employed by the staffing firms compensate hospitals for allowing them to engage in an out-of-network strategy. About 18 percent of emergency room visits made in 2017 by people with health care provided by large employer coverage involved at least one out-of- network charge, according to a survey by Peterson-Kaiser Health System Tracker.

There is growing public outrage about surprise bills, says Marty Makary, a Johns Hopkins University physician and researcher who has studied what he describes as “predatory” hospital billing practices.

In his 2019 book, The Price We Pay: What Broke American Health Care — And How to Fix It, he recounts stories of people whose credit ratings were destroyed when they struggled to pay inflated medical bills. He says that some hospitals will mark up bills to as much as 23 times what Medicare pays for service, and then quickly contract with collections agencies to demand payment.

Makary says he worries the “money games” may erode patients' faith in medicine. A patient who had been overbilled for a minor procedure may avoid a return visit to a physician for needed medical care. The medical community, Makary says, needs to know more about the challenges their patients face and adds that the middlemen are out of control.

“Our research shows most doctors were not even aware of the most extreme and aggressive predatory billing practices done on their patients,” he says. “Our services as physicians are being bought and sold and traded on a grid like energy.”

The American Medical Association argues that insurers are at fault for what it terms “balance billing.” Insurance companies are reducing the size of their clinician networks to save money, thus increasing the odds a patient will see a physician outside of their insurer's networks, the AMA said.

But the insurers' trade group sees it differently. Some physician groups recognize they have leverage in certain markets and use it to bill amounts that do not reflect the actual costs of care or good-faith negotiations, said America's Health Insurance Plans. The group said research has found emergency medicine physicians, anesthesiologists, radiologists and pathologists are most likely to generate surprise medical bills.

Outlook Election Calculations

Congress might send President Trump a bill to take a few steps to address health costs, even though the chances for clearing major legislation ahead of the 2020 election are dwindling, says Joel White, president of the Council for Affordable Health Coverage, a coalition that includes employers, insurers, patient groups, brokers and agents. There's strong bipartisan agreement, for example, of the concept of a cap on how much people enrolled in Medicare will have to contribute to their drug coverage.

“That's the one that's top of the list,” says White, who is a former Republican Ways and Means staffer.

These near-term changes in health policy are likely to be attached to another larger bill rather than move on their own, he says.

Merritt, the America's Health Insurance Plans executive, says lawmakers tend to be less productive in election years, when all members of the House and one-third of the Senate face re-election. In 2020, the presidential contest will likely further complicate efforts to pass legislation. That could delay significant legislation on even widely supported issues until 2021, Merritt says.

“There's strong bipartisan interest in certain issues such as surprise billing and unaffordable drugs. That makes it likely that Congress will return to these issues if they remain unresolved at the end of the current session,” Merritt says. “Hopefully they can come back to them and get something done.”

It's highly unlikely, though, that Congress will pass the kind of transformative legislation backed by Sanders anytime soon, says Merritt.

Wynne, the former Baucus aide, agrees. Instead, a Democratic president may join with states to move toward the creation of public options, Wynne says. In doing this, they may borrow an approach used by Trump.

While Republican lawmakers often talk about repealing the entire ACA, they have found parts of the law useful.

To try to lower medical costs, the ACA's system of waivers permits states to amend insurance rules. The law also created the Center for Medicare and Medicaid Innovation, which allows the government to approve alternative approaches to payment for health care, with an aim of lowering costs.

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A proposal such as the bill sponsored by Sen. Debbie Stabenow, D-Mich., to allow people ages 50 to 64 to buy into Medicare could be implemented through these ACA programs, avoiding a long and likely unsuccessful fight in Congress, Wynne says. Even if Democrats regain Senate control, the politics of a Medicare expansion might still prove thorny, he says.

A Democratic president “will be looking for other ways forward and waiver authority seems like the obvious route to go,” he says.

Another veteran of Washington health policy battles, Liz Fowler, says the United States may eventually get to a point where all of its citizens have access to health care.

After all, many other rich nations already have achieved this, says Fowler, who helped lead the drafting of the ACA when she was chief Democratic health counsel on the Senate Finance Committee.

“Never give up on the possibility that we can achieve universal coverage,” says Fowler, now with the Commonwealth Fund. “I really believe it's possible in this country. How we get there is another question.”

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Pro/Con Would a government-funded system improve access to health care?

Pro Pramila Jayapal Member of Congress, D-Wash.. Written for CQ Researcher, October 2019

Medicare for All would provide universal coverage, dramatically improve health outcomes and save us money in the long run.

Our current health care system is broken and families are suffering. Almost 70 million people are uninsured or underinsured. Among our developed-country peers, we have some of the highest maternal and infant mortality rates and the lowest life expectancy. And yet we spend significantly more on health care than the rest of the world — $3.9 trillion annually, or 18 percent of GDP. Private insurance premiums skyrocket while wages stagnate. More than 500,000 Americans file for bankruptcy every year due to medical costs, and one-third of Americans skip medications or avoid the doctor because of cost.

The Expanded and Improved Medicare for All Act changes this. It improves Medicare by including comprehensive coverage: primary care, vision, dental, prescription drugs, mental health and substance abuse, long-term services, maternal health care and more. It expands Medicare to everyone, with no premiums, copays or deductibles. The government provides guaranteed and comprehensive insurance to everyone so that no one has to worry about insurance when they lose or change a job or start a small business. Patients can see the same doctors and hospitals they currently use, and will have even more choice because they no longer have to worry about out-of-network providers.

Medicare for All is about how we finance our system, not who provides care. Most Americans are happy to get rid of private insurance; they just want to know they can keep their doctors and hospitals. Medicare for All would allow the delivery of medical services to remain largely in the private sector. Rural and safety net hospitals would no longer have to worry about uncompensated care, and all hospitals and clinics will be guaranteed the revenue they need to be sustainable and operate at maximum capacity.

Industry lobbyists don't want you to know that 25 to 30 percent of health care spending goes to wasteful administrative costs and excessive CEO salaries of for-profit insurance companies and pharmaceutical companies. By cutting out these middlemen and streamlining health insurance into one system, Medicare for All saves us hundreds of billions of dollars while ensuring that Americans no longer must choose between cancer treatments and mortgage payments or depend on charity with GoFundMe campaigns.

The scale of our crisis is too big to tinker around the edges; it's time for the bold, transformative solution of Medicare for All.

Con Buddy Carter Member of Congress, R-Ga.. Written for CQ Researcher, October 2019

One of the worst things the Affordable Care Act (ACA) has done to our health care system is remove the free market while greatly reducing or eliminating competition. Without competition, companies do not need to compete for patients' business and have no incentive to lower costs or increase the quality of care.

For example, in my home state of Georgia, patients in 118 out of 159 counties have only one insurer on the health care exchange to choose from. These patients have no choice at all and insurers have no reason to lower costs or increase care. If we want to make health care more affordable and accessible and increase quality of care, we must put the free market back into the system. Unfortunately, we're seeing plans that would do the opposite.

Creating a one-size-fits-all, government-run, single-payer health care system would be a disaster for patients and the American economy. Such a system, funded and run by the federal government, would move us from the limited competition in our current health care system to zero competition. And it has been estimated to cost $32 trillion over a decade.

This would require raising taxes on businesses and families by trillions of dollars. Beyond wild tax increases, under this plan, all Americans would be removed from their current private or employer-sponsored health coverage.

Health care decisions would be made not in the doctor's office or pharmacy but by bureaucrats in Washington.

With a government takeover, provider payment would also be decided in Washington. That means doctors' and other providers' payments would likely be greatly reduced, adding to the current doctor shortage. Fewer providers means longer wait times and dramatically less access to care.

Additionally, the federal government could create a national drug formulary to set prices for prescriptions. If a drug isn't included or Washington bureaucrats decide they won't pay a sustainable amount to the manufacturer, patients won't have access to possibly lifesaving medications.

This government-run system would also turn senior care upside down. Medicare as we know it would no longer exist and seniors would pay the price.

Finally, one of the biggest losers will be rural health providers. As rural hospitals struggle, this government takeover of health care would only exacerbate their problems. The plans would reduce payments, pushing more of these essential health systems toward closing.

As the only pharmacist in Congress, I'm dedicated to delivering more choice and control in health care. A government-run and funded system is absolutely not the solution.

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Chronology 1798–1943 The groundwork for private and public health insurance is laid.

1798 President John Adams signs a law creating what is considered to be the first federal health program, a service for injured and ailing sailors employed by private shippers.

1847 Massachusetts Health Insurance Co. of Boston issues “sickness insurance,” considered the first health coverage in the United States.

1865 President Abraham Lincoln signs a law to establish a national soldiers' and sailors' asylum, a program that evolves over time into the Veterans Health Administration.

1912 Theodore Roosevelt, the presidential candidate of the Progressive Party, calls on employees, employers and “the people at large” to share the burdens of the U.S. population's health costs.

1929 Texas schoolteachers arrange for Dallas' Baylor Hospital to provide room, board and specified services at a predetermined monthly cost.

1940s Enrollment campaigns seek to boost participation in a new kind of insurance, Blue Cross plans, which involve prepayment for medical care.

1942 Congress passes a wartime law limiting wage increases, which fosters the growth of health insurance plans as a way for employers to attract scarce workers.

1943 The Internal Revenue Service (IRS) rules that health insurance provided by employers is not taxable to the employee.

1945–2006 Presidents propose expansion of government health plans.

1945 President Harry S. Truman, a Democrat, makes an unsuccessful bid for a national government health insurance program…. Physician Sidney Garfield and industrialist Henry J. Kaiser open to the public their Permanente Health Plan, which builds on medical insurance previously offered to employees working on major construction projects.

1948 The British government creates the National Health Service, which provides universal medical care.

1954 Congress codifies the tax exemption of employer-sponsored insurance after the IRS in 1953 revisited its previous decision on the tax break.

1965 Democratic President Lyndon B. Johnson signs into law the bill that creates Medicare, which provides health insurance for the elderly, and Medicaid, an insurance program for low-income adults.

1966 Canada's federal government moves to provide publicly funded medical insurance plans, splitting costs with the nation's provinces and territories.

1974 Republican President Richard M. Nixon proposes comprehensive health insurance, including federal and state assistance for those unable to afford such coverage. Congress takes no significant action toward establishing such a plan during his administration.

1989 Congress rolls back the Catastrophic Care Act, which had provided a prescription drug benefit under Medicare, due to protests over a new tax.

1993 Democratic President Bill Clinton unveils a sweeping plan to reform the U.S. health care system. After fierce debate, Senate leaders declare the proposal dead the following year.

1997 Congress and Clinton create the state-federal Children's Health Insurance Program, which covers young people living in families with too much income to qualify for Medicaid but too little to easily afford medical coverage.

2003 Congress and Republican President George W. Bush create the Medicare Part D benefit, helping senior citizens buy drugs at pharmacies.

2006 Massachusetts enacts a universal coverage mandate, sometimes called “Romneycare,” after Republican Gov. Mitt Romney.

2010–Present “Obamacare” opens new era of government health programs.

2010 Democratic President Barack Obama signs into law the Affordable Care Act (ACA), soon dubbed “Obamacare,” which creates government-run insurance marketplaces, offers subsidies to some consumers, bars insurers from denying coverage to people with pre-existing medical conditions and offers money to states to raise income limits for Medicaid.

2012 U.S. Supreme Court finds the ACA's insurance mandate constitutional, but rules against the law's provision for mandatory Medicaid expansion by the states.

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2014 Major provisions of the ACA take effect, with states and the federal government creating online exchanges for the sale of insurance plans to individuals. Some states begin expanding their Medicaid plans.

2017 Under GOP President Donald Trump, congressional Republicans make unsuccessful bids to repeal the ACA. Congress does pass a tax overhaul law that eliminates the ACA's financial penalty on those who fail to buy insurance.

2018 Republican state attorneys general and governors challenge the ACA's legality, arguing the ending of the penalty invalidates the entire law…. Federal District Judge Reed O'Connor declares the ACA invalid, setting up the potential for another Supreme Court decision on the law.

2019 Several Democratic presidential candidates call for Medicare expansion; some favor creation of a single-payer health system with almost no private insurance.

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Short Features

U.S. May Find Lessons in Other Nations' Health Systems

Models include single-payer and public-private mix.

The head of England's public medical service had a quick response when President Trump tweeted in February 2018 that the United Kingdom's system was “going broke and not working.”

Stop by a National Health Service (NHS) hospital and learn about the high-quality care provided there, NHS England Chief Executive Simon Stevens said.

If he did, Trump would discover “that health care for everybody, delivered at half the cost of the U.S. health care system, is something people in this country are deeply and rightly committed to,” Stevens said.

On health care, the United States is an outlier in the Organisation for Economic Co-operation and Development (OECD), a 36-member group comprising the world's strongest economies. Countries such as Germany, the United Kingdom, France and Canada decades ago worked out systems to guarantee their citizens access to basic medical care.

In the United States, universal coverage has not yet been achieved, despite two major initiatives created by the Affordable Care Act in 2010. These took effect in 2014, giving subsidies to many Americans to help them buy health insurance and expanding eligibility for the state-federal Medicaid program for those with lower income levels.

Yet despite these changes, 8.5 percent of all Americans, or 27.5 million people, still lacked health insurance last year, according to Census Bureau data.

Medical care in the United States fares poorly in comparison to developed nations in other aspects, according to OECD research.

About 22.3 percent of Americans skipped medical consultations due to cost, compared with an OECD average of 10.5 percent. The United States had the highest prevalence of obesity in the OECD at 38 percent of adults, compared with an OECD average of 19.4 percent.

And the United States is paying more than other OECD nations to obtain these results. U.S. health costs averaged $10,586 per person in 2018, more than double the OECD average of about $3,992.

Among the reasons for the higher U.S. spending may be something akin to an administrative arm race. Defenders of the U.S. system say it provides greater quality of care than other countries and avoids rationing; former House Speaker John Boehner once called it “the best health care delivery system in the world.” But critics of the system say it produces much waste and unneeded expense, and point to the many hospital and physicians' employees who must specialize in handling complex billing codes in the ongoing tug of war with insurers over payments.

This situation contributes to the frustratingly long lists of often incomprehensible charges routinely seen on U.S. medical bills, wrote physician- journalist Elisabeth Rosenthal in her 2017 book, An American Sickness: How Healthcare Became Big Business and How You Can Take It Back.

A bill for a hip replacement in Belgium runs to about three pages, using simple terms for items such as the room in which a patient stays and the implant parts used, Rosenthal wrote. In the United States, this bill often runs to dozens of pages, filled with strings of numbers and medical terminology little known outside of the field of coding. “Medical coding and coders like ours essentially don't exist in any other health care system,” Rosenthal wrote.

Mark V. Pauly, a health economist at the University of Pennsylvania's Wharton School of business, points to salaries as a root cause of higher U.S. spending on health care. “It's just that we pay better than do the other countries,” says Pauly.

It is an argument Pauly has been making for years. He published one of the earliest studies examining why medical costs consumed different shares of gross national product (GNP).

“When politicians and policymakers ask, ‘How does Germany (or Canada or the United Kingdom) do it?’ a large part of the explanation for a lower GNP share is that they pay health professionals less — not just physicians, but nurses and technologists, too,” wrote Pauly in 1993.

That still appears to be true. The average annual income for a U.S. physician in 2016 was about $273,000, while in the United Kingdom, it was about $153,000, according to Medscape, an online medical news site. In Germany, it was about $146,000 and in France, $116,000.

“In other countries, the governments pay to train physicians so they do not come out with a debt like they do here,” Pauly says.

Advocates for a U.S. single-payer system often cite Canada and Great Britain as models. But the Congressional Budget Office (CBO), in a May report, warned that while a single-payer system offered advantages such as lower administrative costs, the transition to it “could be complicated, challenging, and potentially disruptive.”

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Thousands of marchers in London commemorate the 70th anniversary of Great Britain's National Health Service at a 2018 rally. Britain is one of many developed nations that, unlike the United States, has created a national health system for all citizens. (Getty Images/Barcroft Media/Wiktor Szymanowicz)

The CBO suggested another model: Germany and Switzerland, which have achieved universal health coverage through a mix of private health organizations and government mandates. People buy insurance from competing nonprofit insurers, each offering a comprehensive benefit package set by the government. Insurers cannot deny coverage, which all citizens and legal residents are required to buy.

Sherry Glied, who served as a health policy adviser to the Obama administration, says public programs can ensure that a socially acceptable basic level of care is available to all citizens. If the cost of that care rises more rapidly than anticipated, the government should address that additional cost, she says.

“This is how systems work in Australia, Switzerland, the Netherlands, Israel — all countries with universal coverage and a substantial role for private insurance,” says Glied, who is now dean of New York University's Robert F. Wagner Graduate School of Public Service.

Policymakers should place less emphasis on ideology and more on results as they seek to make changes in the financing of U.S. medical care, Glied says.

“The debate about health insurance would be more productive if we focused on what outcomes we are trying to achieve for people,” Glied says. “Public or private plans are a means to an end — not a goal in themselves.”

— Kerry Dooley Young

[1] Donald J. Trump, Twitter post, Feb. 5, 2018, https://tinyurl.com/y6tlpqo2.

[2] Andrew McConaghie, “After Twitter tirade, Trump invited to visit ‘brilliant' NHS,’ pharmaphorum, Feb. 6, 2018, https://tinyurl.com/y5ga4zrl.

[3] Edward R. Berchick, Jessica C. Barnett and Rachel D. Upton, “Health Insurance Coverage in the United States: 2018,” U.S. Census Bureau, September 2019, https://tinyurl.com/y462mzls.

[4] “Health at a Glance 2017: OECD Indicators,” OECD Publishing, February 2018, p. 26, https://tinyurl.com/ya9erumj.

[5] “Health spending,” OECD data, accessed Oct. 9, 2019, https://tinyurl.com/nzca4rj.

[6] Leigh Ann Caldwell, “Boehner defends Romney's critique of individual mandate,” CBS “Face the Nation,” July 1, 2012, https://tinyurl.com/y652wey9.

[7] Mark Pauly, “U.S. Health Care Costs: The Untold True Story,” Health Affairs, Fall 1993, https://tinyurl.com/y6xvbu4j.

[8] Tim Locke and Véronique Duquéroy, “UK Doctors' Salary Report,” Medscape Medical News, April 4, 2018, https://tinyurl.com/y6f9ysjn.

[9] “Key Design Components and Considerations for Establishing a Single-Payer Health Care System,” Congressional Budget Office, May 2019, https://tinyurl.com/yxd8cgww.

[10] Ibid.

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Some Business Leaders Press for Major Health Care Changes

“A functional market does not regularly drive families into bankruptcy.”

David Steil is a Republican — who supports Sen. Bernie Sanders' Medicare-for-All plan.

The head of a company that makes air-filtration products, Steil says he also favors considering other options for an expanded government role in insurance besides Sanders' plan. He particularly likes the idea of public options run by state governments.

Steil says owners of small businesses would benefit from shedding responsibility for selecting and managing their employees' health plans. It is an onerous and distracting task, and one in which business owners often are at a financial disadvantage in dealing with insurance brokers, he says.

“We know our products. We know our customers. We know our markets,” says Steil, chief executive of MicroTrap Corp., based in Morrisville, Pa. “But we don't know about health care, so we are kind of at their mercy.” The solution, he says, “is to get business out of health care.”

Steil says he does not mind contributing toward his employees' health care. He is looking to shed the administrative hassles of employer-sponsored insurance. These extend beyond the time spent on plan selection to tussling with insurers on behalf of his employees about coverage denials.

Steil is also a former member of the Pennsylvania House of Representatives, where he served from 1993 to 2008. During his time as a legislator, he began to explore the idea of a state-based public option. This might work for states as large as Pennsylvania, which has close to 13 million residents; smaller states might consider banding together, he said.

Steil serves on the board of advisers of the Business Initiative for Health Policy, which is pressing for a single-payer plan. The group's founder, Richard Master, chief executive of MCS Industries of Easton, Pa., which makes wall and poster frames, is seeking to persuade other corporations to leave the negotiations on health costs to government experts.

“I'd rather pay a predictable, manageable payroll tax to finance health care than pay impossibly high and unpredictable premiums,” Master wrote in a May opinion article in Fortune.

With a single-payer system, Americans would lower health care spending by cutting out insurers as middlemen and strengthening negotiating power for rates, he wrote. “Medicare operates at a significantly lower administrative cost than does commercial insurance, and doesn't use money for things like inflated executive salaries, advertising or sales,” Master wrote.

However, Master and Steil's embrace of a single-payer plan is far from a universal view in the business community. For example, the U.S. Chamber of Commerce, which describes itself as the world's largest business organization, rejects the idea. Katie Mahoney, its vice president for health policy, said the supporters of a Medicare-for-All approach “have done a good marketing job putting a shiny, new brand on an old, unpopular idea — socialized medicine.”

“While voters want all Americans to have access to health care, they don't see a one-size-fits all, big-government system as the answer,” Mahoney said. “Instead, they want leaders in Washington to work together to reduce health care costs.”

A somewhat different view was offered by Elizabeth Mitchell, chief executive of the Pacific Business Group on Health, which represents large employers such as the University of California, energy giant Chevron and the Safeway grocery chain. Combined, the group's members spend more than $100 billion annually on their employees' health care.

At a June congressional hearing, Mitchell said large employers generally favor market-based solutions to health care — but increasingly find that “many parts of the health care market are fundamentally broken” and support government intervention in such cases. As a result, she asked the Senate Health, Education, Labor and Pensions Committee to approve legislation that would rein in rising drug costs and reduce instances of “surprise billing,” where patients are hit with unexpectedly high charges.

“A functional market does not regularly drive families into bankruptcy,” Mitchell told the committee. “It does not depend on GoFundMe campaigns for treatment costs. It does not absorb a decade of U.S. wage growth.”

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U.S. Sen. Mike Braun, R-Ind., speaks at a forum on government-run health care in July. While Braun, who is also a small-business owner, opposes such a system, he warns that health insurers must voluntarily stem rising costs to avoid a legislative solution. (Getty Images/SOPA Images/LightRocket/Michael Brochstein)

At the hearing, Sen. Mike Braun, an Indiana Republican, recalled his own battles to control health care costs at his auto-parts distribution firm, Meyer Distributing. Premiums continually crept up — a situation that did not alarm the people who sold insurance to his firm, he said.

“I'd get this smirk of, ‘You're lucky it's only going up 5 to 10 percent a year,’” Braun said.

Increased transparency about health care costs and more competition in the market would slow the growth of this expense, Braun said. In his firm, he encouraged his employees to question their health care expenses — which often are opaque — as much as possible. His firm offered health savings accounts, which allowed employees to set aside money for health expenses and shield it from taxation, and looked for ways to help employees live healthier lives, he said.

These steps paid off in stable premiums over about a decade, Braun said at the Senate hearing. He urged the health care insurance industry to work harder to protect their customers from rising costs. Democrats are presenting frustrated consumers with alternatives, Braun said, making a reference to plans to expand Medicare.

“I give this as a warning to the industry. You ought to be fixing this yourselves, not having us here, having to nudge you with legislation that wouldn't occur in any other sector of our economy,” Braun said.

— Kerry Dooley Young

[11] Richard Master, “Joe Biden Is Wrong. Businesses Will — and Want to — Pay for Medicare for All,” Fortune, May 15, 2019, https://tinyurl.com/y42gnyov.

[12] Ibid.

[13] Katie Mahoney, “‘Medicare for All’ isn't the Health Care Reform Americans Want, Poll Finds,” U.S. Chamber of Commerce, Feb. 21, 2019, https://tinyurl.com/yygo4ac2.

[14] Elizabeth Mitchell, “Testimony for Senate Committee on Health, Education, Labor and Pensions Hearing,” Senate.gov, June 18, 2019, https://tinyurl.com/y2jvz6oy.

[15] Ibid.

[16] “Senate Health Committee Hearing on Health Care Costs,” C-SPAN, June 18, 2019, https://tinyurl.com/y4gzhysh.

[17] Ibid.

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Bibliography Books

Makary, Marty , The Price We Pay: What Broke American Health Care — and How to Fix It , Bloomsbury, 2019. A physician and researcher explores hospital billing practices and urges the health care industry to address high costs and aggressive bill collection procedures that he says are eroding public trust in medical professionals.

Reinhardt, Uwe E. , Priced Out: The Economic and Ethical Costs of American Health Care , Princeton University Press, 2019. An economist contrasts the U.S. health care system with those in other affluent nations and argues for policy changes to lower costs.

Rosenthal, Elisabeth , An American Sickness: How Healthcare Became Big Business and How You Can Take It Back , Penguin Books, 2017. In this investigation of the reasons behind spiraling health care costs, a journalist and physician offers a detailed look at how insurers, hospitals and pharmaceutical companies have dramatically increased profits.

Articles

Anderson, Gerard F., Peter Hussey and Varduhi Petrosyan , “It's Still The Prices, Stupid: Why The US Spends So Much On Health Care, And A Tribute To Uwe Reinhardt,” Health Affairs, January 2019, https://tinyurl.com/y2bhdv3o. Researchers who co-wrote an influential 2003 article detailing differences in health spending between the United States and other countries say prices are the main reason the U.S. health care system still delivers less for the money than systems elsewhere.

Frakt, Austin, and Elsa Pearson , “A Question Rarely Asked: What Would Medicare for All Cover?” The New York Times, July 29, 2019, https://tinyurl.com/y52t5fje. Health care experts at Boston University offer a detailed look at how Medicare operates now and the risk that an expanded version would waste money on treatment of little value.

Gawande, Atul , “Is Health Care a Right?” The New Yorker, Sept. 25, 2017, https://tinyurl.com/y8xplokd. A physician and author looks at the diversity of opinion among Americans about whether health care is a right or a privilege.

Hancock, Jay, and Carmen Heredia Rodriguez , “UVA Suspends Medical Lawsuits In Wake Of KHN Investigation,” Kaiser Health News, Sept. 12, 2019, https://tinyurl.com/y6qfj5ak. A nonprofit news organization that specializes in health care explains how its investigative reporting on the University of Virginia Health System's billing practices prompted the system to suspend lawsuits it had filed against patients for nonpayment.

Keith, Katie , “Trump Administration Asks Court To Strike Down Entire ACA,” Health Affairs, March 26, 2019, https://tinyurl.com/y5cphb8n. A health care consultant provides a detailed overview of legal challenges to the Affordable Care Act.

Saslow, Eli , “The ‘follow-up appointment,’” The Washington Post, Aug. 17, 2019, https://tinyurl.com/y6gw77o9. A reporter looks at how financially struggling hospitals are taking financially struggling patients to court over unpaid bills.

Wynne, Billy, and Alyssa Llamas , “Medicare For All Can Begin In 2021: Here's How,” Health Affairs, Feb. 28, 2019, https://tinyurl.com/y5cr2dax. Health policy experts argue that states could use provisions of the Affordable Care Act to create “Medicare fallback options” to expand health care coverage and stabilize insurance markets.

Reports and Studies

“Key Design Components and Considerations for Establishing a Single-Payer Health Care System,” Congressional Budget Office, May 2019, https://tinyurl.com/yxd8cgww. The nonpartisan congressional agency that evaluates budget matters offers an overview of costs and steps that would be involved in establishing a single-payer health care system run by the government.

Berchick, Edward R., Jessica C. Barnett and Rachel D. Upton , “Health Insurance Coverage in the United States: 2018,” U.S. Census Bureau, Sept. 10, 2019, https://tinyurl.com/y4yalws5. Government researchers present the latest statistics on U.S. health insurance coverage, saying the number of Americans without coverage increased to 27.5 million in 2018.

Collins, Sara R., and Munira Z. Gunja , “What Do Americans Think About Their Health Coverage Ahead of the 2020 Election?” The Commonwealth Fund, Sept. 26, 2019, https://tinyurl.com/y2hljwqg. An organization that works to improve access to affordable health care says its latest survey on health insurance shows 13.8 percent of working-age U.S. adults are uninsured, down from 20 percent just before the Affordable Care Act began expanding coverage.

The Next Step Future of the Affordable Care Act

Goldstein, Amy , “With the Affordable Care Act's future in doubt, evidence grows that it has saved lives,” The Washington Post, Sept. 30, 2019, https://tinyurl.com/y5rgqx8j. Several studies suggest that the Affordable Care Act, and especially its expansion of Medicaid, has made Americans healthier.

Moore, Susan , “Cigna expands Affordable Care Act plans in 19 markets across 10 states,” Healthcare Finance, Sept. 20, 2019, https://tinyurl.com/y2g3u8ph. Cigna and other insurance companies are expanding into more Affordable Care Act markets, even as enrollment is down among consumers who do not qualify for tax subsidies under the law.

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http://worldcat.org/search?q=ti:The+Price+We+Pay:+What+Broke+American+Health+Care+and+How+to+Fix+it

http://worldcat.org/search?q=ti:Priced+Out:+The+Economic+and+Ethical+Costs+of+American+Health+Care

http://worldcat.org/search?q=ti:An+American+Sickness:+How+Healthcare+Became+Big+Business+and+How+You+Can+Take+It+Back

https://tinyurl.com/y2bhdv3o

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Stuart, Christine , “Affordable Care Act could cause ‘humanitarian crisis in Connecticut,’” Connecticut Post, Sept. 28, 2019, https://tinyurl.com/yyqregd4. Sen. Chris Murphy, D-Conn., is concerned that a court ruling invalidating the Affordable Care Act could have a devastating impact on health care in his state and believes Congress should plan for this possibility.

Medicaid Expansion

Baumgartner Vaughan, Dawn, and Paul A. Specht , “Rural NC Republicans to GOP legislators: Reject ‘national party stance’ on Medicaid,” The News & Observer, Oct. 2, 2019, https://tinyurl.com/y28kjfgl. Republicans in North Carolina disagree on whether to expand Medicaid and to include a work requirement for the program, a provision Democrats oppose.

Carpenter, Tim , “Gov. Laura Kelly launches council to guide Medicaid expansion debate,” The Hutchinson News, Sept. 30, 2019, https://tinyurl.com/y53myjtm. Kansas Gov. Laura Kelly, a Democrat, is attempting to reach a deal with the Republican-controlled Legislature on expanding Medicaid.

Ungar, Laura , “State Border Splits Neighbors Into Medicaid Haves and Have-Nots,” NPR, Oct. 1, 2019, https://tinyurl.com/y69476ar. The U.S. Supreme Court's 2012 ruling allowing each state to choose whether to expand access to Medicaid under the ACA has led to disparate health outcomes among people with similar incomes living in neighboring states.

Public Option

Luhby, Tami , “Health care explained: Medicare for All vs. public options vs. the ACA,” CNN, July 30, 2019, https://tinyurl.com/y6q9ce2k. A journalist covering health policy explains how proposals for Medicare for All and a “public option” to compete with private insurance would differ from the Affordable Care Act as it currently stands.

Pradhan, Rachana, and Dan Goldberg , “5 key questions about the country's first public option,” Politico, May 14, 2019, https://tinyurl.com/yyttryvj. Washington state has approved a public option to begin in 2021, and other states may study how the program works before going forward with their own versions.

Ramm, Michaela , “52 rural Iowa hospitals at risk of closing under public option, analysis shows,” The Gazette, Sept. 3, 2019, https://tinyurl.com/y32v9cwc. According to a new analysis, dozens of rural Iowa hospitals could close under a public option plan that uses Medicare reimbursement rates.

Surprise Billing

Huetteman, Emmarie , “Legislation to End Surprise Medical Bills Has High Public Support — In Both Parties,” Kaiser Health Institute, Sept. 12, 2019, https://tinyurl.com/y3oeox22. Majorities among Democrats, Republicans and independents support national legislation to curb unexpectedly high medical bills.

Kliff, Sarah, and Margot Sanger-Katz , “In California, a ‘Surprise’ Billing Law Is Protecting Patients and Angering Doctors,” The New York Times, Sept. 26, 2019, https://tinyurl.com/y4hpoh4a. A California statute that outlaws surprise medical billing appears to be working as intended, but some doctors are upset that their leverage in contract negotiations with insurance companies has been diminished.

Sullivan, Peter , “CBO: Fix backed by doctors for surprise medical bills would cost billions,” The Hill, Sept. 24, 2019, https://tinyurl.com/y6s9m3bm. The Congressional Budget Office found that a bill backed by doctors to end surprise medical costs would increase the federal budget deficit by “double digit billions,” while a rival measure would save the government more than $20 billion over a decade.

Contacts America's Health Insurance Plans 601 Pennsylvania Ave., N.W., South Building, Suite 500, Washington, DC 20004 202-778-3200 www.ahip.org/ Trade association for health insurance companies.

Center on Budget and Policy Priorities 1275 First St., N.E., Suite 1200, Washington, DC 20002 202-408-1080 www.cbpp.org Think tank that examines how government policy affects people living in or near poverty.

Congressional Budget Office Ford House Office Building, Second and D Streets, S.W., Washington, DC 20515 202-226-2700 www.cbo.gov Congressional agency that provides detailed estimates on costs of legislation as well as the long-term outlook for federal spending.

Congressional Research Service 101 Independence Ave., S.E., Washington, DC 20540 202-707-5000 crsreports.congress.gov/ Congress' research arm, providing nonpartisan briefing papers on key issues.

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http://www.ahip.org/

http://www.cbpp.org

http://www.cbo.gov

http://crsreports.congress.gov/

Families USA 1225 New York Ave., N.W., Suite 800, Washington, DC 20005 202-628-3030 www.familiesusa.org Group that advocates on a national and state level to expand access to health care.

Heritage Foundation 214 Massachusetts Ave., N.E., Washington DC 20002-4999 202-546-4400 www.heritage.org Conservative think tank that examines federal health spending.

Kaiser Family Foundation 185 Berry St., Suite 2000, San Francisco, CA 94107 650-854-9400 www.kff.org Nonpartisan organization that provides in-depth studies of federal and state health care issues.

Medicare Payment Advisory Commission 425 I St., N.W., Suite 701, Washington, DC 20001 202-220-3700 www.medpac.gov Federal advisory group that does detailed research on Medicare, including insurer-run Medicare Advantage plans.

Robert Wood Johnson Foundation 50 College Road East, Princeton, NJ 08540-6614 609-627-6000 www.rwjf.org Philanthropy focused solely on health that funds studies of insurance issues.

U.S. Chamber of Commerce 1615 H St., N.W., Washington, DC 20062-2000 202-659-6000 www.uschamber.com Trade association for business that seeks to protect a tax deduction for employer-sponsored health insurance.

Footnotes [1] Rebecca Wood, testimony before House Ways and Means Committee, June 12, 2019, https://tinyurl.com/yxj62jup.

[2] House Ways and Means Committee hearing, YouTube, June 12, 2019, https://tinyurl.com/y6fzs86k.

[3] “Key Facts about the Uninsured Population,” KFF, Dec. 7, 2018, https://tinyurl.com/y79q6mp8; Sara R. Collins, Herman K. Bhupal and Michelle M. Doty, “Health Insurance Coverage Eight Years After the ACA,” The Commonwealth Fund, Feb. 7, 2019, https://tinyurl.com/y2bmn8bc.

[4] Kevin Brady, opening statement before House Ways and Means Committee, June 12, 2019, https://tinyurl.com/y6f25gru.

[5] Sarah Kliff and Dylan Scott, “We read 9 Democratic plans for expanding health care. Here's how they work,” Vox, June 21, 2019, https://tinyurl.com/y3t6ohjf.

[6] Robert Pear, “‘Short Term’ Health Insurance? Up to 3 Years Under New Trump Policy,” The New York Times, Aug. 1, 2018, https://tinyurl.com/y7mmw7n2; Joseph R. Antos and James C. Capretta, “The Graham-Cassidy Plan: Sweeping Changes In A Compressed Time Frame,” Health Affairs, Sept. 22, 2017, https://tinyurl.com/yxmopv9m.

[7] Sen. Charles E. Grassley, floor speech, Executive Session, Congressional Record, Vol. 165, No. 86, May 22, 2019, https://tinyurl.com/yxo6hzqa.

[8] Sen. Mitch McConnell, floor speech, Executive Session, Congressional Record, Vol. 165, No. 37, Feb. 28, 2019, https://tinyurl.com/yxtswb9o.

[9] Sen. Richard Blumenthal, floor speech, Congressional Record, Vol. 165, No. 115, July 10, 2019, https://tinyurl.com/y6q88bdt; Liz Szabo, “As Drug Costs Soar, People Delay Or Skip Cancer Treatments,” Kaiser Health News/NPR, March 15, 2017, https://tinyurl.com/ydh2y55o; Christine M. Bestvina et al., “Patient-Oncologist Cost Communication, Financial Distress, and Medication Adherence,” Journal of Oncology Practice, May 1, 2014, https://tinyurl.com/y3buqzdw; and Darby Herkert et al., “Cost-Related Insulin Underuse Among Patients With Diabetes,” JAMA Internal Medicine, January 2019, https://tinyurl.com/yyyh3dgz.

[10] Sen. Tina Smith, floor speech on Stop Stalling Act and Creates Act, Congressional Record, Vol. 165, No. 81, May 15, 2019, https://tinyurl.com/y45osuxa.

[11] “Transcript: The third Democratic debate,” The Washington Post, Sept. 12, 2019, https://tinyurl.com/yyqrlpr6.

[12] Irene Papanicolas, Liana R. Woskie and Ashish K. Jha, “Health Care Spending in the United States and Other High-Income Countries,” Journal of the American Medical Association, March 13, 2018, https://tinyurl.com/ybzubbqc.

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http://www.heritage.org

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http://www.medpac.gov

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http://www.uschamber.com

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[13] “2019 Annual Report of The Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds,” Centers for Medicare and Medicaid Services, accessed Sept. 19, 2019, p. 148, https://tinyurl.com/y5llkja9.

[14] “Exploring the Growth of Medicaid Managed Care,” Congressional Budget Office, Aug. 7, 2018, https://tinyurl.com/y4ux7lgn.

[15] Tom Kertscher, “Testing Paul Ryan's damning attack on the Affordable Care Act: ‘Obamacare has failed,’” PolitiFact Wisconsin, Feb. 1, 2017, https://tinyurl.com/yyttxgm4; “Early 2019 Effectuated Enrollment Snapshot,” Centers for Medicare and Medicaid Services, Aug. 12, 2019, https://tinyurl.com/yybkt5jg.

[16] “How much does the federal government spend on health care?” Tax Policy Center's Briefing Book, 2018, https://tinyurl.com/y5unpjr4.

[17] “Statement From Health Economists and Policy Analysts About Excise Tax on High-Cost Plans,” Center on Budget and Policy Priorities, July 29, 2019, https://tinyurl.com/y3d6vwoo.

[18] Marshall Allen, “Behind the Scenes, Health Insurers Use Cash and Gifts to Sway Which Benefits Employers Choose,” ProPublica/NPR, Feb. 20, 2019, https://tinyurl.com/yxwb3akl.

[19] Marshall Allen, “Why Your Health Insurer Doesn't Care About Your Big Bills,” ProPublica/NPR, May 25, 2018, https://tinyurl.com/y7u2t58z; Hunter Kellett, Alexandra Spratt and Mark E. Miller, “Surprise Billing: Choose Patients Over Profits,” Health Affairs, Aug. 12, 2019, https://tinyurl.com/y69hxosh.

[20] Sen. Lamar Alexander, floor speech, Congressional Record, Vol. 165, No. 59, April 4, 2019, https://tinyurl.com/y24975xa.

[21] Matthew Rae, Rebecca Copeland and Cynthia Cox, “Tracking the rise in premium contributions and cost-sharing for families with large employer coverage,” Peterson-Kaiser Health System Tracker, Aug. 14, 2019, https://tinyurl.com/yydp78md.

[22] Ashley Kirzinger et al., “Data Note: Americans' Challenges with Health Care Costs,” Kaiser Family Foundation, June 11, 2019, https://tinyurl.com/y2oa4rjf.

[23] “67 percent of bankruptcy filers cite illness and medical bills as contributors to financial ruin,” Physicians for a National Health Program, Feb. 7, 2019, https://tinyurl.com/y8vfrr4h.

[24] “Greg Walden raises concerns about $32 trillion government-run health care system,” press release, Office of Rep. Walden, Feb. 6, 2019, https://tinyurl.com/y3m6k8td.

[25] “Chairman Alexander Statement on CBO Report on Medicare for All,” press release, Office of Sen. Lamar Alexander, May 2, 2019, https://tinyurl.com/y3uj4oh4.

[26] “The Medicare-X Choice Act of 2019,” Sen. Michael Bennet, accessed Oct. 10, 2019, https://tinyurl.com/y5gwkr4h; “The Impact of Medicare-X Choice on Coverage, Healthcare Use, and Hospitals: Supplemental Report,” KNG Consulting LLC for the American Hospital Association and the Federation of American Hospitals, Aug. 6, 2019, https://tinyurl.com/y3tpqddo.

[27] Donald M. Berwick, testimony before House Ways and Means Committee, June 12, 2019, https://tinyurl.com/yxrnfasu.

[28] House Ways and Means Committee hearing, op. cit.

[29] “Sanders, 14 Senators Introduce Medicare for All,” press release, Office of Sen. Bernie Sanders, April 10, 2019, https://tinyurl.com/y3uzthe2.

[30] Robin Bravender, “Raskin Recalls Battle With Cancer in Plea for Medicare for All,” Maryland Matters, April 30, 2019, https://tinyurl.com/yymm211c.

[31] Ibid.

[32] Glenn Kessler, “Democrats seize on cherry-picked claim that ‘Medicare for all’ would save $2 trillion,” The Washington Post, Aug. 7, 2018, https://tinyurl.com/ybocgkox.

[33] Charles Blahous, “The Costs of a National Single-Payer Healthcare System,” Mercatus Center at George Mason University, July 2018, p. 3, https://tinyurl.com/ya5583xk.

[34] “Thank You, Koch Brothers!” YouTube, July 30, 2018, https://tinyurl.com/y9haex9o.

[35] Louis Jacobson, “Did conservative study show big savings for Bernie Sanders' Medicare for All plan?” PolitiFact, Aug. 3, 2018, https://tinyurl.com/y6y28zyt.

[36] “In-Depth Analysis by Team of UMass Amherst Economists Shows Viability of Medicare For All,” Political Economy Research Institute (PERI), University of Massachusetts Amherst, Nov. 30, 2018, https://tinyurl.com/y2gszjoq.

[37] Blahous, op. cit.

[38] Glenn Kessler, “Democrats seize on cherry-picked claim that ‘Medicare-for-all’ would save $2 trillion,” The Washington Post, Aug. 7, 2018, https://tinyurl.com/ybocgkox.

[39] “How Much Will Medicare for All Cost?” Committee for a Responsible Federal Budget, Feb. 27, 2019, https://tinyurl.com/y3zcr7rj.

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[40] “Key Design Components and Considerations for Establishing a Single-Payer Health Care System,” Congressional Budget Office, May 2019, https://tinyurl.com/yxd8cgww.

[41] Ibid.

[42] Dean Baker, “Medicare for all is not a fantasy,” CNN, Feb. 1, 2019, https://tinyurl.com/ycedslav.

[43] Ibid.

[44] “Read the full transcript of ABC News' 3rd Democratic debate,” ABC News, Sept. 13, 2019, https://tinyurl.com/y5d8c2aj.

[45] Howard Markel, “69 years ago, a president pitches his idea for national health care,” PBS Newshour, Nov. 19, 2014, https://tinyurl.com/y42ekj64.

[46] Dylan Scott, “The nation's most prominent doctors group almost dropped its opposition to Medicare-for-all,” Vox, June 12, 2019, https://tinyurl.com/yx96uqeg.

[47] Tatyana Hopkins, “Bernie Sanders Returns to GW,” GW Today, July 18, 2019, https://tinyurl.com/y4qupe7r.

[48] “Public Opinion on Single-Payer, National Health Plans, and Expanding Access to Medicare Coverage,” Kaiser Family Foundation, Oct. 15, 2019, https://tinyurl.com/yyzatu9o.

[49] Tarini Parti and John McCormick, “The Moments That Mattered in Thursday's Democratic Debate,” The Wall Street Journal, Sept. 13, 2019, https://tinyurl.com/y4s6nknt.

[50] Kimberly Leonard, “Buttigieg makes case against ‘Medicare for all’: ‘I trust the American people,’” Washington Examiner, Sept. 12, 2019, https://tinyurl.com/yyzd75ts.

[51] “The Impact of Medicare-X Choice on Coverage, Healthcare Use, and Hospitals,” KNG Consulting LLC for the American Hospital Association and the Federation of American Hospitals, March 12, 2019, https://tinyurl.com/yytowchz.

[52] “S. 981, Medicare-X Choice Act of 2019, Cosponsors,” Congress.gov, Accessed on Sept. 16, 2019, https://tinyurl.com/yyjfbacy; “Health Care,” Biden President, accessed Sept. 16, 2019, https://tinyurl.com/yxskr7lu.

[53] “Full text of ‘The United States Public Health Service, 1798-1950,’” The Internet Archive, accessed Sept. 26, 2019, https://tinyurl.com/y2ug2ynr; Ralph C. Williams, “The United States Public Health Service, 1798-1950,” Commissioned Officers Association of the United States Public Health Service, 1951, accessed Sept. 16, 2019, p. 31, https://tinyurl.com/yybmyfc7.

[54] Laura A. Scofea, “The Development and Growth of Employer-Provided Health Insurance,” Monthly Labor Review, March 1994, p. 3, https://tinyurl.com/yxv8gq2z.

[55] Ibid.

[56] Lorraine Boissoneault, “Bismarck Tried to End Socialism's Grip — By Offering Government Healthcare,” Smithsonian.com, July 14, 2017, https://tinyurl.com/yyl9uxkk.

[57] Scofea, op. cit., p. 4.

[58] Theodore Roosevelt, “A Confession of Faith,” The Ohio State University ehistory, accessed Sept. 16, 2019, https://tinyurl.com/y6dgebsd.

[59] “Since insurance's humble start in Dallas, hospital inflation has always posed challenge,” Dallas Morning News, March 6, 2015, https://tinyurl.com/yyajuxjm.

[60] Richard E. Schumann, “Compensation from World War II through the Great Society,” U.S. Bureau of Labor Statistics, Fall 2001, https://tinyurl.com/y4yejyzc; “Note Exempt Items, Taxpayers Are Told,” The New York Times, Jan. 16, 1943, https://tinyurl.com/y5lxbkhr.

[61] “How it all started,” Kaiser Permanente, accessed Sept. 16, 2019, https://tinyurl.com/y4ooryto.

[62] Markel, op. cit.

[63] “President Lyndon B. Johnson's Remarks on the Medicare Bill,” econedlink, accessed Oct. 8, 2019, https://tinyurl.com/y6pnjgqz; “July 2019 Medicaid & CHIP Enrollment Data Highlights,” Medicaid, accessed Oct. 10, 2019, https://tinyurl.com/gl2bqha.

[64] Martin Gorksy, “The British National Health Service 1948 — 2008: A Review of the Historiography,” Social History of Medicine, Oct. 19, 2008, pp. 437-460, https://tinyurl.com/y2lzdeyw; “Milestones: universal policies,” Canadian Public Health Association, accessed Sept. 16, 2019, https://tinyurl.com/y5vsuod2.

[65] Richard Nixon, “State of the Union Address,” The Miller Center, Jan. 30, 1974, https://tinyurl.com/y23rwbvr.

[66] N.R. Kleinfield, “The King of the H.M.O. Mountain,” The New York Times, July 31, 1983, https://tinyurl.com/yyjf5cpo; Lynn R. Gruber, Maureen Shadle and Cynthia L. Polich, “From Movement To Industry: The Growth Of HMOs,” Health Affairs, Jan. 1, 1988, https://tinyurl.com/y5fd55ce.

[67] William Recktenwald, “Insurance Forum Turns Catastrophic for Rostenkowski,” Chicago Tribune, Aug. 18, 1989, https://tinyurl.com/y5ogpofo.

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[68] Adam Clymer, Robert Pear and Robin Toner, “The Health Care Debate: What Went Wrong? How the Health Care Campaign Collapsed,” The New York Times, Aug. 29, 1994, https://tinyurl.com/y6fy35sb.

[69] Theda Skocpol, “The Rise and Resounding Demise of the Clinton Plan,” Health Affairs, January 1995, https://tinyurl.com/yxo9t46t.

[70] Clymer et al., op. cit.

[71] “State Children's Health Insurance Program,” Benefits.gov, accessed Oct. 10, 2019, https://tinyurl.com/y46ca6zd; “July 2019 Medicaid & CHIP Enrollment Data Highlights,” op. cit.

[72] “Monthly premium for drug plans,” Medicare, accessed Oct. 10, 2019, https://tinyurl.com/y5emnu2p.

[73] “Medicare Part D Vote” C-SPAN, Nov. 21, 2003, https://tinyurl.com/yyptqobh.

[74] Sarah Iselin, “A Foundation Leader Discusses Massachusetts Health Reform at the Five-Year Mark,” Health Affairs, Jan. 26, 2012, https://tinyurl.com/y5ttv4ob.

[75] Angie Drobnic Holan, “Fact-checking claims about the individual mandate,” PolitiFact, June 28, 2012, https://tinyurl.com/y3gfasdg.

[76] Sara Rosenbaum and Timothy M. Westmoreland, “The Supreme Court's Surprising Decision On The Medicaid Expansion: How Will The Federal Government And States Proceed?” Health Affairs, August 2012, https://tinyurl.com/y3f9exn5.

[77] “Status of State Medicaid Expansion Decisions: Interactive Map,” Kaiser Family Foundation, Sept. 20, 2019, https://tinyurl.com/y4tcr87e; “2018 Poverty Rate in the United States,” U.S. Census Bureau, Sept. 26, 2019, https://tinyurl.com/y5eumhwd; and “2018 Uninsured Rate in the United States,” U.S. Census Bureau, Sept. 26, 2019, https://tinyurl.com/yxp9rxfp.

[78] “Final Vote Results for Roll Call 493,” Clerk of House of Representatives, July 17, 2019, https://tinyurl.com/y5a9ge2d.

[79] Jan Hoffman, Robert Pear and Adam Liptak, “Health Law Could Be Hard to Knock Down Despite Judge's Ruling,” The New York Times, Dec. 15, 2018, https://tinyurl.com/y57k2k3c.

[80] Edward R. Berchick, Jessica C. Barnett and Rachel D. Upton, “Health Insurance Coverage in the United States: 2018,” U.S. Census Bureau, September 2019, https://tinyurl.com/y462mzls; Whitney Blair Wyckoff, “Number Of Americans With Health Insurance Fell In 2009,” National Public Radio, Sept. 16, 2010, https://tinyurl.com/yy68frqz.

[81] “S.1129 — Medicare for All Act of 2019,” Congress.gov, accessed Oct. 10, 2019, https://tinyurl.com/y32q5ny9; “S.489 — State Public Option Act,” Congress.gov, accessed Oct. 10, 2019, https://tinyurl.com/y57f748n.

[82] “S.981 — Medicare-X Choice Act of 2019,” Congress.gov, accessed Oct. 10, 2019, https://tinyurl.com/y48q3het; “S.1261 — Choose Medicare Act,” Congress.gov, accessed Oct. 10, 2019, https://tinyurl.com/y37kpbr8.

[83] “Buttigieg takes swipe at Elizabeth Warren's Campaign,” CNN, Sept. 19, 2019, https://tinyurl.com/y4e6ymxm.

[84] Ibid.

[85] Harris Meyer, “States giving public option health plans a hard look,” Modern Healthcare, June 1, 2019, https://tinyurl.com/y3uywah8.

[86] “Remarks by President Trump at Signing of an Executive Order Protecting and Improving Medicare for our Nation's Seniors,” The White House, Oct. 3, 2019, https://tinyurl.com/yxjhmq89; “Executive Order on Protecting and Improving Medicare for Our Nation's Seniors,” The White House, Oct. 3, 2019, https://tinyurl.com/y6l7wa4l.

[87] “TITLE I: Ending Surprise Medical Bills,” U.S. Senate HELP Committee, accessed Oct. 10, 2019, https://tinyurl.com/y5xze3ch.

[88] Sen. Patty Murray, opening statement before U.S. Senate HELP Committee, minutes 41 to 42, June 26, 2019, https://tinyurl.com/y5m85rgz.

[89] Katie Keith, “Trump Administration Asks Court To Strike Down Entire ACA,” Health Affairs, March 26, 2019, https://tinyurl.com/y5cphb8n.

[90] Ibid.

[91] “In the United States Court of Appeals for the Fifth Circuit,” May 1, 2019, https://tinyurl.com/y57tyy8z.

[92] “Protecting Americans With Pre-Existing Conditions Act of 2019,” Congressional Record, May 9, 2019, https://tinyurl.com/yylueacd.

[93] Rachel Bluth and Emmarie Huetteman, “Investors' Deep-Pocket Push To Defend Surprise Medical Bills,” Kaiser Health News, Sept. 11, 2019, https://tinyurl.com/y4klxul5.

[94] “Greg Walden Appears on MSNBC, Discusses Protecting Patients from Surprise Medical Bills,” press release, Office of Rep. Walden, Sept. 16, 2019, https://tinyurl.com/y4vo2mrn.

[95] Zack Cooper, Fiona Scott Morton and Nathan Shekita, “Surprise! Out-of-Network Billing for Emergency Care in the United States,” National Bureau of Economic Research, revised January 2019, https://tinyurl.com/y399dura; Karen Pollitz et al., “An examination of surprise medical bills and proposals to protect consumers from them,” Kaiser Family Foundation, Oct. 16, 2019, https://tinyurl.com/y54s9ccv.

[96] Marty Makary, The Price We Pay: What Broke American Health Care — And How to Fix It (2019), p. 47.

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[98] “Statement for Hearing on ‘Examining Surprise Billing: Protecting Patients from Financial Pain,’” America's Health Insurance Plans, April 2, 2019, https://tinyurl.com/y4r58wm3.

About the Author Kerry Dooley Young is a freelance writer based in Washington, D.C. She specializes in health care, writing often for publications owned by WebMD. She earlier covered Medicare for CQ Roll Call and the pharmaceutical industry and the Food and Drug Administration for Bloomberg News.

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#top

Introduction
Overview

Would a government-funded health care system limit access to care?
Would a single-payer approach overwhelm the federal budget?
Would Americans accept the end of the private health insurance system?

Background

Early Insurance
Government Plans
Notable Stumbles
Public-Private Combinations

Current Situation

Debates Continue

Outlook

Election Calculations

Pro/Con

Chronology
Short Features
Bibliography

Books
Articles
Reports and Studies

The Next Step

Future of the Affordable Care Act
Medicaid Expansion
Public Option
Surprise Billing

Contacts
Footnotes
About the Author