Universal Health Care This Project

¶ … Universal Health Care

This project explores several published articles that report on results from research conducted on Online (Internet) and Offline (non-internet) on the benefits of Americans receiving/participating in Universal Health Care (UHC). The articles, however, vary in their definition in implementing UHC. The Democratic government suggests that UHC is more effective than Private Insurance Carriers (PIC), and advocate the use of supplementary coverage for the millions of previously and otherwise rejected un-insurable Americans. Other articles define UHC differently and therefore, offer different results?

This project examines UHC research in relation to several other research articles to suggest that all areas of UHC should be studied in order to fully understand how UHC will influence (impact) and better the lives of all Americans, regardless of their economic ability to pay. Based on a synthesis of a meta-analysis of representative arguments and a review of the literature, the study provides a summary of the research, important findings and recommendations in the concluding chapter.

Table of Contents

Chapter 1: Introduction

Statement of the Problem

Purpose of Study

Importance of Study

Scope of Study

Rationale of Study

Overview of Study

Chapter 2: Review of Related Literature

Chapter 3: Methodology

Description of the Study Approach

Data-gathering Method and Database of Study

Chapter 4: Data Analysis

Chapter 5: Summary, Conclusions and Recommendations

Varying Differences of Universal Health Care

Chapter 1: Introduction

Statement of the Problem

The debate over the respective roles and rights of the states and the federal government have always been a characteristic of American politics, and the controversy has become particularly pronounced recently as the drive towards universal health care has nearly reached the level of being the law of the land. While it is reasonable to suggest that most compassionate Americans feel that no one should be denied basic life-saving health care services based on their inability to pay for them, there remains a dearth of viable approaches from policymakers that can pay for these services. Moreover, the problems associated with providing the expanded coverage offered by universal health care plans are much more complicated than that, of course, and current trends suggest that although the Health Care Reform Act has passed congressional muster, it faces a groundswell of opposition based on its constitutionality.

Yet another problem facing proponents of a universal health care plan for the United States is the issue of whether there is a mandate for the provision of universal health care at the federal or state level, or a mandate at all for that matter. Indeed, some observers suggest that health care is an individual responsibility and to the extent that government contributes to the process is the extent to which it is being benevolent rather than fulfilling a responsibility. There are some longstanding precedents regarding the participation of the local, state and federal governments in contributing to health care services for Americans. For example, Champlin and Knoedler (2008) emphasize that, "Nearly a century ago, the American Association for Labor Legislation (AALL) began a campaign for universal health insurance based on the notion that health care is the joint responsibility of employers, workers, and the state" (p. 913). In reality, many aspects of the existing American health care system reflect this type of shared health care responsibility, with the costs of health insurance currently be underwritten by all three sectors of the U.S. economy: (a) households; (b) employers; and (c) government; although the underwriting is shared, the actual responsibility for the subsidization is not shared equitably. According to Champlin and Knoelder, "The steady retreat of private firms and government from assuming a substantial share of the burden of health care costs is based on an underlying presumption that health care is entirely an individual's responsibility, while the contributions of government and the private sector are basically optional -- a matter of benevolence rather than responsibility" (p. 913).

Therefore, because the provision of health care is not addressed in the U.S. Constitution, the determination of responsibility remains a matter of state- and federal-level interpretation and funding on a strictly voluntary basis based on the prevailing political views of the era. Past trends suggest that governments at all levels will remain active in some fashion in underwriting the health care needs of their citizens, but the current debate over the Health Care Reform Act and the need for universal health care must address this fundamental issue of responsibility. In this regard, Champlin and Knoelder conclude that, "The likely outcome of the current complicated debates over health care reform will depend on this issue of responsibility. Who should pay for health care? Is it a collective responsibility or an individual one?" (p. 914). These and related issues remain the focus on the current effort to legislate universal health care in the United States, and a growing number of critics suggest that the whole package in unconstitutional in the way in requires citizens to purchase health insurance coverage or face financial penalties. In other words, this means that some Americans who are already unable to afford health care insurance would be placed at a further disadvantage by being forced to pay a penalty for being too poor in the first place. In this environment, identifying the important differences in universal health care approaches to determine what works and what does not -- and why -- has assumed new relevance and represents a timely and valuable contribution to this ongoing debate.

Purpose of Study

Because the stakes involved are high and the rhetoric surrounding the debate has been emotionally charged in recent years, it is important to sort out the facts from the hyperbole. Therefore, the purpose of this study was to provide a review of the relevant juried, scholarly and governmental literature concerning universal health care to identify best practices where they exist and determine common factors involved in successful approaches.

Importance of Study

As noted above, the stakes involved in the provision of universal health care are high across the board. In terms of the human impact, the costs of failing to provide adequate health care coverage for the uninsured as incalculable but from a strictly pragmatic perspective, the economic consequences are well established. For example, in 2007, the United States spent approximately $2.2 trillion on health care or about $7,421 per person (Health care, 2010). This level of spending is almost double what other developed nations around the world currently spend on their health care needs, and Americans spend more on their health care needs than they do on housing or food. In fact, if current projections of health care costs are accurate, the Congressional Budget Office indicates that by 2025, fully 25% of the national economy will be allocated to the health care system. This increased demand on the national budget will have to be offset by cuts in other social programs and investments in infrastructure that are desperately needed across the country (Health care, 2010). As the White House press release concerning the recent efforts to pass the Health Care Reform Act emphasizes, "Rising health care costs also affect our economic competitiveness in the global economy, as American companies compete against companies in other countries that have dramatically lower health care costs" (Health care, 2010, para. 2).

Scope of Study

The scope of the study extended to a review of historic state- and federal-level initiatives designed to provide increased access to health care for the uninsured in general and the provision of universal health care in particular in the United States.

Rationale of Study

Given the enormous amount of money currently being spent on health care in the United States, together with projections of even more money being required in the future, it just makes good business sense to identify what works best and to do more of that. Unfortunately, there are few success stories to draw upon in the analysis of how best to provide universal health care but it is vitally important to determine what approaches have proven more effective than others in the past in order to avoid false starts and missteps while maximizing the return on any additional investments in these initiatives.

Overview of Study

This study used a five-chapter format to achieve the above-stated research purpose. Chapter one of the study was used to introduce the topics under consideration, provide a statement of the problem, as well as the purpose, importance, scope and rationale of the study. Chapter two was used to deliver a review of the relevant peer-reviewed, scholarly, popular and governmental literature concerning universal health care and what approaches have been shown to be effective in the past, as well as what the critics have to say about current efforts to provide universal health care in the United States. A description of the study's methodology in chapter three is followed by an analysis of state-level approaches to universal health care compared to the current efforts to provide UHC at the national level in the data analysis chapter. A summary of the research, relevant conclusions and recommendations are provided in the concluding chapter.

Chapter 2: Review of Related Literature

Chapter Introduction

This chapter provides the background and an overview of the debate concerning national health insurance and the issues surrounding the provision of universal health care in the United States. A discussion of the implications of universal health care for private insurance carriers and other stakeholders is followed by a review of the criticisms being directed at current efforts to reform health care in the U.S. A brief summary of the research concludes this chapter which is followed by a more complete description of the study's methodology in chapter three below.

Background and Overview

A strictly literal definition of universal health care would mean that everyone, including illegal aliens, all children irrespective of their financial or legal status, and those with preexisting conditions, for example, would be equally entitled to health care services, a situation that may appear as pie-in-the-sky but which is closer to reality than many observers might believe. In fact, a popular misperception currently exists concerning just how much health care is already being provided to those who cannot afford to pay for it in the form of national health insurance. The costs associated with providing current levels of health care through a convoluted system of providers and funding, though, make the provision of such care very costly and therefore scarcer for a growing number of American consumers. For instance, a recent essay by Berkowitz (2006) asks, "Why is there no national health insurance in the United States? The answer is that there is national health insurance in the United States and quite a lot of it. The problem lies in the fact that this country has too much health insurance -- making our health care system very costly -- and too little -- limiting access to health care to well over forty million people" (p. 1218). Furthermore, the current approaches to providing health care coverage to employees are heavily burdened by the need for some employers to provide health care coverage for their retirees. According to Champlin and Knoedler (2008), "Companies have moved away from the defined benefit pension in favor of the defined contribution plan. Part of this move has been an effort to avoid offering health benefits as part of the retirement package. Still, several high profile corporations retain substantial obligations to both current and retired employees" (p. 914). Citing as good examples General Motors (which provides health care coverage to 750,000 current and former employees), and Ford (which must cover about 560,000), these authors conclude that, "While some employers continue to pay most or all of the cost for individual coverage, the current trend is for employees to pay a higher percentage of the monthly premium. Only seventeen percent of employers still pay the full cost of health care coverage for individuals and only six percent pay the full cost of family coverage" (Champlin & Knoedler, 2008, p. 914). This trend has placed even employer-provided health insurance beyond the means of many Americans and policymakers are faced with these as well as a broader spectrum of problems that have been identified time and again over the years as efforts to provide equitable access to health care have come and gone.

In fact, the effort to provide health care to all Americans is not a new initiative but is rather a continuation of a century-long attempt to provide health care consumers with the level of care they need while balancing the costs involved. In many cases, these efforts have involved some type of national health insurance which mixed results. Notwithstanding the most recent efforts of the U.S. Congress and President Obama to pass the national Health Care Reform Act, prior efforts from 1970 to 2000 were marked by a swing away from universal health care. In this regard, Berkowitz notes that, "Although the nation has made periodic surges toward national health insurance, the result has never amounted to universal access. In fact, we have moved further away from this ideal in the last third of the last century" (2006, p. 1218).

Although the Health Care Reform Act has passed congressional muster and awaits signature by the president as this project is being researched, it faces a constitutional challenge by a growing number of institutional critics and taxpayers alike but it can be assumed that the bill will pass in substantially its existing form soon. Amid the media hoopla, though, these critics cite a number of constraints and weaknesses in the proposed law that will make it untenable over the long-term and highly costly in the short-term. According to a recent analysis by Bowman (2010), "Supporters have praised President Obama's health care reform bill as a historic landmark in our nation's history -- and so it is, but not for the reasons that many of them claim. The concept itself is not the problem. In fact, it is even commendable" (para. 2). As noted above, the health care reform initiative being promoted today is a continuation of a 100-year trend to this end, but as also noted above, critics suggest that the current legislation is fundamental flawed from a conceptual perspective. In this regard, Bowman adds that, "Providing affordable health care to an entire nation is a noble goal, and that is basically what the bill is trying to achieve. But before we jump onto the bandwagon of reform, perhaps we should take a closer look at how the bill will affect the nation" (para. 2).

This closer examination reveals that during a period of economic downturn, the United States government is seeking to establish additional and potentially onerous mandates on the states and individual citizens that will raise taxes and require the several states to increase funding for health care services (Bowman, 2010). Some estimates of the additional costs of the Health Care Reform Act exceed $500 billion over the next decade, with a significant portion of this money being derived from levies on Medicare and taxpayers (Bowman, 2010). As noted above, besides the funding mechanisms that are involved in the proposed law, there are serious questions concerning the constitutionality of its provisions. In this regard, Bowman notes that, "The bill, when fully implemented, will require all individuals to purchase health care or risk being fined by the government. Several states have vowed to actually sue the federal government over this point, claiming that it infringes on the constitutional rights of citizens. How can the government expect to force us to pay for health care that they themselves provide?" (2010, para. 2). In response to these charges and others, the White House press release concerning the provisions of the Health Care Reform Act emphasizes that:

1. It makes insurance more affordable by providing the largest middle class tax cut for health care in history, reducing premium costs for tens of millions of families and small business owners who are priced out of coverage today. This helps over 31 million Americans afford health care who do not get it today -- and makes coverage more affordable for many more.

2. It sets up a new competitive health insurance market giving tens of millions of Americans the exact same insurance choices that members of Congress will have.

3. It brings greater accountability to health care by laying out commonsense rules of the road to keep premiums down and prevent insurance industry abuses and denial of care.

4. It will end discrimination against Americans with pre-existing conditions.

5. It puts our budget and economy on a more stable path by reducing the deficit by $100 billion over the next ten years -- and about $1 trillion over the second decade -- by cutting government overspending and reining in waste, fraud and abuse (Health care, 2010, para. 3-4).

Nevertheless, some critics cite the lack of a so-called public option (meaning that consumer choices for health care are limited to private insurance carriers) in the Health Care Reform Act which they regard as an essential element if the legislation is going to pass a review of its constitutionality (Bowman, 2010). Instead of a public option, the current approach mandates a government option only. According to Bowman, the government option is "a rationed plan with benefits and treatments chosen by a government committee. The problem with that option is, you have no say in the benefits that are given (or withheld), and there is no appeals process if you disagree. In addition to this, according to the bill itself, no company can sue the government for price-fixing, and no 'judicial review' is permitted against the government" (2010, para. 3). Despite these constraints and drawbacks, the Health Care Reform Act is set to become the law of the land in the near future and the implications for private insurance carriers and American healthcare consumers is profound, and these issues are discussed further below.

Implications of Universal Health Care Coverage

Universal health care plans inevitably confront the harsh realities involved in hammering out viable approaches to coordinating administrative and payments methods between health care providers and private insurance carriers. According to Olson and Wasson (2004), "Health care providers often agree to certain fee schedules with private insurance carriers, under which they accept as full payment less than the amount billed to the patient. The provider then must write off the difference between the amount charged and the amount received" (p. 172). Comparable circumstances result when health care providers deliver medical services under the purview of the federally sponsored Medicare or Medicaid programs (Olson & Wasson, 2004). There are some restrictions involved concerning how long the health care providers has to submit a bill for services and providers typically receive far less than what they charge Medicare or Medicaid (generally they receive about one-third of their billed charges) and current law stipulates that the health care provider must write off the remaining balance, and it is unable to collect any additional payments for the remaining amounts charged (Olson & Wasson, 2004).

It is little wonder, then, that private insurance carriers are alarmed at any proposed changes in the status quo that would cost them even more money as the result of federal government mandates contained in the Health Care Reform Act. In fact, some of the protections touted by the White House for the reform include the following that will have a direct impact on private insurance carriers:

1. No discrimination for pre-existing conditions (insurance companies will be prohibited from refusing coverage because of a medical history);

2. No exorbitant out-of-pocket expenses, deductibles or co-pays (insurance companies will have to abide by yearly caps on how much they can charge for out-of-pocket expenses);

3. No cost-sharing for preventive care (insurance companies must fully cover, without charge, regular checkups and tests that help prevent illness, such as mammograms or eye and foot exams for diabetics);

4. No dropping of coverage for seriously ill (insurance companies will be prohibited from dropping or watering down insurance coverage for those who become seriously ill);

5. No gender discrimination (insurance companies will be prohibited from charging more because of gender);

6. No annual or lifetime caps on coverage (insurance companies will be prevented from placing annual or lifetime caps on coverage);

7. Extended coverage for young adults (children would continue to be eligible for family coverage through the age of 26);

8. Guaranteed insurance renewal (insurance companies will be required to renew any policy as long as the policyholder pays their premium in full and insurance companies will not be allowed to refuse renewal because someone became sick) (Health insurance consumer protections, 2010).

As noted above, the move to provide universal health care in America is certainly not new, but has been taking place for more than a century. According to Berkowitz (2008), the proposals for these initiatives have largely mirrored the political needs of the policymakers involved. For instance, Berkowitz notes that, "In the progressive era, labor economists and others with an interest in the terms of the wage bargain tended to dominate the discussion. The result was proposals from groups such as the American Association for Labor Legislation to have the state subsidize health insurance for the working classes" (p. 1218). While this funding approach is considered de rigueur today, such proposals were regarded as radical for the day. In this regard, Berkowitz adds that, "This class-specific formulation of the problem rankled many Americans, including conservative businessmen and upwardly mobile members of labor unions. The progressives imported many of their ideas from abroad. At the time, the European welfare state was far from universal in its scope of coverage. Instead it used the state to confer benefits on particular occupational groups" (2006, p. 1218).

Another proposal for increasing universal access to health care in the U.S. emerged during the 1920s that would have even longer lasting effects on the country. The public health community argued that if there was an abundance of health care facilities available, the issue of access would no longer be a problem. While the Great Depression would spell an end to this ambitious approach, it did highlight some of the same types of problems that plague the policymaking today. In this regard, Berkowitz notes that this early initiative failed to address who was entitled to what: "One problem, of course, was that there were a lot of vagaries concerning who [would be treated], as reflected in the very nature of a country that raised racial and regional barriers to providing services of any sort" (2006, p. 1218).

While the racial problems have largely been resolved through legislative means, the underlying entitlement issues remain salient today. Current approaches to providing extended health care coverage are based in large part to efforts in the late 1960s when LBJ's Great Society initiative resulted in a combination of approaches used in the progressive era and the 1920s to create Medicare and Medicaid. According to Berkowitz, "It was health care for those left behind in the tremendous expansion of private health insurance in the postwar era. The federal programs took the specific forms of health benefits for the elderly and for those on welfare" (2006, p. 1219). In the pay-for-play approach embodied by Medicare, Berkowitz notes that, "Medicare in particular continued to reflect the progressive era emphasis on the wage bargain in its emphasis on social insurance and payroll taxes, and its passage coincided with an exponential increase in federal money for hospitals, medical schools, medical research and other pieces of what might be called the medical infrastructure" (2006, p. 1219). Even during the halcyon days of funding for social programs such as health care, the trends involved only served to make matters worse for health care consumers who could not afford employer- or government-provided insurance by making health care in general more expensive for everyone. "The problem was that social insurance," Berkowitz writes, "which insured workers but not others in the general population, mitigated against the very notion of universal health care. The structure of permissive programs like Medicare helped to raise medical care costs and create a crisis in health care finance" (2006, p. 1219).

Because so many Americans were already affected by Medicare and Medicaid, these costs took center stage over the larger debate concerning the need for universal health care, a debate that lost ground as the economy worsened and the nation's priorities changed during the 21st century. In this regard, Berkowitz adds that, "As rising costs became the central problem of medical policy, the issue of universal access tended to be shunted aside, with tragic consequences for those on the edges of American society" (2006, p. 1219). The high costs associated with the Medicare and Medicaid programs also worked against universal health care advocates. According to Agrawal and Veit (2002), "During the 1970s, there was widespread sentiment that universal health care coverage was not economically feasible. Only a few short years after Medicare and Medicaid expanded access to health care coverage, the need to control health care cost inflation was obvious. Expanding the then-current style of medical practice to an ever-increasing number of citizens would cost more than the nation was willing or able to pay" (p.12). Some of the early efforts to address these problems met with mixed results, such as Oregon's plan during the early 1990s that was targeted at improving health care access by aggressively expanding the state's Medicaid program. One of the distinctive aspects of this approach was the use of diverted funds from a convoluted rationing system that weighted health care treatments according to a proven efficacy scale and only provided coverage for those with the best track records (Klein, 2007). The program met with some early successes. For instance, Klein notes that, "Oregon's plan sought to protect itself from the fiscal downturns and strains that bedeviled other efforts. Between 1992 and 1996, the state's uninsured population dropped by 7%, and the electorate voted twice to hike cigarette taxes in order to better fund the program" (Klein, 2007, p. 26).

The economic downturns experienced since the beginning of the 21st century, though, have doomed Oregon's efforts. The approach used in Oregon was expanded in 2002, but this expansion took place during a dismal economic period and there was no money available to fund the expanded approach. As a result, services to health care consumers were reduced and charges were increased, a compromise that received bipartisan support in the state but which resulted in its failure. According to Klein, "Instead of expanding by 50%, the program contracted by 75%, as the increased cost sharing and stringent payment regulations caused thousands of Oregonians to leave or be kicked off the state's rolls" (2007, p. 26). This outcome was not necessarily inevitable, but it does serve to highlight the fact that the costs of health care cannot be avoided, only moved around among the major stakeholders involved.

Individual Mandates at the State Level

Other states have attempted to avoid the mistakes made by Oregon by a simple shift in responsibility for these cost and making the issue of health care an individual responsibility. According to Klein, the Health Care Reform Act is similar to these state-level approaches by mandating that health care is in fact an individual responsibility. In this regard, Klein writes, "The new crop of state health care plans are trying to avoid the failures of the past by attempting something new: individual mandates. Here, Massachusetts led the way. Its plan forces everyone in the state to have health insurance, with subsidies for those who can't afford it" (p. 26). As noted above, it is important to differentiate the provision of health care to those who are unable to obtain it otherwise from those who are simply unwilling to do so. These "free riders" add to the national costs of providing health care services to everyone of course by increasing insurance premiums for those with insurance and by forcing health care providers to charge more for their services to everyone to cover the costs of unreimbursed services. According to Callahan (2006), "The Massachusetts plan shows how a resourceful governor can manage to bring together a number of diverse interests and constituencies" (p. 28).

The approach used in Massachusetts, like the mandates contained in the Health Care Reform Act tackle this problem head-on and may result in more health care consumers enrolling in programs that will help transfer these costs in ways that more equitably balance the load. This point is also made by Klein who emphasizes that, "The genius of this approach is that many of those who lack health insurance aren't poor or ailing -- they're middle-class people who have decided they're healthy enough that they don't need to spend money on health coverage. Forcing these people to buy insurance (like similar reforms that require all drivers to have auto insurance) has the useful effect of bringing more money into the system while spreading the risk" (p. 26). Because there have been no successful challenge to the requirement by states for motorists to have valid insurance, it is reasonable to suggest that such a requirement for health care might just squeak by judicial review in the future. To date, although Massachusetts was the first state to enact such an individual mandate, other states, including California, Illinois, New Jersey, and Connecticut, are considering universal plans that contain comparable individual mandates (Klein, 2007). Furthermore, individual mandates have proven successful for Massachusetts at least, where state officials reported that based on the increased funding available through insurance payments from previously uninsured residents, they would be able to offer premiums on a sliding scale that would provide at least minimal coverage for 99% of the adult residents in the state (Klein, 2007).

This success, though, must be balanced by the fact that Massachusetts already had one of the lowest insured populations in the U.S. (10% vs. 16% nationally) and more of the state's uninsured population is able to purchase health care insurance because of the state's higher wages (the median household income in Massachusetts is $8,000 above the national average) (Klein, 2007). Finally, Klein points out that Massachusetts enjoys yet a third advantage over most other states because it continues to receive funding from an earlier effort to provide universal health care that failed but portions of which (more than a half billion dollars in 2007) are still used to reimburse health care providers for services delivered to uninsured residents (Klein, 2007). This analyst suggests that for the foregoing reasons, individual mandates will be faced with more resistance in other states, particularly less affluent states such as New Mexico where 26% of the population is uninsured and the median household income is 20% lower compared to the national average (Klein, 2007). The implications of individual mandates for New Mexico and similarly situated states include the need for additional funding over the long-term, a requirement that savvy politicians may be reluctant to support when things get especially though economically. In this regard, Klein makes a blood-out-of-a-turnip analogy and concludes that in New Mexico:

Even if everyone in the state without insurance were mandated to have it, only a relatively small portion could afford to buy that insurance without massively generous subsidies. To provide those subsidies, the government would have to seek tax increases of a size that no state in recent memory has been able to pass. And to sustain the program, it would have to hold firm during all manner of recessions and downturns, when the calls for tax relief grow strongest but when the program's funding may actually need to be increased. (2007, p. 26).

Unfortunately, even some of the other states that have higher household incomes may not be able to afford universal health care either. The initiatives proposed in Illinois and California have been met with a crisis in funding that doomed them to failure but the successes and failures at the state level to date have been valuable for one reason in particular: "One of the great things about state governments is that they have more freedom than the federal government does to test new policy ideas. But it pays to look honestly at what the results of those tests actually say. And in this case, the results are pretty clear: states are no good at delivering universal health care" (Klein, 2007, p. 26). Likewise, citing the cost inefficiencies of Medicare, a recent essay by Barry Goldwater (2009) emphasizes that, "Nowhere in the debate regarding health care has anyone asked if the government is able and qualified to run such a system. Before we ask government officials to manage universal health care, let's check them out. How successful has the federal government been in managing agencies, programs and businesses?" (p. 8). In answering his own question, Goldwater also notes that:

The president and Congress propose to extend Medicare to cover the 47 million people who lack health care coverage. Did anyone remind Congress that Medicare is broke? It's rampant with fraud and abuse. Medicare and Medicaid fraud cost taxpayers an estimated $60 billion per year. Medicare is legally required to pay full retail prices for drugs that could be obtained for far less in a competitive-bidding system. (2009, p. 8).

Given this mixed track record of results with universal health care and varying definitions of what elements are needed to qualify as "universal," a review of how other authorities have weighed in on these issues is needed and this analysis is provided in chapter four below.

Chapter summary

This chapter reviewed the relevant literature to provide the background and an overview concerning national health insurance and the issues involved in the provision of universal health care in the United States. A discussion of the implications of universal health care for private insurance carriers and other stakeholders was followed by a review of the criticisms being directed at current efforts to reform health care in the U.S. A description of the study approach used and the data-base of study employed are provided in chapter three below.

Chapter 3: Methodology

Description of the Study Approach

This study used a mixed methodology consisting of a review of the relevant literature together with a qualitative meta-analysis as its study approach based on the following rationale. According to Gratton and Jones (2003), a review of the relevant literature represents an important component of most types of research projects. These authors note that, "A literature review is the background to the research, where it is important to demonstrate a clear understanding of the relevant theories and concepts, the results of past research into the area, the types of methodologies and research designs employed in such research, and areas where the literature is deficient" (Gratton & Jones, 2003, p. 51). As to the meta-analysis component, Baskin and Enright report that, "Meta-analysis is a popular vehicle of synthesizing results across multiple studies" (p. 79). Social researchers have used both quantitative as well as qualitative meta-analytical approaches to date (Neuman, 2003). A qualitative meta-analysis has a number of advantages that were able to contribute to the robustness of the study's findings, an outcome that is congruent with Dimatteo & Rosenthal (2001) guidance that the use of a meta-analysis approach allows researchers to arrive at conclusions that are more accurate and credible than could be produced in a single primary study or a single non-quantitative, narrative review. In addition, Dimatteo and Rosenthal note that the meta-analytical study approach has been used to good effect in investigating social problems.

Because complex problems require complex solutions, a qualitative meta-analysis is particularly well suited for an examination of the issues involved in the provision of universal health care today. In this regard, Dimatteo and Rosenthal point out that, "Inquiries often demand immediate answers to complex and multifaceted questions in which existing data may be quite variable and steps depend upon reconciliation of disparate findings" (2001, p. 59). In this study, the arguments for and against universal health care were indeed disparate, but even the arguments in support (or against) UHC were frequently characterized by different reasons for such support (or opposition), making the meta-analytical approach a useful framework in which to review these arguments. To facilitate the review and comparison of these disparate arguments, the results of the meta-analysis are presented in a series of word tables in chapter four below, an approach that is also congruent with the American Psychological Association's Publication Manual (5th ed.), which states, "Word tables present qualitative comparisons or descriptive information. For example, a word table can enable the reader to compare characteristics of studies in an article that reviews many studies, or it can present questions and responses from a survey or shown an outline of the elements of a theory. Word tables illustrate the discussion in the text" (p. 161).

Data-gathering Method and Database of Study

This study consulted both university and public libraries, online resources such as Questia and EBSCO, as well as relevant governmental and organizational Web sites.

Chapter 4: Data Analysis

Author(s), Date, Title, Publication, Page No.

Key Findings

Comments

Klein, E. (2007, July-August). Over stated: Why the 'laboratories of Democracy' can't achieve universal health care. Washington Monthly, 39(7), p. 26.

Hawaii's generous attempt to provide UHC resulted in what is termed the "woodwork effect," where a new government program entices people out of the woodwork, leading to more applicants and higher costs than anticipated, a result that was combined with an economic downturn to doom the initiative. Recessions rob government of the revenue it needs to cover the uninsured at precisely the moment that the most people need subsidies to get them through the lean times; states are incapable of responding, since they, unlike the federal government, are constitutionally barred from running deficits.

Hawaii responded by cutting back the program and rather than offering benefits for those whose income was up to three times the federal poverty line, it restricted eligibility to people whose income was twice the poverty line, and introduced an assets test, thereby eliminating the "universal" qualities that it wanted to achieve. The Kaiser Family Foundation estimates that 9% of Hawaii's population is uninsured, compared to 15% nationwide, and it spends 12% of its gross state product on health care -- exactly the same proportion as the rest of the country.

Edwards, J. (2008). Building one America through universal health care. American Journal of Health Education, 39(1), p. 5.

Forty-seven million Americans do not have health insurance. And even those who do have it are worried about how they're going to pay for it -- and whether it will be enough to pay their bills in the event of a crisis. Across the country, families as well as businesses are being squeezed by rising health care costs. Too many families are one major illness away from financial disaster.

To fix this crisis, we don't need an incremental shift, we need a fundamental change. We need truly universal health care. For more than 20 years, Democrats have talked about universal health care, but have gotten nowhere because the big insurance companies, drug companies, and HMOs have spent millions to block real reform.

Callahan, D. (2006). Universal health care: From the states to the nation? The Hastings Center

Report, 36(5), p. 29.

Successful state programs could teach Congress that an effort must be made to close all gaps, but to do it as a package and at once. The preferred, cautious course for politicians in recent decades has been incrementalism of one kind or another, as if small steps will pave the way for larger ones. Coverage for children, surely a good cause, is the most popular of such steps. But there is no evidence that incrementalism opens the way for larger reforms.

In 1965, the Medicare program was seen by many as a clever way to open the door to universal care. That never happened, and if anything, the unexpectedly high costs of that program scared many legislators away from that larger step.

Boaz, R.F. (1999). Rethinking universal health care security and cost containment. Challenge, 37(4), p. 28.

Any program intended to guarantee universal health care security would have to:

(1) substitute risk-blind for risk-based (experience-rated) health insurance;

(2) sever the link between employment status and health insurance coverage;

(3) stipulate uniform and comprehensive benefits;

(4) specify an income-based ceiling on out-of-pocket expenses;

(5) eliminate cost-shifting; and,

(6) minimize non-medical expenses.

The central question that has to be answered is how to fashion a program that can guarantee all Americans equal access to high-quality health care without enmeshing the government in an open-ended financial commitment at a time when its capacity to raise taxes is extremely limited.