Universal Health Care in the United States: Debate and Reform

Introduction and Statement of the Problem

The debate over the respective roles and rights of the states and the federal government has always been a characteristic of American politics, and the controversy has become particularly pronounced as the drive toward 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 fund these services. Moreover, the problems associated with providing the expanded coverage offered by universal health care plans are much more complicated than that, and current trends suggest that although the Health Care Reform Act 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. Indeed, some observers suggest that health care is an individual responsibility and that to the extent government contributes to the process is the extent to which it is being benevolent rather than fulfilling a responsibility. There are longstanding precedents regarding the participation of 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 responsibility, with the costs of health insurance currently being 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 subsidization is not shared equitably. According to Champlin and Knoedler, "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).

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, shaped by 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 must address this fundamental issue of responsibility. In this regard, Champlin and Knoedler 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). A growing number of critics suggest that the entire package is unconstitutional in the way it requires citizens to purchase health insurance coverage or face financial penalties. In other words, 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 peer-reviewed, scholarly, and governmental literature concerning universal health care, to identify best practices where they exist, and to determine the common factors involved in successful approaches.

Importance of Study

The stakes involved in the provision of universal health care are high across the board. In terms of human impact, the costs of failing to provide adequate health care coverage for the uninsured are 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 health care than they do on housing or food. In fact, if current projections 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 a White House press release concerning the Health Care Reform Act emphasized, "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, Rationale, and Overview 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.

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 makes good sense to identify what works best and to do more of it. 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.

This study used a five-chapter format. Chapter one introduced the topics under consideration and provided a statement of the problem as well as the purpose, importance, scope, and rationale of the study. Chapter two delivered 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. Chapter three described the study's methodology, followed by a data analysis chapter comparing state-level approaches to universal health care with the current efforts to provide UHC at the national level. A summary of the research, relevant conclusions, and recommendations are provided in the concluding chapter.