Health care reform in the United States

The debate over health care reform in the United States centers around questions of access, efficiency, quality, and sustainability. The mixed public-private health care system in the US is the most expensive in the world, with the US spending more on health care, both as a proportion of gross domestic product (GDP) and on a per capita basis, than any other nation. Current estimates put U.S. health care spending at approximately 16% of GDP. In 2007, the U.S. spent a projected $2.26 trillion on health care, or $7,439 per person. Health care costs are rising faster than wages or inflation, and the health share of GDP is expected to continue its historical upward trend, reaching 19.5 percent of GDP by 2017.

The U.S. is the only wealthy, industrialized nation that does not have a universal health care system, according to the Institute of Medicine of the National Academy of Sciences. Americans without health insurance coverage at some time during 2006 totaled about 16% of the population, or 47 million people.

International comparisons that could lead to conclusions about the quality of the health care received by Americans are inconclusive and subject to debate. The US lags other wealthy nations in such measures as infant mortality and life expectancy, but some argue that these differences have little to do with the structure of its health care system. Other comparisons indicate that the US system performs better on some measures, such as responsiveness and higher cure rates for serious illnesses such as cancer.

Whether a government-mandated system of universal health care should be implemented in the U.S. remains a hotly debated political topic, with Americans divided along party lines in their views of the US health system and what should be done to improve it. Those in favor of universal health care argue that the large number of uninsured Americans creates direct and hidden costs shared by all, and that extending coverage to all would lower costs and improve quality. Opponents of government mandates or programs for universal health care argue that people should be free to opt out of health insurance and that government programs would require higher taxes, increase utilization, and reduce health care quality. Opponents also claim that the current level of government involvement in US health care contributes to higher costs, and point to free-market solutions to increase efficiency, stimulate innovation, and make consumers rather than third parties more responsible for cost decisions. Both sides of the political spectrum have also looked to more philosophical arguments, debating whether people have a fundamental right to have health care provided to them by their government.

Background
The cost and quality of care in the United States are frequently the two major issues of discussion. The US performs worse than the average developed country in health measures such as infant mortality, maternal death , and life expectancy, although some studies claim the data collected regarding infant mortality and life expectancy do not lend themselves to fair comparison. Access to advanced medical treatments and technologies is greater than in most other developed nations and waiting times may be substantially shorter for treatment by specialists.

The US does spend more on health care, as an absolute dollar amount and per capita, than any other nation. It also spends a greater fraction of its national budget on health care than Canada, Germany, France, or Japan. In 2004 the US spent $6,102USD per person on health care, 92.7% more than any other G7 country, and 19.9% more than Luxembourg, which, after the US, had the highest spending in the Organisation for Economic Co-operation and Development (OECD). Risk factors specific to the US population, such as a relatively high prevalence of obesity, may partially explain increased health care spending; however, many other industrialized nations share these problems to some extent. Although the US Medicare coverage of prescription drugs began in 2006, most patented prescription drugs are significantly more costly in the US than in most other countries. Factors involved are the absence of government price controls, enforcement of intellectual property rights limiting the availability of generic drugs until after patent expiration, and the monopoly purchasing power seen in national single-payer systems. Some US citizens obtain their medications, directly or indirectly, from foreign sources, to take advantage of lower prices.

The US system already has substantial public components. Of every dollar spent on health care in the US, 45 cents comes from some level of government. The federal Medicare program covers the elderly and people with disabilities, the federal-state Medicaid program provides coverage to the poor, the State Children's Health Insurance Program (SCHIP) extends coverage to low-income families with children, merchant seamen are covered by the Public Health System, and retired railway workers and military veterans are also covered by the government. Government also affects private sector medicine through licensing and regulatory barriers to entry into health professions.

Various health care analysts have asserted that market failure occurs in health care markets, but some have suggested that it is a result of too much government involvement rather than too little. Consumers want unfettered access to medical services; they also prefer to pay through insurance rather than out of pocket. These two needs create problems for cost-efficiency. Some studies have found no consistent and systematic relationship between the type of financing of health care and cost containment.

The consumers of health care often lack basic information compared to the medical professionals they buy it from, and fully informed choices (particularly in emergencies) are often implausible. Meanwhile, health insurance companies and care providers also suffer from information asymmetry, as patients are almost always more aware of their particular family histories and risky behaviors than the firms are. Price theory dictates that the risk cost associated with this lack of information gets passed on to consumers. Demand is likely to be inelastic. The medical profession potentially may set rates that are well above ideal market value, and they are controlled by licensing requirements, with some degree of monopoly or oligopoly control over prices. Monopolies are made more likely by the variety of specialists and the importance of geographic proximity. Private insurers have been perhaps the only stabilizing force, as they pay a contractually fixed cost for a given procedure. With no more than one or two heart specialists or brain surgeons to choose from, competition for patients between such experts is limited, so contractually pre-arranged pricing helps reduce supply-limited pricing.

Increased use of preventive care is often suggested as a way of reducing health care spending. Research suggests, however, that in most cases prevention does not produce significant long-term cost savings. Preventive care is typically provided to many people who would never become ill, and for those who would have become ill, it is partially offset by the health care costs during additional years of life.

Reforming or restructuring the private health insurance market is often suggested as a means for achieving health care reform in the US. Insurance market reform has the potential to increase the number of Americans with insurance, but is unlikely to significantly reduce the rate of growth in health care spending. According to one study conducted by the Urban Institute, if not implemented on a systematic basis with appropriate safeguards, market reform has the potential to cause more problems than it solves.

Since most Americans with private coverage receive it through employer-sponsored plans, many have suggested employer "pay or play" requirements as a way to increase coverage levels. However, research suggests that current pay or play proposals are limited in their ability to increase coverage among the working poor. These proposals generally exclude small firms, do not distinguish between individuals who have access to other forms of coverage and those who do not, and increase the overall compensation costs to employers.

Premium subsidies to help individuals purchase their own health insurance have also been suggested as a way to increase coverage rates. Research confirms that consumers in the individual health insurance market are sensitive to price. Estimates of the demand elasticity in this market vary, but generally fall in the range of -0.3 to -0.1. It appears that price sensitivity varies among population subgroups and is generally higher for younger individuals and lower income individuals. However, research also suggests that subsidies alone are unlikely to solve the uninsured problem in the US.

A report published by the Commonwealth Fund in December 2007 examined 15 federal policy options and concluded that, taken together, they had the potential to reduce future increases in health care spending by $1.5 trillion over the next 10 years. These options included increased use of health information technology, research and incentives to improve medical decision making, reduced tobacco use and obesity, reforming the payment of providers to encourage efficiency, limiting the tax federal exemption for health insurance premiums, and reforming several market changes such as resetting the benchmark rates for Medicare Advantage plans and allowing the Department of Health and Human Services to negotiate drug prices. The authors based their modeling on the effect of combining these changes with the implementation of universal coverage. The authors concluded that there are no magic bullets for controlling health care costs, and that a multifaceted approach will be needed to achieve meaningful progress. The Congressional Budget Office has concluded that increased use of health information technology alone is unlikely to significantly reduce overall health care spending unless it it combined with broader measures to reduce costs.

A fundamental problem in evaluating reform proposals is the difficulty estimating their cost and potential impact. Because proposals often differ in many important details, it is difficult to provide meaningful side-by-side cost comparisons. The empirical data and theory underlying cost estimates in this area are limited and subject to debate, increasing the variation between estimates and limiting their accuracy.

History of reform efforts
U.S. efforts to achieve universal coverage began with Theodore Roosevelt and continue to today. The Medicare program was established by legislation signed into law on July 30, 1965, by President Lyndon B. Johnson. Medicare is a social insurance program administered by the United States government, providing health insurance coverage to people who are either age 65 and over, or who meet other special criteria. The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) amended the Employee Retirement Income Security Act of 1974 (ERISA) to give some employees the ability to continue health insurance coverage after leaving employment.

Health care reform was a major concern of the Bill Clinton administration headed up by First Lady Hillary Clinton; however, the 1993 Clinton health care plan was not enacted into law. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) made it easier for workers to keep health insurance coverage when they change jobs or lose a job, and also provided national standards for protecting personal health information.

In 2001, a Patients' Bill of Rights was debated in Congress, which would have provided patients with an explicit list of rights concerning their healthcare. This initiative was essentially taking some of ideas found in the Consumers' Bill of Rights and applying it to the field of healthcare. It was undertaken in an effort to ensure the quality of care of all patients by preserving the integrity of the processes that occur in the healthcare industry. Standardizing the nature of healthcare institutions in this manner proved rather provocative. In fact, many interest groups, including the American Medical Association (AMA) and the pharmaceutical industry came out vehemently against the congressional bill. Basically, providing emergency medical care to anyone, regardless of health insurance status, as well as the right of a patient to hold their health plan accountable for any and all harm done proved to be the biggest stumbling blocks for this bill. As a result of this intense opposition, the Patients' Bill of Rights initiative eventually failed to pass Congress in 2002.

Expanding health care was one focus of John Kerry's 2004 presidential campaign.

More recently, President George W. Bush signed into law the Medicare Prescription Drug, Improvement, and Modernization Act which included a prescription drug plan for elderly and disabled Americans. Health care reform have also been advanced as part of the 2008 presidential campaign platforms of both Hillary Clinton and Barack Obama.

In January of 2007 Rep. John Conyers, Jr. (D-MI) has introduced The United States National Health Insurance Act (HR 676) in the House of Representatives. As of January 2008, HR 676 has 88 co-sponsors. Also in January of 2007, Senator Ron Wyden introduced the Healthy Americans Act (S. 334) in the Senate. As of May 2008, S. 334 had 14 cosponsors.

Political debate
Issues regarding publicly funded health care are frequently the subject of political debate. Whether or not a publicly funded universal health care system should be implemented is one such example.

The case for publicly funded health care
Supporters of publicly funded health care claim that publicly funded health care has several advantages over free market provisions. It has been suggested that the largest obstacle is a lack of political will.

One of the leading organizations in support of single payer in the U.S. is Physicians for a National Health Program (PNHP), which seeks to establish a system similar to that in Canada.

Converting to a single-payer system is seen by proponents as a solution to the flaws in the current system. The U.S. health care system is the most expensive in the world on both a per-capita basis and as a percentage of GDP. Despite this expenditure, the current U.S. system fails to provide universal coverage. Nearly 47 million Americans, about 16 percent of the population, lacked health insurance in 2006. The lack of universal coverage contributes to another flaw in the current U.S. health care system: on most dimensions of performance, it underperforms relative to other industrialized countries. In a 2007 comparison by the Commonwealth Fund of health care in the U.S. with that of Germany, Britain, Australia, New Zealand, and Canada, the U.S. ranked last on measures of quality, access, efficiency, equity, and outcomes.

For example, U.S. ranks 22nd in infant mortality, between Taiwan and Croatia, 46th in life expectancy, between Saint Helena and Cyprus, and 37th in health system performance, between Costa Rica and Slovenia.

The U.S. system is often compared with that of its northern neighbor, Canada (see Canadian and American health care systems compared). Canada's system is largely publicly funded. In 2005, Americans spent an estimated US$6,401 per capita on health care, while Canadians spent US$3,326. This amounted to 15.3% of U.S GDP in that year, while Canada spent 9.8% of GDP on health care.

A 2007 review of all studies comparing health outcomes in Canada and the U.S. found that "health outcomes may be superior in patients cared for in Canada versus the United States, but differences are not consistent." Proponents of health care reform argue that moving to a single-payer system would reallocate the money currently spent on the administrative overhead required to run the hundreds of insurance companies in the U.S. to provide universal care. An often-cited study by Harvard Medical School and the Canadian Institute for Health Information determined that some 31 percent of U.S. health care dollars, or more than $1,000 per person per year, went to health care administrative costs.

Theoretically, advocates suggest, shifting the U.S. to a single-payer health care system could provide universal coverage, give patients free choice of providers and hospitals, and guarantee comprehensive coverage and equal access for all medically necessary procedures, without increasing overall spending. Shifting to a single-payer system could also theoretically eliminate oversight by managed care reviewers, restoring the traditional doctor-patient relationship.

Quality of care
Some reports have claimed that a free market solution to health care provides a lower quality of care, with higher mortality rates, than publicly funded systems. The quality of health maintenance organizations and managed care has also been criticized by proponents of publicly funded health care.

According to a 2000 study of the World Health Organization, publicly funded systems of industrial nations spend less on health care, both as a percentage of their GDP and per capita, and enjoy superior population-based health care outcomes. However, conservative commentators have criticized the WHO's comparison method for being biased; the WHO study marked down countries for having private or fee-paying health treatment and rated countries by comparison to their expected health care performance, rather than objectively comparing quality of care.

While most Americans are generally satisfied with the quality of their own health care, some medical researchers say that patient satisfaction surveys are a poor way to evaluate medical care. Researchers at the RAND Corporation and the Department of Veterans Affairs asked 236 elderly patients at 2 managed care plans to rate their care, then examined care in medical records, as reported in Annals of Internal Medicine. There was no correlation. "Patient ratings of health care are easy to obtain and report, but do not accurately measure the technical quality of medical care," said John T. Chang, UCLA, lead author.

Cost and efficiency
Proponents of publicly funded health care point out that the United States, which has a partly free market health care system, spends a higher proportion of its GDP on health care (16%) than any other country in the world. The number of uninsured has been rising, and the number of employers who offer health insurance is declining. Costs for employer-paid health insurance are rising rapidly: since 2001, premiums for family coverage have increased 78%, while wages have risen 19% and inflation has risen 17%, according to a 2007 study by the Kaiser Family Foundation. Private insurance in the US varies greatly in its coverage; one study by the Commonwealth Fund published in Health Affairs estimated that 16 million U.S. adults were underinsured in 2003. The underinsured were significantly more likely than those with adequate insurance to forgo health care, report financial stress because of medical bills, and experience coverage gaps for such items as prescription drugs. The study found that underinsurance disproportionately affects those with lower incomes &mdash; 73% of the underinsured in the study population had annual incomes below 200% of the federal poverty level. One indicator of the consequences of Americans' inconsistent health care coverage is a study in Health Affairs that concluded that half of personal bankruptcies involved medical bills, although other sources dispute this.

Proponents of health care reforms involving expansion of government involvement to achieve universal health care argue that the need to provide profits to investors in a predominantly free market health system, and the additional administrative spending, tends to drive up costs, leading to more expensive health care provision.

The case against publicly funded health care
Those who oppose publicly funded health care, predominantly on the political right, have pointed out a number of flaws in publicly funded health care systems, such as those which operate in Canada, the United Kingdom and Germany. Public health care systems have been criticized for poor quality of care, long waiting lists, and slow access to new drugs.

Several criticisms have been leveled against the idea of changing the U.S. health care system to a single-payer system.

Supporters of the free market medicine would contend that the high level of administrative costs cited by advocates of publicly funded care arise out of the substantial level of government regulation that exists in the United States's health care sector. According to a Cato Institute study, this regulation provides benefits in the amount of $170 billion but costs the public up to $340 billion.

While polling data indicate that US citizens are concerned about health care costs and there is substantial support for some type of reform (see Polls, below) most are generally satisfied with the quality of their own health care. According to a Joint Canada/United States Survey of Health in 2003, 86.9% of Americans reported being "satisfied" or "very satisfied" with their health care services, compared to 83.2% of Canadians. In the same study, 93.6% of Americans reported being "satisfied" or "very satisfied" with their physician services, compared to 91.5% of Canadians (according to the study authors, that difference was not statistically significant).

For this reason, some U.S. reformers argue for other, more incremental changes to achieve universal health care, such as tax credits or vouchers. However, proponents of a single-payer system, such as Marcia Angell, M.D., former editor of the New England Journal of Medicine, assert that incremental changes in a free-market system are "doomed to fail."

Quality of care
International comparisons of health care quality are difficult and have yielded mixed results. For example, an international comparison of health systems in six countries by the Commonwealth Fund ranked the UK's publicly funded system first overall and first in quality of care. Systems in the United States and Canada tied for the lowest overall ranking and toward the bottom for quality of care.

Overall, Canadians are quite satisfied with the quality of health care they receive. In a regularly conducted opinion poll, 70% of Canadians reported that they were either very satisfied or somewhat satisfied with the quality of care they receive compared to 30% being somewhat dissatisfied or very dissatisfied. The main factor of dissatisfaction is waiting times. A 2006 study by Nadeen Esmail and Michael Walker of the Fraser Institute found that Canadians are more likely than citizens of most other developed countries to experience long waiting lists for medical care, and that access to doctors is comparatively difficult; the study criticized the Canadian model of universal health care.

Public health care varies significantly from country to country. Many countries allow for private medicine in addition to the public health care system. Some countries, e.g. Norway, have more doctors per capita than the United States. Also, the US does not have any official record for waiting lists, but a 2005 survey by the Commonwealth Fund of sick adults in six nations found that only 47% of US patients could get a same- or next-day appointment for a medical problem, worse than every other country except Canada.

Innovation and development of new treatments
It has also been noted that the largely free market system of health care in the United States has led to the faster development of more advanced medical treatment and new drugs, and that cancer patients in the United States for many forms of cancer, including those of the breast, thyroid and lung, have higher survival rates than their counterparts in publicly-funded health systems in Europe. Some analysts have pointed out the difficulty of comparing international health statistics. In particular, the mortality rates for cancer in the United States is at about the same level as many other countries, suggesting that the higher survival rates are a function of the way cancer is diagnosed. Many have theorized that public care systems, in which there is more bureaucratic government involvement and less financial incentive in the health care industry, lead to less motivation for medical innovation and invention.

The United States, with its partly free-market health care system, is the world leader in medical innovation. According to economist Tyler Cohen quoted in The New York Times, the American system leads in converting new ideas into workable commercial technologies, and the research environment in the United States, compared with Europe, is richer, more competitive, more meritocratic and more tolerant of waste. Cohen argues that the American government could use its size to bargain down health care prices, but in the longer run it would cost lives because of the reduced innovation. Cohen argues that one reason America's leadership in innovation does not translate into relatively higher life expectancy is that other wealthy countries also benefit from US medical innovations. Economist Arnold Kling says that America's role in medical innovation is crucial not just for Americans, but for the entire world.

Impact on physicians
Some commentators have pointed out that in publicly funded systems, health care workers' pay is often unrelated to quality or speed of care. There is also less financial motivation for the most able people to enter health care professions. For example, in Canada, which has a publicly funded health system, the average physician earns roughly half the annual salary earned by counterparts in the United States, according to 1996 health data collected by the OECD. This difference in physician income reflects Canada's more limited spending on health care overall; in 2004, combined public and private spending on health care consumed 15.4% of U.S. annual GDP; in Canada, 9.8% of GDP. By limiting the amount of money in the health care system through political mechanisms, shortages of health care resources (such as physicians, nurses, medical equipment, medical devices, pharmaceuticals, and hospitals) are more likely to occur, sometimes resulting in longer waits for care.

Common arguments for and against a national health care system
Common arguments forwarded by supporters of universal health care systems include:
 * Health care is a human right, and as such, access to health treatment should not be based on ability to pay.   or entitlement.
 * Since people perceive universal health care as free, they are more likely to seek preventative care which makes them better off in the long run.
 * Universal health care would provide for uninsured adults who may forgo treatment needed for chronic health conditions. For those people who would otherwise go without care, any quality care is an improvement.
 * In most free-market situations, the consumer of health care is entirely in the hands of a third party who has a direct personal interest in persuading the consumer to spend money on health care in his or her practice. The consumer is not able to make value judgments about the services judged to be necessary because he or she may not have sufficient expertise to do so. This, it is claimed, leads to a tendency to over produce. In socialized medicine, hospitals are not run for profit and doctors work directly for the community and are assured of their salary. They have no direct financial interest in whether the patient is treated or not, so there is no incentive to over provide. When insurance interests are involved this furthers the disconnect between consumption and utility and the ability to make value judgments. Others argue that the reason for over production is less cynically driven but that the end result is much the same..
 * The profit motive in medicine values money above public benefit. For example, pharmaceutical companies have reduced or dropped their research into developing new antibiotics, even as antibiotic-resistant strains of bacteria are increasing, because there's less profit to be gained there than in other drug research.  Those in favor of universal health care posit that removing profit as a motive will increase the rate of medical innovation.
 * Paul Krugman and Robin Wells say that in response to new medical technology, the American health care system spends more on state-of-the-art treatment for people who have good insurance, and spending is reduced on those lacking it.
 * The profit motive adversely affects the cost and quality of health care. If managed care programs and their concomitant provider networks are abolished, then doctors would no longer be guaranteed patients solely on the basis of their membership in a provider group and regardless of the quality of care they provide. Theoretically, quality of care would increase as true competition for patients is restored.
 * Wastefulness and inefficiency in the delivery of health care would be reduced. A single payer system could save $286 billion a year in overhead and paperwork. Administrative costs in the U.S. health care system are substantially higher than those in other countries and than in the public sector in the US: one estimate put the total administrative costs at 24 percent of U.S. health care spending.  Universal health care could reduce wastefulness in the delivery of health care by adding a middle man, the government, to regulate the supply of health care.  For example, it might only take one government agent to do the job of two health insurance agents. According to one estimate roughly 50% of healthcare dollars are spent on healthcare, the rest go to various middlemen and intermediaries. A streamlined, non-profit, universal system would increase the efficiency with which money is spent on healthcare.
 * About 60% of the U.S. health care system is already publicly financed with federal and state taxes, property taxes, and tax subsidies - a universal healthcare system would merely replace private/employer spending with taxes. Total spending would go down for individuals and employers.
 * Several studies have shown a majority of taxpayers and citizens across the political divide would prefer a universal healthcare system over the current U.S. system
 * America spends a far higher percentage of GDP on health care than any other country but has worse ratings on such criteria as quality of care, efficiency of care, access to care, safe care, equity, and wait times, according to the Commonwealth Fund.
 * A universal system would align incentives for investment in long term health-care productivity, preventive care, and better management of chronic conditions.
 * Ensuring the health of all citizens benefits a nation economically. Universal health care could act as a subsidy to business, at no cost thereto. (Indeed, the Big Three of U.S. car manufacturers cite health-care provision as a reason for their ongoing financial travails. The cost of health insurance to U.S. car manufacturers adds between USD 900 and USD 1,400 to each car made in the U.S.A.)
 * In countries in Western Europe with public universal health care, private health care is also available, and one may choose to use it if desired. Most of the advantages of private health care continue to be present, see also Two-tier health care.
 * Universal health care and public doctors would protect the right to privacy between insurance companies and patients.
 * Public health care system can be used as independent third party in disputes between employer and employee.
 * A study of hospitals in Canada found that death rates are lower in private not-for-profit hospitals than in private for-profit hospitals.

Common arguments forwarded by opponents of universal health care systems include:
 * Health care is not a right. As such, it is not the responsibility of government to provide health care.
 * Free healthcare can lead to overuse of medical services, and hence raise overall cost.
 * Universal health coverage does not in practice guarantee universal access to care. Many countries offer universal coverage but have long wait times or ration care.
 * The federal Emergency Medical Treatment and Active Labor Act requires hospitals and ambulance services to provide emergency care to anyone regardless of citizenship, legal status or ability to pay. The health care safety net, which includes free medical clinics, charity care, nonprofits and government-run community hospitals, provides necessary care to the uninsured.
 * Eliminating the profit motive will decrease the rate of medical innovation.
 * It slows down innovation and inhibits new technologies from being developed and utilized. This simply means that medical technologies are less likely to be researched and manufactured, and technologies that are available are less likely to be used.
 * Publicly-funded medicine leads to greater inefficiencies and inequalities.  Opponents of universal health care argue that government agencies are less efficient due to bureaucracy. Universal health care would reduce efficiency because of more bureaucratic oversight and more paperwork, which could lead to fewer doctor-patient visits. Advocates of this argument claim that the performance of administrative duties by doctors results from medical centralization and over-regulation, and may reduce charitable provision of medical services by doctors.
 * Converting to a single-payer system could be a radical change, creating administrative chaos.
 * In a single-payer system where hospitals and practitioners remain private, public money goes into private hands and therefore must be guarded to protect public trust. This could require a level of bureaucracy similar to the bureaucracy associated with private insurance.
 * Countries with health systems based on greater government control tend to have more obstacles to care, such as long wait times, rationing and restrictions on the choice of doctors. Universal heath care would result in increased wait times, which could result in unnecessary deaths.  Data on liver and heart transplants suggest that access to transplants (especially the sickest patients) and outcomes are are as among the best in the world.  The extra spending in the US is cost effective if expected life span increases by only about half a year as a result.
 * Unequal access and health disparities still exist in universal health care systems.
 * The problem of rising health care costs is occurring all over the world; this is not a unique problem created by the structure of the US system.
 * Socialized medicine suffers from the same financial problems as any other government planned economy.  It requires governments to greatly increase taxes as costs rise year over year.  Universal health care essentially tries to do the economically impossible. Empirical evidence on the Medicare single payer-insurance program demonstrates that the cost exceeds the expectations of advocates.  As an open-ended entitlement, Medicare does not weigh the benefits of technologies against their costs.  Paying physicians on a fee-for-service basis also leads to spending increases.  As a result, it is difficult to predict or control Medicare's spending.  Large market-based public program such as the Federal Employees Health Benefits Program and CalPERS can provide better coverage than Medicare while still controlling costs as well.
 * National health systems tend to be more effective as they incorporate market mechanisms and limit centralized government control.
 * Universal healthcare is unfair to healthy tax payers because it gives people who smoke, drink, use illegal, and eat unhealthily unfair benefits by asking society to pay for their irresponsible decisions. It is argued that these costs should be incurred solely by those making those poor decisions.
 * Some commentators have opposed publicly-funded health systems on ideological grounds, arguing that public health care is a step towards socialism and involves extension of state power and reduction of individual freedom.
 * The right to privacy between doctors and patients could be eroded if government demands power to oversee the health of citizens.
 * A single-payer system could put the government, rather than health care providers and insurers, in the role of deciding which procedures and medications would be covered.
 * Universal health care systems, in an effort to control costs by gaining or enforcing monopsony power, sometimes outlaw medical care paid for by private, individual funds.

Debate in the 2008 U.S. Presidential election
The issue of health care in the 2008 U.S. presidential election has caused a resurgence in use of the term by Republicans. For example, in a July 2007 campaign speech, Republican presidential candidate Rudy Giuliani made a direct connection between socialized medicine and socialism. Giuliani also quoted statistics from his health care advisor, Canadian psychiatrist David Gratzer, to support his claim that he had a better chance of surviving prostate cancer in the U.S. than he would have had in England. According to cancer experts cited in fact check articles by the Annenberg Public Policy Center's FactCheck.org, the St. Petersburg Times and its PolitiFact.com, The New York Times, The Washington Post, and The Times, Giuliani's statistics were "false" and very "misleading" and his conclusions were complete "nonsense". In response, Canadian psychiatrist and Giuliani health care advisor David Gratzer said: "The mayor is right.""Krugman and others have compared statistical apples to oranges. My 44% figure, replicated by economist John Goodman and others, looks at a snapshot in time, based on decade-old OECD data; Krugman's 74% is a five-year relative survival rate from government sources today."Annenberg's FactCheck.org found no merit in Gratzer's response:"Marie Diener-West, professor of biostatistics at Johns Hopkins Bloomberg School of Public Health, said Gratzer's attempts to calculate cancer survival rates were “inappropriate” and “very misleading.' Peter Albertsen, professor and chief of urology at the University of Connecticut Health Center, called Gratzer's calculations a “very dangerous thing to do” and “complete nonsense.”" Nor did The Washington Post, which awarded Giuliani and Gratzer's response the same "Four Pinocchios" rating (reserved for "whoppers") it awarded Giuliani and Gratzer's original claim.

States
A few states have taken serious steps toward universal health care coverage, most notably Minnesota and Massachusetts, with a recent example being the Massachusetts 2006 Health Reform Statute. Other states, while not attempting to insure all of their residents, cover large numbers of people by reimbursing hospitals and other health-care providers using what is generally characterized as a charity care scheme; New Jersey is perhaps the best example of a state that employs the latter strategy. It is typical for most forms of general liability insurance sold in the U.S., such as home, automobile, or business insurance to have a significant premium allocation for medical damages. In the event that a third party is responsible for injury or illness (e.g., the responsible driver in an automobile accident), action can be taken in the U.S. court system to prove liability and collect the money for medical bills from the responsible party's liability insurances.

Several single payer referendums have been proposed at the state level, but so far all have failed to pass: California in 1994, Massachusetts in 2000, and Oregon in 2002.

In 2006, the state legislature of California passed SB 840, The Health Care for All Californians Act, a single payer health care system, but Governor Arnold Schwarzenegger (R) vetoed the bill. California State Senator Sheila Kuehl has reintroduced the bill.

The percentage of residents that are uninsured varies from state to state. Texas has the highest percentage of residents without health insurance at 24%. New Mexico has the second highest percentage of uninsured at 22%.

States play a variety of roles in the health care system including purchasers of health care and regulators of providers and health plans, which give them multiple opportunities to try to improve how it functions. While states are actively working to improve the system in a variety of ways, there remains room for them to do more.

One municipality, San Francisco, California, has established a program to provide health care to all uninsured residents (Healthy San Francisco).

Polls
Survey research shows that Americans see expanding coverage as a top national priority, and a majority express support for universal health care. There is, however, much more limited support for tax increases to support health care reform. Most Americans report satisfaction with their own personal health care. Confidence in government, and the willingness to support large expansions of government, have declined significantly since the 1960s. Support for a single-payer system is less than the level of dissatisfaction with the current system and desire for increased coverage might suggest.

In recent public opinion polls, majorities of Americans say that the current health care system needs fundamental changes, and that they are dissatisfied with the quality and costs of health care, although they are satisfied with the quality of their own health care. Those polled believe the federal government should guarantee insurance for all Americans, even if they had to pay higher taxes. In some polls, respondents prefer a universal health insurance program, "like Medicare," even if it limited their choice of doctors, and even if there were waiting lists for non-emergency treatments. But respondents were split when they were asked whether the federal government should require all Americans to participate in a national health plan.

According to a New York Times/CBS News poll in February 2007, 54% of respondents said that "fundamental changes are needed" in the health care system, and 36% said that "Our health care system has so much wrong with it that we need to completely rebuild it." 57% were dissatisfied with the quality of health care in this country, although 77% were satisfied with the health care they themselves received. 81% were dissatisfied with the cost of health care, and 52% were dissatisfied with the costs of their own health care. 65% said that providing for the uninsured was more important than keeping costs down. 95% said that it is a serious problem that many Americans do not have health insurance. 64% said that the federal government should guarantee health insurance for all Americans, and 60% would pay higher taxes to do so. But only 43% said that it would be fair for the government in Washington to require all Americans to participate in a national health care plan funded by taxpayers, compared to 48% who said it would be unfair.

According to a Washington Post-ABC News poll in October 2003, 62% of respondents preferred "a universal health insurance program, in which everybody is covered under a program like Medicare that's run by the government and financed by taxpayers," compared to 32% who preferred the current system, in which most people get their health insurance from employers. 56% would support a universal health insurance program even if it limited their own choice of doctors, and 63% would support it even if it meant there were waiting lists for some non-emergency treatments.

A poll released in March 2008 by the Harvard School of Public Health and Harris Interactive found that Americans are divided in their views of the US health system, and that there are significant differences by political affiliation. When asked whether the US has the best health care system or if other countries have better systems, 45% said that the US system was best and 39% said that other countries' systems are better. Belief that the US system is best was highest among Republicans (68%), lower among independents (40%), and lowest among Democrats (32%). Over half of Democrats (56%) said they would be more likely to support a presidential candidate who advocates making the US system more like those of other countries; 37% of independents and 19% of Republicans said they would be more likely to support such a candidate. 45% of Republicans said that they would be less likely to support such a candidate, compared to 17% of independents and 7% of Democrats.

Another poll released in February 2008, conducted by the Harvard School of Public Health and Harris Interactive, indicated that Americans are also divided in their opinions of "socialized medicine," and this split too correlates strongly with their political party affiliation. Two-thirds of those polled said they understood the term "socialized medicine" very well or somewhat well. When offered descriptions of what such a system could mean, strong majorities believed that it means "the government makes sure everyone has health insurance" (79%) and "the government pays most of the cost of health care" (73%). One-third (32%) felt that socialized medicine is a system where "the government tells doctors what to do". The poll showed "striking differences" by party affiliation. Among Republicans polled, 70% said that socialized medicine would be worse than the current system. The same percentage of Democrats (70%) said that a socialized medical system would be better than the current system. Independents were more evenly split, with 43% saying socialized medicine would be better and 38% worse.

Physicians' opinions on a national health insurance program have evolved. A 2008 survey of doctors, published in Annals of Internal Medicine, shows that physicians support universal health care and national health insurance by almost 2 to 1.

In an article published in the May/June 2008 issue of Health Affairs, pollsters William McInturff and Lori Weigel concluded that the current health care debate is very similar to that of the early 1990s, when the 1993 Clinton health care plan was under consideration. Similarities noted by the authors include a strong desire for change, a weakening economy, and an increased willingness to accept a larger governmental role in health care. New factors include high military spending and a relatively higher burden placed on businesses by health care costs. However, the authors argue that many of the barriers to reform that existed in the early 1990s are still in play, including a strong resistance to government as the sole provider of care ("'I like national health insurance,' patiently explained one focus-group respondent. 'I just don’t want the government to run it.'"). The authors conclude that incremental change appears more likely than wholesale restructuring of the system.

Price of prescription drugs
During the 1990s, the price of prescription drugs became a major issue in American politics as the prices of many new drugs increased exponentially, and many citizens discovered that neither the government nor their insurer would cover the cost of such drugs. In absolute currency, the U.S. spends the most on pharmaceuticals per capita in the world. However, national expenditures on pharmaceuticals accounted for only 12.9% of total healthcare costs, compared to an OECD average of 17.7% (2003 figures). Some 25% of out-of-pocket spending by individuals is for prescription drugs.

The U.S. government has taken the position (through the Office of the United States Trade Representative) that U.S. drug prices are rising because U.S. consumers are effectively subsidizing costs which drug companies cannot recover from consumers in other countries (because many other countries use their bulk-purchasing power to aggressively negotiate drug prices). The U.S. position is that the governments of such countries should either deregulate their markets or directly remit the difference (between what the companies would earn in an open market versus what they are earning now) to drug companies or to the U.S. government. In turn, those companies would be able to lower prices for U.S. consumers. Currently, the U.S., as a purchaser of pharmaceuticals, negotiates some drug prices but is forbidden by law from negotiating drug prices for the Medicare program.