Health Care

The nation's health care system is once again under the microscope as growing numbers of Americans are uninsured, costs keep rising, and the public grows increasingly worried about it.

The U.S. spends more money on health care than any other nation. Health care spending will increase to $4.3 trillion by 2017, or $13,000 per person, according to the annual projection by the Centers for Medicare & Medicaid Services. Put another way, the rate of annual growth for health care will be 6.7 percent, which is three times the rate of inflation. Experts attribute the increase to higher demand for care and an aging population.

Yet higher spending on health care does not necessarily correspond to a healthier population, or even that everyone will get care. Some 47 million Americans go without health insurance, according to the Census Bureau, mostly people in jobs that don't offer it as an employee benefit. One-third of adults in the United States are obese, one of the highest rates in the world, according to the National Center for Health Statistics. Children too are increasingly overweight, contributing in part to the unprecedented levels of long-term health conditions like diabetes. And although Americans are indeed living longer than ever, the U.S. has been slipping in international rankings of life expectancy (it's currently at No. 42).

Managed Coverage and Moderating Costs

Countries rich and poor all struggle with how to provide affordable health care for their citizens without breaking the bank. Many countries, such as Canada and Britain, for example, have national health insurance programs, where the government provides health care. But the U.S. health care system is more market-driven, combining both private insurance and government programs.

Most Americans (about six in 10) get their health coverage as an employee benefit. As a result, the number of uninsured people tends to swing up and down with the economy, as employers lay off or cut back in hard times. Low-income people and young adults are most likely to be uninsured. Those without insurance are 25 percent more likely to die during any given year than those with insurance. And of course, even though people with employer-provided insurance only pay a fraction of their health costs, it’s far from free – the Kaiser Family Foundation reports the average family premium is more than $12,000 per year, of which employees pay roughly one-quarter.

The government does play a major role in providing health care, through programs for the elderly (Medicare), the poor (Medicaid) and low-income children, as well as through veterans benefits and insurance for federal employees and their families. In fact, the federal government currently pays for more than 40 percent of the nation’s health care bills. The government also provides substantial tax breaks ($225 billion total) for employers who provide insurance.

People who aren’t covered by an employer or the government can still buy health coverage from an insurance company on their own – but relatively few do. Individuals end up paying the highest rates, because businesses usually negotiate a cheaper group rate.

Some proposals to reign in health costs include embracing a free-market approach to make the insurance marketplace more competitive and less expensive by using tax credits to encourage more people to buy health insurance on their own instead of receiving it from their employers. Supporters say one reason expenses are rising is that it’s hard for most people to tell how much their health care really costs. Most people who have insurance only pay part of the cost through co-pays, deductibles or employee contributions – the insurance company pays the rest, and the patient may or may not ever see a bill. And since different insurance plans negotiate different deals with providers, the bills for two people with the same illness could be quite different. Many experts say that since the patient isn’t bearing the real cost, there’s no incentive to control costs.

Other experts say the only real way to tame health care costs is to do what Canada and many European countries have done by going to a government "single-payer" plan, something that might work like Medicare or Medicaid but would cover everyone. Advocates say countries say this will cut costs because the government could eliminate the inefficiency in our current mixed system and use its enormous purchasing power to get the best deals. Opponents say this would wipe out private insurance and leave employers and patients with less control over their coverage.

In the absence of any national health insurance, some states and municipalities are taking action themselves to provide universal coverage: San Francisco, for example, offers free or subsidized health care to all city adults without insurance. Since 2007, Massachusetts has required residents to have health insurance, with state subsidies available to make it affordable for low-income residents.

The Public Voice

On this issue, the attitudes of many Americans are a bundle of contradictions, which is an indication that, on many issues, the public has not yet “worked through” their views. Majorities say the health care system needs to be fundamentally changed, and most say it is the government's responsibility to ensure everyone has adequate health care coverage. But responses vary when faced with the potential costs and tradeoffs of a universal health care system.

Access to healthcare and its costs now top Americans' perceptions of the most urgent health problem facing the country today, a marked change from two decades ago when AIDS ranked first on the list of the nation's health problems, and virtually no one mentioned access or costs.

More than half of Americans say they are dissatisfied with the quality of health care in the U.S. Most say HMOs and other managed-care programs have decreased the quality of care, and a majority say HMOs do a bad job serving their customers. Yet most Americans belong to managed-care plans, and the vast majority report receiving good or excellent care for themselves and their families.

Choicework

For additional perspective on how society could address this issue, visit our Discussion Guide which sets out three alternative approaches.
The points of view are drawn both from what the experts say about an issue and from what the public thinks about it, based on surveys and focus groups. We call this section "Choicework." Each point of view comes with the arguments for and against, along with some potential costs and tradeoffs.

• From one perspective, rising costs are still the main problem with the U. S. health care system. Accordingly, in that view, reforms should focus on containing costs.
• A second perspective, which is concerned chiefly with medical coverage, insists on recognizing a universal right to health care.
• A third perspective is primarily concerned with the quality of health care and the importance of ensuring the best health care possible.