- Response to Dr. Gunnar
In response, I will briefly summarize the organization and principal findings of my book.
Mandate for 21st Century America begins by establishing that the American health care system is badly broken. The American health care system has three world records for inefficiency and inequity: it has the highest health care costs in the world; it provides less access to health care than any industrialized nation because of its fractured and inequitable health insurance system; and it has a poor patient safety record that subjects patients in America to greater risks than other industrialized nations. Even though American physicians practice the most technologically sophisticated medical care in the world,Americans do not have lower morbidity and mortality rates than people in the rest of the developed world. Consumers and voters need to ask the question: why do Americans pay more, receive lesser quality care, and have so many citizens without any coverage at all?
The book, then, asks whether America's political system is up to the challenge of reforming America's health care delivery and financing system and concludes that the 2008 presidential and congressional elections offer a propitious opportunity for both parties to offer their ideological versions of how reform could be best undertaken. Two principal changes in the political landscape surrounding health care reform are occurring: first, global competition from countries with national health insurance is eroding the ability of American business to compete while financing health insurance for workers in this country; and second, the aging of America's population is making the nation's health entitlement unaffordable—we can no longer afford a middle-class health entitlement. Both of these political changes will put increasing pressure on conservatives who have generally blocked health care reform throughout the 20th century. Once conservatives recognize the change, health care reform will be in play legislatively.
After briefly establishing that tinkering with the health care system cannot solve its systemic problems, Chapter 2 summarizes two major types of reform: a market-driven reform or a single-payer government reform system. The two prototypes of federal health insurance are based on either universal health insurance (UHI) or national health insurance (NHI) and are defined. However, because [End Page 292] UHI is based on reforming the health care market, the problems in the current health care market are first analyzed, noting the structural defects in the health insurance market and the lack of price competition in the health delivery system. The only exception occurred in the 1990s, when managed care organizations reached high enough market penetration to create some price competition among health care providers and the rate of increase in health care costs was briefly dampened. However, consumers, who were not rewarded by managed care (employers got all the benefits), revolted, and competition again disappeared from the health care marketplace. The lack of price competition, together with an overemphasis on first- or low-dollar comprehensive health insurance coverage in employee health benefits, has created a most unusual market that is dominated by health care producers, specifically doctors and hospitals. The UHI proposal, providing free care to lower-income Americans and income-related catastrophic health protection for all other Americans, makes health care available to all. By linking federal health insurance benefits to the financial ability to pay, middle-class Americans will be forced to view health care like the other goods and services in their budgets and, thus, consider the price of services in their choices. Consumer price sensitivity will instill price competition into the health care market and end producer domination of that market. Conversely, the NHI proposal would make government totally responsible for all health care, abolish the private market for health care—including the abolition of all for-profit health care enterprises and health insurance companies—and provide free health care to all citizens.
The economic implications of the two different federal health insurance proposals are considered in Chapter 3. First, universal income-related catastrophic health insurance for all Americans above 200 percent of the family poverty level is shown to induce affluent Americans to take responsibility for financing their own family's care in the same prudent manner they manage...