March Public Forum: Affirmative

Sorry about the delay, the website has been down…

MARCH AFFIRMATIVE
Meredith Price
Lewis & Clark College
price@lclark.edu

Overview:

1. In order to win this debate round you need to take the moral high ground. (Think Bush’s rhetorical strategy for ‘No Child Left Behind’ minus all of the ridiculous policies). I truly advocate making sure that your framing of the affirmative case be done in such a manner there is a clear line between what the opposition is advocating. This rhetorical difference can be added to case; i.e. “My opponents would have you believe their normative claims about economic impacts outweigh making sure all Americans have health care”, or do so in your Crossfire time (use it wisely, make offensive questions and comments THE WHOLE TIME…NO DEFENSE).

2. There are economic benefits to universal health care, which I will explain, but make sure you balance this out well. Between the two different advocacies, there is going one side that advocates social well being over economic benefits…YOU CAN BALANCE THIS!

3. Use plain terms, statistics, and case studies to prove the efficiency…I will give you links to good articles, but since everyone and their mom has access to this resource, I recommend you become creative and write blocks to defensive arguments to my case and Terry’s case.

4. GOOD LUCK AT YOUR QUALIFYING TOURNAMENT. Confidence, rhetorical precision, and a solid case is key to winning. I’ve heard from people that negative teams are only running a neg case in their first constructive…this is bad. You need to get your offensive and defensive arguments out in the first negative speech, or there is going to be little clash. Also, it completely weakens you ability to address information in you opponents case that is contradictory to yours, don’t let these ambiguities stick around, clear it up for you lay critic.

a. Don’t get into an evidence war! “My study says 3 million Americans…blah blah blah.” The reason Terry and I were successful was because of a great trick which he and I called “Spin’’. If you can’t do this, you’re in trouble. There are always flaws in other peoples arguments, and you can find them if you look hard enough. Find the logical holes and exploit them. I don’t care what their numbers say, chance are you can find newer numbers that say the opposite thing. Focus on logic.
b. I recommend the good cop bad cop strategy. I hear ya’ll Public Forum Debaters are too nice to each other. This is unfortunate, and antithetical of the concept by which Ted Turner was originally derived. Watch the TV show Crossfire if you haven’t before, and use their ‘spin’ tactics, and speaking styles. No one is really nice, they are pretty confrontational (in a professional manner) to each others ideas. Use your opponent’s first name when addressing them, throw them off. There is a reason why Public Forum is in existence, it is to try to get students to revert back to classical rhetorical persuasion to win, not evidence. Practice with a coach to figure out how this can best work for you.

5. One last aside, Terry told me over the phone the other day he thinks that it is a rad (that’s right, I used the word rad, keep alive the 80’s) idea to have the negative team advocate universal coverage rather than universal health care. I just realized, Mr. Ter-Bear, that this is your slimy way of slipping counter plans into Public Forum Debate. This is absolutely hysterical…So, in essence, topical counter plans (or advocating universal coverage) are illigit…They prove the resolution true, which is your affirmative burden, not the negs. (Don’t argue abuse, please, for the love of God, Public Forum isn’t ready for ground abuse arguments) If you want some bad ass Topical Counter plans illigit arguments, e-mail me. However, I really don’t believe that there are enough speeches in Public Forum debate to begin really toying with theory. Let me know if you are daring. I’ll give you some arguments as to why that is bad, but moreover, that is wholly abusive. Those of you who do policy would note that this is the time that you run a topicality argument, obviously not in the same format. In Parliamentary debate, we call it in front of lay critics “Resolutional Analysis”. Here is a toned down version, minus as much lingo as possible so people won’t think you do policy or your ruining the event by being intellectual (that’s right, I heart topicality—not as much as ASPEC, though).

a. Here’s a format….I would change the wording however, because you want to shell this out in about 30 seconds to 1 minute…you should theoretically still have arguments on your case and their case to discuss. This would come out in the 2nd Affirmative speech…

i. Interpretation: Universal coverage is a subset idea of universal health care (for more explanation look to the History of Universal Health Care section). Essentially, under this system all people will receive health care, this is merely a matter of implementation.

ii. Violation: The negation team decided to do something really cool this round…argue in affirmation of the resolution. If they contend that there is a pressing problem in the status quo to resolve the need for health care, and they even go on to give a system by which to fix it. By definition, all Americans are receiving health care through universal coverage…this is the same fundamental principle.

1. ****this could get into a definition debate…have definitions for coverage v. health care, and how universally they can be interpreted the same.

iii. Standards: (Come up w/ different ones as you please)

1. Grammatical Precision: it is important that we interpret the meaning of words, and interpret them correctly. How is the Negation reasonably making the connection that the US should give universal coverage into “The United States should NOT (the not being their burden) provide universal health insurance to all U.S. citizens.” Does that logical connection really make sense.

2. Framers Intent: No where is it stipulated in the NFL rules that we are debating the merits of the policy. We are here to talk about ideas, and whether or not it is good or bad. (The debate should look like: US provide health care v. private companies; which is better?)

3. This isn’t policy debate (sniff) so we aren’t advocating a system of implementation, nor do we have to. We debate the merits of a theory in practice, not the implementation arena.

a. (Generalized arguments come into play, like “it will cost the government money to do this and that is bad”…and your response is “it is better than children who only see a doctor on the rare occasion they can make it to the emergency room, plus economically it is more sound.”—I’ll give you that argument later…

iv. Voters:

1. There is now no longer a reason for you to vote for the opposition team…they agree with us. Universal Health coverage should be given to all U.S. citizens.

2. They are trying to corrupt the event…this again isn’t suppose to be about who can come up with the best policy of implementation (coverage v. socialized v. subsidized, etc.). Vote for the team who has the integrity to guide this new event in a positive light.

**Again, seeing as everyone and their mom has access to this, if you want different arguments, responses to them, etc, e-mail me, and I’ll help you out.

Overview of the Health Care System:

The need for universal health coverage in the United States is growing
more acute, and failure to provide such coverage threatens the health
status of the public.

Health Care Coverage in the United States:

According to Mohammad N. Akhter from the American Journal of Public Health (these are all really awesome arguments from him…the citation for the entirety of his work is at the bottom), more than 38 million Americans younger than 65 years were uninsured as
the new millennium began. This represented a decline of approximately
2.4 million in the number of uninsured during 1998 and 1999 owing to a
robust economy and low unemployment levels. However, the stalking
economic decline that has occurred during the past 2 years will
undoubtedly lead to an increase in the number of the uninsured that may
well raise it beyond the peak of 43 million attained in 1998.
In addition to the lack of health insurance among nearly 15% of the
population of the United States, there are major economic and racial and
ethnic disparities among those who have no coverage. Nearly two thirds
of the uninsured come from low-income families, and nearly three
quarters of these individuals are from families with at least one
full-time worker. In addition, racial and ethnic minorities constitute
half of the uninsured, with the highest concentration among Hispanics.
The most vunerable citizens within America are now at risk because we allow private companies to prioritize profits before public health. My opponents would lead you to believe that there will be a significant cost to the federal government, but not only is that not true, but it assumes that we take a nihilistic approach to a serious problem. (NOTE: THIS IS THE TYPE OF STATEMENTS YOU NEED TO BE MAKING…OFFENSE).

Health Status of the Uninsured:

What are the health-related consequences for those individuals who lack
adequate health coverage? A major consequence is that the uninsured do
not have ready access to health care services, a situation that is
compounded by the decline in “safety net” facilities and other forms of
free or subsidized care. As a result, the uninsured receive less
preventive care, are diagnosed at more advanced stages of disease, and
tend to receive fewer definitive therapeutic interventions once a
diagnosis is established. In addition, the uninsured contribute to
the crowding of emergency departments whose services they
inappropriately seek for both major and minor illnesses, while at the
same time reducing the availability of emergency services for the entire
population.

The lack of health insurance coverage also has a negative impact on an
individual’s health and economic status. It is estimated that if
uninsured individuals could obtain health insurance, their mortality
rates would be reduced by 10% to 15%, their educational attainment would
increase, and their annual earnings would rise by 10% to 300%. In
addition, the higher rates of morbidity and mortality among the
uninsured reduce the health stares of the entire population and make it
less able to compete in the modern world.

History of Attempts for Universal Health Care:

There is widespread agreement that the solution to lack of access to
quality health care by a large fraction of the US population is the
development of a system of comprehensive health care coverage for all
Americans. This has been an objective of successive US presidents for
many years, dating back to the Truman administration. The most ambitious
and comprehensive efforts were made by the Clinton administration in the
early 1990s (the Clinton plan was introduced to Congress as the Health
Security Act of 1993), and like all previous presidential initiatives,
this effort failed. The reasons for these failed efforts are multiple
and complex, but it is clear the intense political action undertaken by
many competing special interest groups was a major contributing factor.
Furthermore, none of the proposed solutions had the consistent and
widespread public support that might have overcome the efforts of the
special interests.

The Need for Universal Health Care:

Despite past setbacks, now is the time to take a fresh look at the
possible routes to universal health coverage, including approaches to
this goal taken by other countries.
Here are good resources to check them out, all in theAmerican Journal of Public Health!
1. Deber RB. Rekindling reform: lessons from Canada Am J Public
Health. 2003;93:20-24.
2. Light DW. Universal health care: lessons from the British
experience. Am J Public Health. 2003;93:25-30.
3. Rodwin VG. The health care system under French national health
insurance: lessons for health reform in the United States. Am J Public
Health. 2003; 93:31-37.
4. Lee J-C. Health care reform in South Korea: success or failure? Am
J Public Health. 2003;93:48-51.
5. Elias PEM, Cohn A. Health reform in Brazil: lessons to consider.
Am J Public Health. 2003;93:44-48.
6. Altenstetter C. Insights from health care in Germany. Am J Public
Health. 2003;93:38-44.
In each instance there is a strong role of government in the development, operation, and funding of the health care delivery system. It is also of interest to note that
most of these systems were rated as being more cost-effective than the health care delivery system in the United States by a recent World Health Organization study. All of the health care delivery systems discussed provide a wide array of health care services, including preventive and curative care, and do so at a cost to the sponsoring governments and the public that is modest compared with the annual expenditures for health care in the United States.

How useful are any of these health systems as a role model for US health care reform? Certainly there is much that can be learned from them. However, it should be recognized that there is a certain amount of turbulence in a number of these systems, and it would be helpful to understand the reasons for it so as to avoid importing dysfunctional practices into the United States.
***NOTE: THIS IS THE RATIONALE YOU NEED TO MAKE WHEN YOUR OPPONENTS CITE HOW MESSED UP OTHER INTERNATIONAL SYSTEMS ARE, YOUR COULD BE…

An indicator of this turbulence is the finding of discrepancies between
the rankings of the efficiency and effectiveness of a country’s health care systems in the World Health Organization study and the levels of satisfaction expressed by individuals who use these systems. Another indicator is the major and continuing emphasis among political leaders on health system reform in a number of countries with favorably
rated delivery systems.

Advocacy Stances:
1. You can advocate a specific countries health care system (I would strongly advise looking at the six countries above if you plan on doing so).

2. Look at the coverage systems in Vermont, and the recent change in California (I’ll recommend articles to look at)…that could be a jumping point for you rational…

3. An incremetal refor of the US Health Care System could work…this is what the author the American Journal of Public Health advocates.
a. Instead of relying on models from other countries, I believe that the
most effective way to reform the US health care system is to build on
its existing structures and institutions by an incremental process of
change. A number of observers, including Kahn and Pollock, have
recommended that the health care reform effort be spearheaded by a
coalition of stakeholders from across the political spectrum, and that
efforts of this coalition be focused on that segment of the population
that is most in need of assistance (i.e., low-income workers). In
addition, they and others have suggested that planning efforts build on
insurance coverage systems that exist at present, such as Medicaid, the
State Children’s Health Insurance Program (SCHIP), and Medicare.

4. Keep in mind you don’t really need an advocacy as to how to do it…you merely need to prove it is important, and there are viable options out there. By presenting possible options, you could very well prevent slimey neg teams from running a Public Forum style counter plan.

***A few arguments for the econ. debate….

1. You need to argue that whenever social welfare is at stake the government has an obligation to get involved. This is the principle behind welfare economics.

2. The government has the lowest overhead cost to administer medicine, 2%. Compare that to the average of 18% for private companies…

a. ***The World Health Organization Article Gives you all these numbers…it is one of the footnotes.

3. Universal coverage is more inefficient! If you can’t beat them with a resolutional analysis, here is the rational. From an economic standpoint there are multiple transactions that take place between the government and separate firms. Each time a transaction takes place, especially between private groups, there is a large deadweight loss. If you don’t understand these terms, or need to comprehend them to articulate it better, I recommend reading Chapter 4 & 5 in Mankiw’s PRINCIPLES OF ECONOMICS, or any basic econ book that talks about taxes, supply & demand, and elasticity.

4. Universal health insurance doesn’t have to lack equity! Check out this article!
Equity in Canadian health care: Does socioeconomic status affect
waiting times for elective surgery?
Shortt, Samuel E.D., Shaw, Ralph A.
CMAJ: Canadian Medical Association Journal; 2/18/2003,
Vol. 168 Issue 4, p413, 4p, 1 chart
Abstract: Abstract Background Waiting times for surgical and other
procedures are an important measure of how well the health care system
responds to patient needs. In a universal health care system such as
Canada’s, it is important to determine if waiting times vary by
socioeconomic status (SES). We compared waiting times for elective
surgery of patients living in low and high socioeconomic areas. Methods
We reviewed the medical charts of all patients who underwent elective
surgery at a Canadian academic health centre between 1992 and 1999.
Using patient postal codes we assigned SES on the basis of 5
characteristics in the 1996 census data. We compared waiting times for
surgery for people from regions in the lowest third (low SES group) with
that for patients from regions in the upper third (high SES group).
Results On average, patients in the high SES group waited 31.1 days and
those in the low SES group waited 29.3 days. When differences in waiting
times for 22 common procedures were examined between the groups, only
the difference for prostatectomy was statistically significant: patients
in the high SES group waited 4.4 fewer days than those in the low SES
group. Interpretation We found little evidence that residing in a region
in which SES was in the lowest third was associated with longer waiting
times for elective surgery. [ABSTRACT FROM AUTHOR]

5. On the econ debate, keep it simple, chances are you judge might not know what you’re talking about. You still need to understand these concepts to explain it however.

INTERESTING ARTICLES TO HELP YOU GRASP BASIC IDEAS:

Article One
Title: Is universal health care still in the works?
Authors: Holtzman, Michael
Source: Christian Science Monitor; 7/09/99, Vol. 91 Issue 156,
p11, 0p
Document Type: Article
Subject Terms: *PUBLIC health — United States
Abstract: Details that health care for all is closer to reality
now than it was when President Bill Clinton unveiled his plan in the
1994 State of the Union address. Impracticality of his plan; How, by
offering it in installments, Clinton has been able over time to enact a
significant part of his original health care program; Challenges
remaining; How Clinton has managed to grasp victory from defeat.
Section: OPINION

IS UNIVERSAL HEALTH CARE STILL IN THE WORKS?

THIS time there’s no sign of global budgets, alliances, or even health
security cards.No Byzantine flow charts. Not even a discouraging word
from “Harry and Louise,” the infamous insurance industry spokescouple.
But make no mistake: Health care for all is closer to reality now than
it was when President Clinton unveiled his sweeping initiative in his
1994 State of the Union Address.

Although an alliance between insurance companies, employers, and
congressional Republicans doomed his original proposal, Mr. Clinton
understood that these critics attacked his plan for its impracticality
-without challenging his basic assertion that government should
guarantee the right to health coverage.

This tactic left conservatives and other opponents vulnerable to a more
piecemeal strategy.

In a September 1997 speech to the Service Employees Union, Clinton
summarized his new approach to reform: “If what I tried before won’t
work, maybe we can do it another way. That’s what we’ve tried to do, a
step at a time, until we eventually finish this.”

By offering it in installments, Clinton has been able over the last four
years to enact a significant part of his original health care program.
The first installment traces back to early 1996, when Sens. Nancy
Kassebaum (R) of Kansas and Ted Kennedy (D) of Massachusetts cosponsored
a bill allowing people who lost or changed their jobs to keep their
health insurance. After deciding that opposing it was not worth the
political damage, Congress relented and passed it. Clinton signed the
bill into law.

That same year, Clinton effectively raised child immunization rates to
an all-time high.

Then in 1997, he signed legislation representing the single largest
investment in health care for children since 1965 - the 824 billion
Children’s Health Insurance Program (CHIP), which provides coverage for
up to five million poor children.

In a speech at the White House in January 1998, President Clinton
proposed the largest expansion of Medicare in 25 years, offering
coverage to early retirees at age 62, and the opportunity for displaced
workers at age 55 and older to buy coverage under Medicare.

In his FY2000 budget proposal, Clinton called for a long-term care
initiative to provide respite, home care services, and information and
referral assistance to the approximately 250,000 families caring for
elderly relatives who are identified as chronically ill or disabled.

The budget also offers tax credits to encourage small businesses to
provide health insurance benefits; earmarks 81 billion for comprehensive
health care delivery systems for the uninsured; calls for Medicare
clinical trials to give more Americans access to cutting-edge cancer
treatments; and increases funding for Ryan White HIV/AIDS treatment
grants, among other measures.

In January the president endorsed a proposal by Sens. Jim Jeffords (R)
of Vermont and Kennedy that would provide $1.2 billion in health care
incentives to help states allow disabled workers to buy insurance
through Medicaid even if their incomes would ordinarily make them
ineligible. And last week, the President called for expanded
prescription-drug coverage under Medicare.

Of course, critics abound. Conservative commentator Robert Novak refers
to Clinton’s creative efforts to achieve universal health care as
“covert plans for big government.” House majority whip Dick Armey (R) of
Texas calls Clinton’s progress “socialized medicine on an installment
plan.”

Clinton’s success has not been unqualified. Long-term health care
challenges remain. The solvency of the Medicare system, for example,
dangles on perhaps overly optimistic assumptions about future budget
surpluses, not to mention the GOP’s zeal for a “l O-year, trillion
Dollar tax cut” that would blow a hole in revenues needed to shore up
the system.

The fact that many of his initiatives have passed or enjoy broad public
support shows Clinton has again managed to grab victory from the hands
of defeat.

A master of taking the best ideas of his opponents and making them his
own, perhaps Clinton’s. reinvigorated health care activism owes to
Louise’s-oft-muttered kitchen-table mantra: “There’s got to be a better
way.”

~~~~~~~~

By Michael Holtzman

Michael Holtzman is vice president of Shandwick International,’ a public
affairs firm. He was press secretary to the Council on Foreign Relations
from 1995 to 1997.

Article Two:
Title: Survey: Majority wants health reform.
Source: H&HN: Hospitals & Health Networks; 05/05/97, Vol. 71
Issue 9, p56, 1/8p
Document Type: Article
Subject Terms: *HEALTH care reform
Geographic Terms: UNITED States
Abstract: Deals with a report of a recent survey conducted for the
Washington, D.C.-based Citizen Action Group that Americans want
universal health care coverage and tighter controls over managed care
companies. Results of the survey; National standards for Health
Maintenance Organizations (HMO) supported by some respondents of the
survey.
Section: NEWS AT DEADLINE
SURVEY: MAJORITY WANTS HEALTH REFORM

Americans want universal health care coverage and tighter controls over
managed care companies, according to a recent survey conducted for the
Washington, D.C.-based Citizen Action group. More than three-quarters of
the 850 respondents say employers should have to contribute to health
insurance coverage for employees and their families. The same proportion
also favors mandating coverage for children under 18. Sixty-seven
percent support national standards for HMOs, such as providing consumer
information, shifting profits to medical care, and limiting denial of
medical procedures. Nearly the same percentage supports laws limiting
abuses like drive-through deliveries and mastectomies.

Article Three:
NOTE: THIS ARTICLE IS THE TYPE OF RATIONALE YOU NEED TO USE WHEN APPEALING TO YOUR JUDGE.
Title: Harsh words about our health care system.
Source: Pediatrics; Jun96 Part 1 of 2, Vol. 97 Issue 6, p895,
1/5p
Document Type: Article
Subject Terms: *MEDICAL care — United States
Geographic Terms: UNITED States
Reviews & Products: SELF-Interest & Universal Health Care (Book)
NAICS/Industry Codes 62 Health Care and Social Assistance
Abstract: Presents an excerpt from the book `Self-Interest and
Universal Health Care,’ by L.R. Churchill, criticizing the American
health care system.
Database: Academic Search Elite

HARSH WORDS ABOUT OUR HEALTH CARE SYSTEM
. . . the U.S. health care system is flawed principally because we have
never asked what its goals are. So long as that fundamental moral
question remains unanswered, no amount of political or economic
tinkering will fix the system’s problems. If we carefully examine the
present workings of our system, we would have to conclude that its goals
are two: maintain the prerogatives of physicians and the well-being of
the private insurance industry. Such goals hardly represent an exercise
of moral choice, and . . . are morally indefensible.

Churchill LR. Self-Interest and Universal Health Care. Boston: Harvard
University Press; 1994. Reviewed by Brody H. Ethics-in-Formation.
October 1995.

~~~~~~~~

Submitted by Student

Article Four:
This is long, so I’ll give you the citation and abstract. I’d recommend reading it, it’s all about grassroot movements.

Title: Health Care Reform and Social Movements in the United States.
Authors: Hoffman, Beatrix
Source: American Journal of Public Health; Jan2003, Vol. 93
Issue 1, p75, 11p, 4bw
Document Type: Article
Subject Terms: *SOCIAL movements
*MEDICAL care
Geographic Terms: UNITED States
Abstract: Because of the importance of grassroots social
movements, or “change from below,” in the history of US reform, the
relationship between social movements and demands for universal health
care is a critical one. National health reform campaigns in the 20th
century were initiated and run by elites more concerned with defending
against attacks from interest groups than with popular mobilization, and
grassroots reformers in the labor, civil rights, feminist, and AIDS
activist movements have concentrated more on immediate and incremental
changes than on transforming the health care system itself. However,
grassroots health care demands have also contained the seeds of a wider
critique of the American health care system, leading some movements to
adopt calls for universal coverage. [ABSTRACT FROM AUTHOR]

Article Five:
*HERE’S YOUR REASONING FOR REAL CHANGE…POLITICIANS HAVEN’T DONE ENOUGH OVER THE PAST 10 YEARS…ETC.
Title: The US health care system: On a road to nowhere?
Authors: Oberlander, Jonathan
Source: CMAJ: Canadian Medical Association Journal; 7/23/2002,
Vol. 167 Issue 2, p163, 6p, 2 charts, 1 graph

Abstract: THIS ARTICLE REVIEWS THE CURRENT STATE AND FUTURE
PROSPECTS of the health care system in the United States. The 1990s were
a decade of reform and change in US medical care, with the debate over
the Clinton plan for universal insurance and, after its defeat, the
spread of managed care. In particular, managed care had a profound
impact on the delivery of medical services, transforming traditional
insurance arrangements. However, after all of the changes, the United
States appears to be no closer to solving the problems that have
characterized its health care system for the past 3 decades. Over 40
million Americans lack health insurance, universal coverage is nowhere
in sight, and medical care costs are rising again after a period of
moderation. It is doubtful that incremental health reforms will
significantly ameliorate these problems. [ABSTRACT FROM AUTHOR]
The US health care system: On a road to nowhere?

THIS ARTICLE REVIEWS THE CURRENT STATE AND FUTURE PROSPECTS of the health care system in the United States. The 1990s were a decade of reform and change in US medical care, with the debate over the Clinton
plan for universal insurance and, after its defeat, the spread of
managed care. In particular, managed care had a profound impact on the
delivery of medical services, transforming traditional insurance
arrangements. However, after all of the changes, the United States
appears to be no closer to solving the problems that have characterized
its health care system for the past 3 decades. Over 40 million Americans
lack health insurance, universal coverage is nowhere in sight, and
medical care costs are rising again after a period of moderation. It is
doubtful that incremental health reforms will significantly ameliorate
these problems.

The health care system in the United States remains a paradox of excess
and deprivation. 1 The United States spends more on medical services
than any other nation, and US physicians earn more than their
counterparts in Canada, Europe and Japan. Americans with insurance have
access to the latest in sophisticated medical technology and innovative
medical procedures; rates of diffusion for many medical technologies,
such as magnetic resonance imaging, are generally higher in the United
States than in other industrialized democracies. 2 Indeed, the
availability of these resources is so widespread that some analysts
believe that well-insured Americans are receiving too many medical
services. At the same time, millions of Americans receive too little
medical care. 3 Over 40 million Americans do not have health insurance,
4 which makes the United States the only democratic country in the world
with a substantial uninsured population.

The 1990s was a decade of reform and change in US health care. After the
1994 failure of then President Bill Clinton’ effort to enact a
government-sponsored system of universal health care insurance, the
private market emerged as the engine of health reform. US medicine moved
toward managed care arrangements, with rising enrolment in health
maintenance organizations (HMOs) and the growth of for-profit health
plans. Market-based health reform was viewed by proponents as a solution
to health care cost inflation and an opportunity to enhance both quality
of care and patient choice. However, by the end of the decade a
widespread backlash against managed care had developed.

What is the state of the US health care system after a decade of
turbulence? What has been the impact of managed care? And what is the
outlook for health care reform? This article reviews the current status
and future prospects of the US health care system. In particular, I
focus on the persistent problem of the uninsured, efforts at cost
control and the role of managed care.

Little progress for the uninsured

The US health care system is often erroneously labelled a private health
care system. In fact, the United States has a mixed system of public and
private insurance, though the word system connotes much more
organization and logic than is actually at work. Most working-age
Americans receive health insurance through their employers. Medicare, a
federal government program similar in structure to Canada’ single-payer
medicare insurance, provides health insurance to all Americans over 65
years of age as well as to persons with disabilities or end-stage renal
disease. Medicaid, a jointly funded federal–state program, covers
low-income Americans (it reaches about 40% of the poor), including
seniors who spend down their incomes and assets to a level that
qualifies them for Medicaid–funded nursing-home care. In between those
covered by this hodgepodge of private and public plans, however, lies a
substantial population without any health insurance at all (Table 1).

In 2000, 14% of Americans lacked health insurance. 5 About 80% of the
uninsured are either workers or live in families with workers. They
typically have low-wage jobs or work in small businesses in which the
employer does not offer health insurance or, if it is offered, they
cannot afford to purchase it. 6 The uninsured are disproportionately of
low income. In 2000, one-third of the poor were uninsured, and
two-thirds of uninsured adults had incomes less than 200% of the federal
poverty line, or US$26 580 (Can$39 498) for a family of 3. 6
Substantially more black (18.5%) and Hispanic (32%) than white (13%)
Americans were uninsured in 2000.

Many Americans mistakenly believe that the uninsured obtain adequate
care from hospital emergency rooms and other charity sources. Studies
have consistently found, however, that the uninsured receive
significantly less medical care than the insured. 7 Nearly 25% of
uninsured children and 40% of uninsured adults have no regular source of
medical care. 6 The uninsured are much more likely to delay or forgo
needed treatment, have their conditions diagnosed at a later stage and
be admitted to hospital for avoidable conditions. 6 Moreover, inadequate
insurance coverage carries with it financial as well as medical risks–
the costs of medical treatment are a leading cause of bankruptcy in the
United States. 8 Indeed, about half of all bankruptcies in the United
States involve a medical reason or large medical debt.

The number of uninsured individuals actually declined from 1998 to 1999,
from 44.3 to 42.6 million, and in 2000 fell again to 38.7 million
(though this latter drop was mainly due to statistical adjustments in
how the government counts the uninsured). Yet perhaps most striking is
not the decrease but, rather, that it took so long to happen and that
the overall trend in the past decade remained one of an expanding
uninsured population. Since the early 1990s, the United States has
enjoyed ideal conditions for an expansion of health insurance. The
economy has gone through an unprecedented era of sustained growth, the
rates of general inflation and unemployment have remained low, and the
rate of health care inflation has moderated. Still, from 1990 to 1998
the number of uninsured people increased by nearly 10 million (Fig. 1).

That even these favourable circumstances did not generate any
significant expansion of health insurance is disquieting. And future
trends are no more encouraging. The US economy slowed in 2000, and the
unemployment rate rose. This economic downturn generated new ranks of
the uninsured– the recent decline in the uninsured rate has ended.
Because most Americans receive health insurance through their employer,
a recession would have a strong negative impact on access to insurance.
For the foreseeable future, then, the number of uninsured Americans is
likely to continue to grow.

The politics of health reform

National health insurance periodically emerged on the US political
agenda during the 20th century and was often tantalizingly close to
enactment. The most recent failure came in 1994, with the defeat of the
Health Security Act, sponsored by President Bill Clinton (and drafted
under the guidance of his wife, Hillary). Clinton proposed to achieve
universal coverage in the United States by mandating that all employers
provide private health insurance to their employees and by giving small
businesses and unemployed Americans subsidies with which to purchase
insurance. However, the Clinton plan triggered fierce opposition from
the insurance industry (which disliked the proposed regulation of
behaviours, such as experience rating, which has enabled them to charge
higher premiums for sick patients), the business community (which
criticized the employer mandate), ideologic conservatives (who saw the
plan as an unwarranted nationalization of the health care system) and
large segments of the public (who were anxious about the plan’ emphasis
on moving patients into HMOs). Confronted with this opposition and the
lack of a liberal political majority in Congress, the act was defeated.
The American Medical Association, which initially endorsed and then
waffled on the idea of universal insurance coverage, did not play a
prominent role in the 1993/94 debate, a sign of its deteriorating
influence on US health politics.

One legacy of the Clinton plan’ failure has been caution regarding
health policy. Many politicians took the lesson of the plan’ demise to
be that comprehensive reform — transforming the US system into one of
national health insurance, like Canadian medicare — is not politically
feasible. Consequently, talk of attaining universal coverage has all but
disappeared. Neither of the 2 major parties’ presidential candidates in
the 2000 election, Al Gore and George W. Bush, offered plans for
universal insurance coverage. None of the plans currently under serious
consideration in Congress attempts to cover all of the uninsured. And
even one of the few organized advocates for the uninsured, the consumer
group Families USA, has toned down its calls for universal coverage in
favour of more modest policy goals.

What is remarkable about the absence of proposals for universal coverage
in the period 1999–2001 is that the fiscal circumstances of the United
States appeared to be conducive to their adoption. After 2 decades of
budget deficits, the federal government in 2000 ran a sizeable budget
surplus, projected at $5.6 trillion over the next decade. 10 It has long
been assumed that the lack of affordability of a public program was a
central barrier, particularly in an era of sizeable federal deficits in
which large spending initiatives were politically constrained and tax
increases taboo. Now, though, the affordability argument has been
exposed as a fallacy. Despite the availability of a budget surplus that
could be used to pay the costs of covering the uninsured, universal
coverage did not emerge as a central political issue in 2000/01.
Instead, political attention focused on improving the medical
experiences of the already insured through regulation of managed care
and expansion of Medicare to cover outpatient prescription drugs.

It is clear that the most relevant fact about US health politics is not
that some 15% of the population are uninsured but that about 85% of the
population are insured. Those who are insured are generally satisfied
with their own medical care, even if they think poorly of the system as
a whole; consequently, they are not a strong constituency for change.
Indeed, any reform that threatens to alter the medical care arrangements
of the insured is likely to provoke public opposition. The formidable
constituency against reform is mobilized, wealthy and politically
influential. Meanwhile, the uninsured are disproportionately low-income,
unorganized and apparently politically expendable. As the Clinton plan
exemplified, the political benefits to a president and legislators
willing to take on a trillion-dollar health care industry that opposes
reform are uncertain, but the costs are certain to be high. The result
is that universal coverage remains an elusive reform in the United
States, and the uninsured continue to live in an aura of invisibility.

Incremental reforms

Although there is currently little appetite for comprehensive reforms
that would assure universal coverage, there is momentum for incremental
measures that would reduce the ranks of the uninsured. Two main pathways
to improved coverage have emerged. The first approach is to expand
existing public insurance programs, including Medicaid, which provides
insurance to about 40% of the poor, and the State Children’ Health
Insurance Program (SCHIP), which provides insurance to children living
in families with incomes up to 200% of the federal poverty line.
Proponents of this approach would change eligibility requirements for
these programs, opening them up to more of the poor and near-poor (e.g.,
to parents of children enrolled in SCHIP). One of the more ambitious
plans would extend Medicaid and SCHIP coverage, without premiums or
cost-sharing, to all persons with incomes below 150% of the federal
poverty line and subsidize enrolment for persons with incomes up to
300%.12 It is estimated that this plan would extend eligibility for
public insurance to over 25 million Americans who are currently
uninsured. Most plans, however, would not expand coverage so broadly and
would thus not reach most of the uninsured.

A second approach — one favoured by the Bush administration — is to
adopt tax credits that would help the uninsured purchase private
insurance. This approach appears to be especially attractive given the
political appeal of tax cuts and the promise of expanded coverage with
minimal government involvement. Most tax-credit proposals would target
individuals, though some plans have instead focused on credits for
employers. Credits could be refundable, so that even low-income persons
who do not pay federal income tax would be eligible.

There are several problems, however, with tax-credit proposals in
particular and incremental reforms more generally. The main problem with
tax credits is the mismatch between the size of the credits that are
being proposed and the cost of insurance. The average annual premium of
a health insurance policy in the United States is now more than US$6000
(Can$8910) for a family and more than $3000 for an individual. President
Bush’ proposal would provide a tax credit of only $2000 to a family and
$1000 to an individual. It is questionable how much difference these tax
credits would make to the uninsured, many of whom have little disposable
income. This is especially true because insurance for individuals has
much higher administrative costs than group insurance, and consequently
higher premiums.

More fundamentally, neither tax credits nor expanded public insurance
does anything to control medical care spending. The debate has changed
markedly since the early 1990s, when concerns over rapidly rising costs
and the economic competitiveness of US firms drove health reform.
Politically, the absence of cost containment in the current proposals is
hardly surprising. After all, health care costs equal the total incomes
of the providers of medical care, a group comprising not merely
physicians but also insurers, hospitals, nursing homes, pharmaceutical
companies and all those selling medical services and products. Any
attempt to restrain national health spending is viewed by providers as
an assault on their livelihood, which triggers intense opposition. An
understandable reading by US politicians of the Clinton reform debacle
is that expanding coverage is difficult; simultaneously mandating
spending controls would be political suicide.

Yet there are signs that the moderate medical care inflation that made
inattention to cost control comfortable is ending. Absent cost control,
then, incremental reforms may become self-defeating, with high rates of
medical care inflation leading to higher-than-expected program costs,
which could make expansion of insurance coverage less affordable and
politically problematic.

The rise of managed care

US medical care has long been the most expensive in the world. 14, 15
The defeat of comprehensive health reform in 1994 did not obviate the
pressures to control health spending; rather, it shifted the engine of
control to the private sector. Employers looking to hold down their
medical bills embraced managed care and, in a staggeringly short time,
managed care became the norm. By 2000, 92% of persons with
employer-sponsored insurance were enrolled in a managed care plan. 16
Managed care has also spread to public programs for the elderly, poor
and disabled — Medicare and Medicaid — though enrolment in such plans
is generally lower than for the employer-sponsored population.

Managed care has come to refer to a wide range of health plans and
practices that depart from the traditional US model of insurance. In the
traditional model, insured patients chose their physician; physicians
treated patients with absolute clinical autonomy; insurers generally
paid physicians whatever they billed on a fee-for-service basis; and
employers paid premiums for their workers to private insurers, footing
the bill regardless of its cost. Managed care has altered all of these
arrangements. As a consequence of not having national health insurance,
cost control in the United States has focused more on setting limits on
the individual medical encounter ( managing care ) than on establishing
budgetary limits for the entire health care sector. The rise of managed
care has brought about 4 major changes in US medical care. First is the
substantial decline in traditional indemnity-insurance arrangements,
which allowed unfettered access to physicians and unregulated delivery
of medical care. The proportion of Americans with employer-sponsored
indemnity coverage declined from 95% in 1978 to 14% by 1998. 18 This
drop was accompanied by an increase in enrolment in a wide variety of
managed-care insurance programs, including HMOs, Preferred Provider
Organizations (PPOs) and Point of Service plans (POSs). Not only did
HMOs grow in enrolment — from 36.5 million in 1990 to 58.2 million in
1995 — but they also changed substantially in form. In particular,
there has been rapid growth in for-profit HMOs as well as network and
individual-practice association models that contract with providers; in
contrast, group or staff-model HMOs (such as Kaiser Permanente) own
their facilities, and their physicians work exclusively for them. 19
Yet, while they continue to be regarded as the symbol of managed care,
the growth of HMOs has stalled in recent years, and more Americans with
job-provided insurance are now enrolled in PPOs (41%) than in HMOs
(29%).

Second, patients in managed care receive full coverage for services only
if they choose a physician within the plan’ network. In the case of
HMOs, patients receive no coverage if they see an out-of-network
provider. In some plans, patients must go through a gatekeeper,
typically a primary care physician, to obtain a specialty referral. The
corollary is that most insurers no longer contract with all physicians
in a community. Rather, they contract with a limited number of doctors,
negotiating price discounts in exchange for guaranteed patient volume
and excluding high-cost providers.

Third, physicians’ clinical decisions are now regularly subject to
external review by insurance plans. Indeed, US physicians probably
experience more intrusion into their clinical lives than physicians
anywhere in the industrialized world, an ironic development given that
the American Medical Association long opposed national health insurance
as a threat to clinical autonomy. 20 Under utilization-review
arrangements, physicians may have to seek permission from the patient’
insurance company for admission to hospital, diagnostic tests or medical
procedures. Utilization review and physician profiling may also occur
after treatment, with the goal of identifying inappropriate or excessive
care according to the insurer’ standards. Proponents of managed care
argue that these practices can not only control costs but also enhance
quality of care — for instance, by assuring adherence to evidence-based
medicine.

Fourth, insurers no longer give physicians a blank cheque; instead, they
may dictate not only the price of reimbursement but also the form. This
has led to the widespread adoption of predetermined fee schedules for
physician payment by managed care plans, which seek discounts from
normal fees. HMOs have also adopted capitated payment, often focusing on
primary care providers. Under capitated payment, physicians receive a
set amount for each patient enrolled in their practice, regardless of
that patient’ actual use of services. The stated aim is to avoid the
financial incentive for overtreatment inherent in fee-for-service
payment. Another important change in payment arrangements is the
introduction of bonuses and other incentives for physicians to meet
targets in providing care. Frequently these incentives are aimed at
ensuring that physicians hold down costs in a capitated environment; for
instance, bonuses may be provided to physicians whose rate of admission
to hospital for their patient pool is lower than the insurer’ target.
Along with capitation, these arrangements put the incomes of many
physicians at substantial risk.

The impact of managed care on costs and quality

Since the advent of managed care in the early 1990s, health care
spending in the United States has slowed. From 1993 to 1998, the share
of gross domestic product (GDP) devoted to national health expenditures
declined from 13.7% to 13.5%, and premiums for employer-sponsored health
insurance actually grew more slowly than the per capita GDP. 22 However,
the United States continues to spend far more on medical care than any
other nation– in 1998, it spent $4270 per capita, compared with $2400
in Germany, which spent the second-highest amount, and $2250 in Canada.

There is substantial disagreement among analysts about the significance
of the relative success of the United States in controlling health care
spending during the mid-1990s. Some observers believe that this
experience demonstrates managed care’ effectiveness in controlling costs
and the efficiencies inherent in strategies such as selective
contracting, utilization review and capitation. Others attribute the
slowdown to a one-time switch from indemnity insurance that cannot be
duplicated or to temporary circumstances that cannot be sustained, such
as marketing strategies that led insurers to underprice their products
to expand market share. The long-term cost-containment potential of
managed care consequently remains uncertain. However, health care
spending in 1999 and 2000 rose at higher rates– insurance premiums
increased by 8.3% in 2000 (Table 2), 23 and even larger increases were
expected for 2001. 24 This suggests that the era of low medical care
inflation is over and that managed care’ ability to restrain spending
has been exaggerated.

Evidence for the impact of managed care on the quality of care is mixed.
Most studies have found little difference in quality of care between
traditional insurers and managed care plans, though there is evidence of
worse outcomes for chronically ill seniors in HMOs. 25 That quality of
care in many cases did not deteriorate despite reduced volume and
intensity of services suggests that the previous standard of unmanaged
care incorporated significant amounts of unnecessary services. However,
these findings also cast doubt on the premise that managed care is
improving quality through practice guidelines, preventive care, primary
care, disease management, integrated delivery systems and other
strategies. Too often, these strategies exist more as marketing labels
than as workable or proven innovations, though that has not stopped them
from being aggressively promoted outside the United States, often to
receptive audiences looking for new levers to control costs and improve
quality and consumer service. Yet, so far, managed care plans have not
consistently implemented these practices, and market competition has not
resulted in significant quality improvements. Instead, plans have
focused on managing costs, a decision reinforced by employers, who are
much more likely to select insurance on the basis of price than on the
basis of quality.

The managed-care backlash

Regardless of the evidence, there is strong sentiment among both
physicians and patients that managed care is harming quality of care.
Consequently, there has been a push to enact patients’ bills of rights
and other laws that regulate the behaviour of managed care plans. 27
Virtually all of the 50 US states now have such laws on the books, and
Congress is debating federal legislation that would permit patients to
sue HMOs, guarantee access to specialists and establish procedures for
appealing health plan decisions denying coverage or medical care. If
adopted, this legislation will no doubt provide political benefits to
its sponsors, who can assure the voting public that they are doing
something about HMO abuses. Its impact on patients and quality of care
is less certain. The legislation is sufficiently vague that it is
difficult to know how strictly it will be implemented and how much it
will change health plan behaviour. Moreover, the proposed law does not
address issues such as financial bonuses for physicians and the
incentives of capitation that significantly affect patient care.

Conclusion

After a decade of change, the United States appears to be no closer to
solving the problems of cost control and access that have characterized
its health care system for the past 3 decades. The question is, after
the political system takes care of the already insured through
managed-care protections and expanded Medicare benefits for the elderly,
what will it do for the uninsured?

The September 11, 2001, bombings of the World Trade Center and the
Pentagon have triggered a new period in US politics, dominated in the
short term by President Bush’ war on terrorism. In the aftermath of the
terrorist strikes, United we stand became a national slogan of
solidarity. Some health reformers hope that this communitarian spirit
and the renewed faith of Americans in government will give national
health insurance a new life. And enactment of incremental expansions of
public insurance programs and tax credits for the uninsured is a real
possibility. But it is not clear that health reform will move beyond
these limited steps, which would leave the bulk of the uninsured
population untouched. Absent a sustained economic downturn that makes
the middle class anxious about their own coverage, prospects for
universal coverage and comprehensive health care reform remain dim. The
more things change in US health care policy, the more they seem to stay
the same.

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