Healthcare reform continues to be one of the most contentious subjects of debate in American politics. Healthcare accounts for over 16% of federal expenditures, forecasted to increase in the years ahead1. The two main political parties represent the interests of an array of interest groups and providers at state and national levels. Republicans protect private interests, promoting the view that healthcare should be a privilege, and quality should be preserved over expansion. Democrats champion reform, seeking to expand single-payer networks, and promote healthcare as a moral right for every citizen. The main tension in the reform debate is that the expansion coverage through a single-payer system leads to higher government expenditures and lower quality of care, while private insurers leave many Americans uninsured. Political partisanship between groups and parties fuels a circular debate over what constitutes successful reform.
To understand the tension underlying the healthcare debate, it is important to consider how coverage is distributed to consumers. The U.S. system uses a hybrid network of private and public plans, each operating with different goals, providing coverage to a different pool of consumers. Private for-profit insurer’s market expensive, high quality plans to low risk, wealthy, employed consumers. Public insurers offer single-payer plans through Medicare and Medicaid to unemployed and elderly consumers. Private insurers tend to raise prices and exclude coverage to high risk individuals in order to maximize profits. Meanwhile, the government funded Medicaid and Medicare programs fail to offer the same quality of care as private insurers. While these two systems provide coverage to 80% of U.S. citizens, a third group of constituents, known as the chronic “working poor,” are excluded from either network, unable to afford private insurance plans, yet considered to have too much money to qualify for single-payer coverage. The chronic “working” poor generally are individuals employed by small companies with 11-50 employees. These employees lack funding and bargaining power to negotiate contracts with their employers, and are unable to afford individual, private plans. Chronic “working” poor account for 16% of the American population.2 The only real accesses these individuals have to medical providers are through urgent and emergency care, the lowest quality form of healthcare.
It is important to consider what is at stake with reform in order to understand how the policymakers deal with the dilemmas in the healthcare debate. Private insurers offer plans with low co-pays and quality specialized care for those who can afford the high monthly premiums. Though, if the single-payer system were eliminated, private industry would reject the unhealthy poor and elderly from their networks. On the other hand, relying solely on a single-payer system to deliver universal coverage would lead to higher government expenditures and deterioration of the quality of care. Democratic reformers promote increasing single-payer coverage, lowering the cost of healthcare for poor and elderly, and increasing access to the working poor. Since neither level of government is interested in expanding their single-payer programs, a coordination problem arises. While the aggregate amount of single-payer expansion is clear to bureaucrats at all government levels, federal politicians try to assign more responsibility to state run Medicaid programs. In response, state representatives respond with delay tactics and litigation, often calling for the judiciary to review the constitutionality of federal orders and mandates. Disputes between state and federal governments are a major source of gridlock that delays democratic efforts to implement healthcare reform.
` The main point of contention among reformers is the inability to present a comprehensive plan that delivers
