A proposal for guaranteed, affordable health care for all
b y J a c o b S . H a c k e r
America’s $2.2-trillion-a-year medical complex is enormously wasteful, ill-targeted, inefficient, and unfair. The best medical care is extremely good, but the Rube Goldberg system through which that care is financed is extremely bad—and falling apart. One out of three non-elderly Americans spend some time without health insurance every two years, and the majority of those remain uninsured for more than nine months. Meanwhile, runaway health costs have become an increasingly grave threat, not just to the security of family finances, but also to corporate America’s bottom line. The United States spends much more as a share of its economy on health care than any other nation, and yet all this spending has failed to buy Americans the one thing that health insurance is supposed to provide: health security.
Health insecurity is not confined to one part of the population. It is experienced by all Americans: those without insurance as well as those who risk losing coverage; those who are impoverished as well as those with higher incomes who experience catastrophic costs; those who are sick or injured as well as those who are just one sickness or injury away from financial calamity. As health care costs have skyrocketed and the proportion of Americans with stable benefits has eroded, health insecurity has become a shared American experience, felt by those who thought they had it made as well as those just struggling to get by.
This growing problem is pushing health care reform back onto the agenda of American politics after more than a decade of neglect. And yet, nothing guarantees that this debate will end differently than previous battles. Again and again in the 20th century—most recently, in the early 1990s—efforts to make health insurance an integral piece of the American social fabric were stymied. The stakes are too high to allow reform to be blocked again. America’s economy, the finances of its middle class, the quality of its medical care, and the health of its citizens all hang in the balance.
To avoid the dismal fate of previous reform campaigns, a successful agenda must take seriously the political constraints and organizational realities that have hamstrung reform efforts in the past. Limits on public budgets, resistance to measures that might be seen as taking away what Americans already have, and the embedded realities of the present system all stand squarely in the path of grand policy redesigns—from single-payer national health insurance, to individual mandates requiring that everyone purchase private coverage, to a universe of individualized Health Savings Accounts. Instead, the most promising route forward is to build on the most popular elements of the present structure—Medicare and employment-based health insurance for well-compensated workers—through a series of large-scale changes that are straightforward, politically doable, self-reinforcing, and guaranteed to produce expanded health security.