There is widespread discussion of whether the U.S. health care system is in a state of crisis. A consensus on this has not been reached but appears to be slowly emerging. It perhaps reached a critical breakthrough with the special U.S. Senate election in Pennsylvania in November 1991. Many political analysts regard health care as the single most important issue that crystallized voter preference in that election, and the ensuing public debate during the 1992 presidential election only substantiated the impression that a sufficient critical mass in public opinion would necessitate a positive political response to this public policy problem.
Of course, political events tell nothing about what the response is likely to be or whether the political calculations that inevitably must be made will result in a response that goes beyond stopgap measures and patchwork changes to embrace a comprehensive reform that addresses the underlying problems facing America's health care system. As a consequence, it is important to consider some of the reforms that have been proposed in response to the public concern over the state of health care in America and to identify how well these alternative proposals address the underlying problems. This article does three things: (1) It discusses the problems that constitute the crisis in American health care; (2) it delineates the criteria by which any health care reform proposal should be evaluated; and (3) because the crisis in U.S. health care is as much a political as it is a public policy problem, the article evaluates three proposals for reform considered by the U.S. Congress.
The proposals to be evaluated include the Universal Health Care Act of 1991 (H.R. 1300), proposed by Representative Marty Russo (D-IL), hereinafter referred to as the Russo bill; Senate bill S. 1227, sponsored by Majority Leader George Mitchell (D-ME), hereinafter referred to as the Senate bill; and the Pepper Commission report on Access to Health Care and Long-Term Care for All Americans (U.S. Bipartisan Commission on Comprehensive Health Care, 1990), hereinafter referred to as the Pepper Commission Report. These proposals represented two of the major alternatives in the current policy debate: the "single-payer" model (the Russo bill) and the "play or pay" model (the Senate bill and the Pepper Commission Report).
Factors Contributing to the Health Care Crisis
The crisis in American health care comprises a number of distinct problems, but this article will focus on two fundamental issues: absence of universal access and excessive costs.
Absence of Universal Access
The absence of universal access to health care constitutes for many the number 1 problem in America's health care system. Access is restricted on the basis of employment; ability to pay; current level of health; and, most significantly, ability of certain individuals to obtain health insurance (for example, those with pre-existing conditions). Recent estimates indicate that between 32 million and 37 million Americans are without any health insurance and that another 25 million have only minimal or inadequate health insurance (Cohn, 1991).
Ironically, Medicare contributes to the problem of nonuniversal access by creating a select population guaranteed adequate access and denying other groups such access. Some refer to this as America's two-track system in health care. However, the problem goes deeper. The United States has a multitrack system that includes private employment-based health insurance policies; Medicare for elderly people; Medicaid for poor people; and a grab bag of leftover or no options for those who are unemployed, underemployed, self-employed, or employed by companies that offer no health insurance benefits. The current employment-based system is predicated on the assumption that health insurance is a fringe benefit rather than a fundamental right.
Another factor contributing to the problem of nonuniversal access is the widespread practice by health insurers of restricting or denying coverage to individuals with prior health problems (pre-existing conditions). …