Previously we examined the health care system reform proposals of the major candidates in the 2008 Presidential Primaries (Flint & Gorin, 2008). Whatever the outcome of the 2008 election, pressure for reform is not likely to dissipate. In this article we assess the current climate for and possibility of reform. We also identify and discuss four current approaches--conservative reform, a single-payer system; private--public models; and state reform.
Readers of this journal are well aware of the problems facing our health care system, particularly in the areas of access and cost. More than 47 million Americans are completely uninsured, and the number of underinsured people (that is, individuals with inadequate coverage) has reached 25 million, having grown 60 percent between 2003 and 2007 (Schoen, Collins, & Kriss, & Doty, 2008). According to the Urban Institute, 22,000 adults (ages 25 to 64) a year die because of a lack of health insurance (Dorn, 2008). Although health care inflation has slowed in recent years, this modest respite is likely temporary (Ginsburg, 2008). Despite the recent moderation in medical care inflation, nearly a fifth of the population went without or delayed receiving "needed" care (Cunningham & Felland, 2008). Although problems with access were particularly intense for individuals without coverage and those in poorer health, "insured people also faced large increases in unmet need" (Cunningham & Felland, 2008, p. 1). The central reason cited for problems with access was concern about cost.
Health care costs are spreading beyond impeded access to care. The Government Accountability Office recently warned that health care inflation poses a serious threat to the long-term fiscal stability of the nation ("Long-Term Fiscal Outlook," 2008). Given these circumstances, the pressure for health reform is not likely to dissipate any time soon.
Prospects for Reform
Prognosticating is fraught with risk, particularly because at the time of this writing we do not know which party will win the White House or control the Congress. Nonetheless, on the basis of the information we have, this is our best estimate of the current climate and prospects for reform.
Wyden and Bennett (2008) argued that we have entered a period during which it may be possible to "break 60 years of gridlock" and enact meaningful health care reform. They point to bipartisan support for Senate Bill 334, the Healthy Americans Act (2007), which guarantees universal coverage though "market-driven health care choices like those that members of Congress have today" (Wyden & Bennett, 2008, p. 690). They cite "an ideological truce" between Republicans and Democrats, and recognition by business and labor groups that they must work together to modernize our employer-based system to "meet the needs of both workers and employers" (Wyden & Bennett, 2008, p. 690). Democratic pollsters assert that "fundamental" reform may be possible, but warn that "the opportunity could easily dissipate" (Lake, Crittenden, & Mermin, 2008).Voters believe that health care should be a right and recognize reform as an investment in the future. They also want the security and "peace of mind" universal coverage would bring. Despite this, opponents will actively work "to sow confusion, doubt, and fear about major change" (Lake et al., 2008, p. 698).
Immigration is a particular "wild card." Opponents of reform are likely to attack any universal proposal as benefiting "illegal immigrants," a charge that is "potentially a greater liability than any of the usual attacks on taxes, government control, and so on" (Lake et al., 2008, p. 697). Although reform is a "real possibility," advocates cannot take it for granted but must work "strategically as well as passionately for the changes they seek" (Lake et al., 2008, p. 698). McInturff and Weigel (2008), prominent Republican pollsters, argue that the situation we face today is similar to that in the early 1990s. …