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"Healthcare for All"?: The Gap Between Rhetoric and Reality in the Affordable Care Act

Introduction.

According to its proponents, the passage of the Affordable Care Act (ACA) 1 “enshrined . . . the core principle that everybody should have some basic security when it comes to their health care.” 2   However, the ACA does not ensure healthcare coverage for many groups.  Indeed, projections indicate that 27 million uninsured Americans will remain even after enactment of all of the ACA ’s provisions. 3   Most sizeable among these groups are certain classes of noncitizens, including but not limited to undocumented immigrants.

Why does the statutory reality differ from the lofty, expansive language used by the ACA ’s proponents in Congress and the White House, especially with respect to noncitizens?  A parsing of the ACA ’s legislative history, particularly the congressional floor debates over the bill, reveals two possible answers.  Both answers are instructive to advocates hoping to extend access to health insurance coverage to all noncitizen groups.  First, at least some legislators implicitly qualify the notion of healthcare for all with the requirement that beneficiaries of the law must pay taxes  Second, at least some legislators seem to exclude certain noncitizen groups from their definition of “Americans,” which is used interchangeably with the terms “everybody” or “all” throughout the legislative history of the ACA .

Part I of this Essay examines the ACA ’s statutory and accompanying regulatory language, identifying three noncitizen groups that receive reduced or no protections under the law: (1) recently arrived legal immigrants; (2) noncitizens present under temporary nonimmigrant visas, known as nonim­migrants; and (3) undocumented immigrants.  Part II explores the legislative history of the ACA and the idealistic statements repeatedly made by legislators about the idea of healthcare for all.  It identifies similar statements made by proponents of previous versions of healthcare reform during prior presidential administrations, suggesting a historical pattern of disconnect.

Part III concludes that implicit normative and economic arguments legislators made against the expansion of healthcare coverage to these excluded groups, particularly the undocumented, offer a partial explanation for the gap between the rhetoric and reality of the ACA .  It also critiques these arguments and offers suggestions to advocates for expanded healthcare coverage in overcoming these implicit arguments against true healthcare for all.

I. The Affordable Care Act and Exclusion of Certain Noncitizen Groups

This Part distills a general outline of the ACA ’s contours before analyzing how recent legal immigrants, legal nonimmigrants, and undocumented immi­grants are not protected under the new legislation.  The ACA is both voluminous and complex, clocking in at nearly 1000 pages and containing various provisions that will not go into effect until later this decade. 4   Multiple constitutional and political challenges to the ACA , the most significant of which the U.S. Supreme Court resolved only in June of 2012, 5 slowed down the states’ implementation of the bill. 6   Further, the U.S. Department of Health and Human Services is still promulgating regulations in accordance with the statute’s decrees more than two years after the bill’s passage. 7   All of this uncertainty over the ACA makes it difficult to analyze the ACA with a high degree of specificity.  However, even a general summary of the law demonstrates the notable absence of the three groups identified above from all of the ACA benefits.

A. General Outline of the ACA

B. reduced protections for recently arrived legal immigrants, c. reduced protections for legal nonimmigrants.

The ACA also fails to offer full protections to the nearly two million nonimmigrant residents in the United States. 32   Nonimmigrants, who are present in the country on temporary visas and include university students, skilled and unskilled laborers recruited by U.S. employers, and family members of U.S. citizens or lawful permanent residents, 33 are often a forgotten group. 34   Yet many of these individuals lawfully reside in this country for up to several years.  Many of them undoubtedly require access to healthcare at some point during their time here.

D. Reduced Protections for Undocumented Immigrants

Finally, the estimated eleven million undocumented immigrants in this country 40 are specifically excluded from virtually all of the ACA ’s protections  As one commentator summarizes:

II. Legislative History of and Rhetoric Surrounding the Affordable Care Act

The ACA deliberately refrained from extending full access to healthcare for recently arrived LPRs and nonimmigrants.  The ACA also excluded undocu­mented immigrants from all, or virtually all, of its protections.  Yet, as this Part demonstrates, the ACA ’s statutory realities appear to belie the expansive language used by the ACA ’s advocates, who repeatedly defended the idea of healthcare access to “everyone” or “all Americans” in the sponsor statements, floor debates, and signing statements associated with the bill. 47   This trend is a continuation of history, as policymakers who pushed previous iterations of healthcare reform during previous presidential administrations also employed universal language in publicizing their efforts.  Yet policymakers did not include groups like the undocumented in their policy proposals.  The result is an apparent, longstanding tension between the ideas of healthcare for all and healthcare for noncitizens.

A. The Legislative History of the ACA

Representative Louise Slaughter’s seemingly contradictory statements are indicative of this paradox.  Representative Slaughter called up the bill for a vote and in her remarks stated:

The legislative history of the bill is less clear, however, about the reasons for offering diminished protection to newly arrived LPRs and nonimmigrants.  Only one congressman made a floor statement about the plight of newly arrived legal immigrants under the bill.  Representative Honda lamented that the bill did not “lift the 5 year bar on legal immigrant participation in Medicaid.  Legal immigrants are tax paying [sic] citizens in waiting who work hard and contribute.  It is only fair that we afford them equal access to the benefits of Medicaid.” 58   Meanwhile, no floor statements, committee reports, or other statements made by lawmakers suggested that legislators were preoccupied by the fate of nonimmigrants under the bill.

Finally, after the bill passed both Congressional houses and landed on President Obama’s desk on March 23, 2010, the president also used expansive, even universal, language when referring to the beneficiaries of the ACA :

B. History of Healthcare Reform Advocacy in America

The ACA was an unprecedented overhaul of our nation’s healthcare system.  It was the product of decades of advocacy for expanded access to healthcare for Americans that germinated in Theodore Roosevelt’s presidential administration nearly a century ago. 60   As healthcare costs and the number of uninsured in the United States continued to balloon, the political will to reform the system strengthened.  And just like with the ACA , the idea that “all Americans” deserved access to healthcare animated the political discourse through Republican and Democratic presidencies alike in the last hundred years, though the concrete proposals failed to extend protection to all noncitizen groups.  The ACA ’s repetition of history may be instructive in understanding why legislators persist in leaving out certain noncitizens from their conception of universal healthcare.

The rhetoric past legislators and policy advocates used to push for such legislation also centered around the notion that “all Americans deserve healthcare.”  For example, Mrs. Clinton and other advocates of her plan 1993 Health Care Reform Plan made such statements as “If we do not have universal coverage . . . we do not have health care reform.” 65   And yet, past iterations of healthcare expansion legislation, such as the 1993 plan, did not cover undocumented immigrants beyond already existing emergency Medicaid protections in the event of immediate and severe health crises. 66   In the past, as in the present, a gap existed between the ideals that animated the push for healthcare reform and the substance of the proposals ultimately put forth with respect to noncitizen groups like the undocumented.

III. Implicit Rationale for the Gap Between Reality and Rhetoric: The Definition of “American”

It is, of course, impossible to definitively explain how the entire 111th U.S. Congress rationalized the exclusion of the three noncitizen groups identified above.  Parsing the legislative history—particularly the floor debates—reveals implicit economic and normative social assumptions legislators made about the role of undocumented immigrants in particular.  Perhaps these assumptions explain, at least in part, the inconsistencies in the statutory language of and legislative history about the ACA explored in this Article.  This Part explores these potential economic and social rationales, critiques them, and offers ways for healthcare reform advocates to overcome them.

A. Concerns About Economic Freeridership

Most of the comments made by legislators concerned the potential for undocumented immigrants to benefit from the ACA are economic in nature.  Time and time again, legislators opposed to the bill mentioned the fear that undocumented immigrants would benefit from free healthcare at the (presumably legally present) taxpayers’ expense 67 and “open[] the floodgates” to millions more of the undocumented who would further burden our welfare system. 68   News reports suggest the floodgates argument also partially explains why legislators declined to lift the Medicaid residency and immigrant status requirements in the ACA for legal immigrants and nonimmigrants. 69   A plausible way this fear qualifies the seemingly unconditional healthcare for all is the idea that legislators actually mean healthcare for all who pay into the system.

Second, the floodgates argument is also specious.  The number of legal immigrants and nonimmigrants would not increase with expanded access to Medicaid because the United States has caps on the number of immigrants and nonimmigrants who may enter the country each year. 74   Further, many immi­gration analysts argue that undocumented are primarily motivated to enter this country due to the presence of brighter economic opportunities, especially in the unskilled and low-skilled sectors, where the supply of U.S. citizen workers is low. 75   Whether healthcare benefits are available is ancillary when compared to whether upward social and economic mobility is possible through available jobs. 76   The decrease in the number of undocumented immigrants during the past four years 77 as the American economy underwent a recession and a slow recovery 78 supports this view of immigration.

Finally, some studies have shown that giving all individuals access to preventative and nonemergency healthcare is ultimately more cost-effective for the nation as a whole. 79   In support of this point, it is worthwhile to note that the undocumented population is generally younger and healthier than the American population as a whole, 80 and adding them into insurance risk pools may lower premiums and costs of emergency healthcare for all. 81   It is true that other studies claim that the federal government may not gain money from subsidizing so many Americans’ health insurance. 82   It is impossible, however to deny the longterm gains in economic productivity and reduction in emergency room and emergency Medicaid costs that would result if all people—including recently arrived LPRs, nonimmigrants and the undocumented—had health insurance. 83   The possibility of realizing such gains would seem to merit seriously considering expanding undocumented immigrants’ rights to access healthcare.

Perhaps most who opposed the ACA covering undocumented immigrants generally oppose the concept of the ACA .  It is true that those who mentioned the potential economic burdens that undocumented immigrants would create by receiving benefits under the ACA were opposed to the ACA as a whole on other grounds.  This includes the idea that the ACA was too redistributivist. 84   This counterargument, however, fails to explain why those who supported the ACA and the idea that wealthy taxpayers pay more taxes for all less wealthy Americans’ health insurance also supported excluding the noncitizen groups identified above from the bill.

If indeed some legislators were motivated to deny undocumented immi­grants, recently arrived LPRs, and nonimmigrants access to full healthcare benefits under the ACA because of economic concerns, those who advocate for expanded healthcare coverage for these three noncitizen groups may do well to make two primary economic arguments supporting coverage.  First, these groups, particularly the undocumented, contribute to federal tax revenue.  Second, the national economy and federal government would benefit from an expansion of coverage for all three groups.

B. Healthcare as a Privilege of Citizenship

Another solution to overcoming legislators’ exclusive definition of “American” is to expand the definition of “American” in the political discourse to include the noncitizen groups in question.  This task would be no less Herculean, as it requires changing long-held views on the role of immigrants in the United States. 106   This effort, however, would have the added benefits of staving off the desire of some legislators to oppose CIR efforts if and when that mantle is again taken up by public officials and of preventing legislators from potentially limiting the benefits to which newly legalized immigrants are entitled.

A close examination of the ACA ’s legislative history suggests two possibly interrelated ways that legislators reconciled the competing concepts of universal healthcare and fewer healthcare protections for noncitizens in crafting the ACA .  Perhaps understanding these rationales will allow healthcare advocates on behalf of noncitizens to redouble their efforts to obtain equal access to healthcare for recently arrived legal immigrants, nonimmigrants, and the undocumented.

Despite the rhetoric of universal healthcare and healthcare for all that pervaded the healthcare debate, the ACA does not fully protect certain legal immigrants or nonimmigrants and fails to protect the undocumented at all, leaving millions of Americans still without access to health insurance.  The legislative history of the ACA suggests that legislators’ biases towards these noncitizen groups, particularly with respect to the economic impact of insuring them and the idea that they are not “American,” may explain this gap.  Advocates for universal healthcare must combat these biases, push for comprehensive immigration reform, or, preferably, employ both strategies in order for rhetoric to meet reality in the concept of healthcare for all.

• For the purposes of this Essay, the ACA also refers to the Health Care and Education Reconciliation Act of 2010, which was passed a week later to amend portions of the Patient Protection and Affordable Care Act.  See Pub. L. No. 111-152, 124 Stat. 1029 (2010). ↩
• Joe Biden & Barack Obama, Remarks by the President and Vice President at Signing of the Health Insurance Reform Bill (Mar. 23, 2010), available at http://www.whitehouse.gov/the-press-office/remarks-president-and-vice-president-signing-health-insurance-reform-bill . ↩
• How the Number of Uninsured May Change With and Without the Health Care Law , N.Y. Times , June 27, 2012, http://www.nytimes.com/interactive/2012/06/27/us/how-the-number-of-uninsured- may-change-with-and-without-the-health-care-law.html . ↩
• U.S. Dep’t of Health & Human Serv., Key Features of the Affordable Care Act by Year , Healthcare.gov , http://www.hhs.gov/healthcare/facts/timeline/timeline-text.html (last visited June 30, 2013). ↩
• Adam Liptak, Justices, by 5–4, Uphold Health Care Law; Roberts in Majority; Victory for Obama , N.Y. Times , June 29, 2012, at A1. ↩
• Abby Goodnough & Robert Pear, With Obama Re-elected, States Scramble Over Health Law , N.Y. Times, Nov. 8, 2012, http://www.nytimes.com/2012/11/09/health/states-face-tight-health-care-deadlines.html . ↩
• See, e.g. , Patient Protection and Affordable Care Act; Establishment of Exchanges and Qualified Health Plans; Small Business Health Options Program, 78 Fed. Reg. 33,233 (June 4, 2013) (to be codified at 45 C.F.R. pts. 155–156). ↩
• Health Care Reform Tops Obama’s Priority List , PBS NewsHour (June 8, 2009, 12:30 PM), http://www.pbs.org/newshour/updates/health/jan-june09/healthpreview_06-08.html . ↩
• Shailagh Murray & Lori Montgomery, House Democrats Pull Together on Health Care , Wash. Post , Oct. 30, 2009, http://www.washingtonpost.com/wp-dyn/content/article/2009/10/29/AR2009102901841_pf.html . ↩
• Sheryl Gay Stolberg & Robert Pear, Obama Signs Health Care Overhaul Bill, With a Flourish , N.Y. Times , Mar. 23, 2010, http://www.nytimes.com/2010/03/24/health/policy/24health.html . ↩
• See id. ↩
• Allison K. Hoffman, Three Models of Health Insurance: The Conceptual Pluralism of the Patient Protection and Affordable Care Act , 159 U. Pa. L. Rev. 1873, 1915–16 (2011). ↩
• See Liptak, supra note 5. ↩
• Robert Pear & Abby Goodnough, States Decline to Set Up Exchanges for Insurance , N.Y. Times , Nov. 17, 2012, at A14 . ↩
• Originally, state-run exchanges were slated to begin running on January 1, 2014; however, delays have ensued due to constitutional uncertainty surrounding the Act and recalcitrance on the part of some states.  The federal government will run exchanges in any states that are unwilling or unable to run their own exchanges.  Id. ↩
• Hoffman, supra note 12, at 1916–17. ↩
• Id . at 1916 . ↩
• Id. at 1920. ↩
• See Robert Pear, Uncertainty Over States and Medicaid Expansion , N.Y. Times , June 29, 2012, at A16 . ↩
• Liptak, supra note 5. ↩
• John Elwood, What Did the Court “Hold” About the Commerce Clause and Medicaid? , Volokh Conspiracy (July 2, 2012, 11:28 AM), http://www.volokh.com/2012/07/02/what-did-the-court-hold-about-the-commerce-clause-and-medicaid .  States may now choose whether to expand Medicaid coverage without incurring a loss of federal Medicaid funding if they choose not to expand.  Pear, supra note 19.  If they do choose to expand, they may seek the ACA ’s additional funding for the expansion.  Id. ↩
• Id. ↩
• Karla Guerrero, Waiting Five Years for Healthcare: How Restricting Immigrants’ Access to Medicaid Harms All , 21 Annals Health L. Advance Directive 109, 113 (2011). ↩
• Id. at 112–13. ↩
• Ruth Ellen Wasem, Cong. Research Serv., Noncitizen Eligibility for Federal Public Assistance: Policy Overview and Trends 4 (2012). ↩
• Guerrero, supra note 23, at 115 (“Emergency Medicaid covers the costs of emergency medical treatment through the Emergency Medical Treatment and Labor Act (EMTALA), enacted in 1986, which requires hospitals to treat individuals facing medical emergencies regardless of their ability to pay, their immigration status, or whether the hospital could receive reimbursement for services that went beyond simply stabilizing the patient’s medical emergency.”). ↩
• See Mee Moua et al., Immigrant Health: Legal Tools/Legal Barriers , 30 J.L. Med. & Ethics 189, 192 (2002). ↩
• Alison Siskin, Cong. Research Serv., Treatment of Noncitizens Under the Patient Protection and Affordable Care Act 4 (2011). ↩
• Guerrero, supra note 23, at 115–16 (footnote omitted). ↩
• Michelle Nicole Diamond, Legal Triage for Healthcare Reform: The Conflict Between the ACA and EMTALA , 43 Colum. Hum. Rts. L. Rev. 255, 298–99 (2011); see also Tim Rutten, Op-Ed., Immigration Reform and the Healthcare Debate , L.A. Times , Jan. 9, 2010, http://articles.latimes.com/2010/jan/09/opinion/la-oe-rutten9-2010jan09 (explaining how Los Angeles–area hospitals would be disproportionately impacted by cuts to the emergency medical treatment program). ↩
• Emily Deruy, Healthcare Overhaul Would Cause Longer Emergency Room Lines for Some Immigrants , ABC News (Sept. 25, 2012), http://abcnews.go.com/ABC_Univision/Politics/longer-emergency-room-lines-undocumented-immigrants-affordible-care/story?id=17321383 . ↩
• Michael Hoefer et al., Office of Immigration Statistics, Estimates of the Unauthorized Immigrant Population Residing in the United States: January 2011 , at 4 (2012). ↩
• See Justin Hess, Comment, Nonimmigrants, Equal Protection, and the Supremacy Clause , 2010 B.Y.U. L. Rev. 2277, 2278. ↩
• Id. at 2287. ↩
• See, e.g. , Ill. Health Matters, Immigrants and the ACA : A Primer 1, http://illinoishealthmatters.org/wp-content/uploads/2012/09/Immigrants-and-the-ACA-1.pdf (last visited June 30, 2013); see also Nathan Cortez, Embracing the New Geography of Health Care: A Novel Way to Cover Those Left out of Health Reform , 84 S. Cal. L. Rev. 859, 889 (2011). ↩
• Nat’l Immigration Law Ctr., “Lawfully Present” Individuals Eligible Under the Affordable Care Act 1, 6 (2012), www.nilc.org/document.html?id=809. ↩
• Siskin , supra note 28, at 7–8. ↩
• Howard F. Chang, Immigration Policy, Liberal Principles, and the Republican Tradition , 85 Geo. L.J. 2105, 2109 (1997). ↩
• See Diamond, supra note 30, at 275–78. ↩
• Id. at 277. ↩
• Cortez, supra note 35, at 870 (footnotes omitted). ↩
• See Sarah Kliff & Ezra Klein, Individual Mandate 101: What It Is, and Why It Matters , Wash. Post , Mar. 27, 2012, http://www.washingtonpost.com/blogs/wonkblog/post/individual-mandate-101-what-it-is-why-it-matters/2011/08/25/gIQAhPzCeS_blog.html . ↩
• The U.S. Department of Health and Human Services recently issued a rule clarifying that individuals granted deferred action were not considered “lawfully present” under the law.  Robert Pear, Limits Placed on Immigrants in Health Care Law , N.Y. Times , Sept. 17, 2012, http://www.nytimes.com/2012/09/18/health/policy/limits-placed-on-immigrants-in-health-care-law.html . ↩
• Maggie Mertens, Health Care for All Leaves 23 Million Uninsured , NPR (Mar. 24, 2010, 10:37 AM), http://www.npr.org/blogs/health/2010/03/health_care_for_all_minus_23_m.html . ↩
• See supra notes 30, 38, and accompanying text. ↩
• Jennifer Ludden, Health Care Overhaul Ignores Illegal Immigrants , NPR (July 8, 2009, 12:00 AM), http://www.npr.org/templates/story/story.php?storyId=106376595 . ↩
• This Paper utilizes a narrow approach to legislative history, following the example of Lee Epstein & Gary King, The Rules of Inference , 69 U. Chi. L. Rev. 1, 75 (2002).  See Janet L. Dolgin & Katherine R. Dieterich, When Others Get Too Close: Immigrants, Class, and the Health Care Debate , 19 Cornell J.L. & Pub. Pol’y 283, 312–14 (2010) for a broader view of the ACA ’s legislative history with respect to the undocumented. ↩
• House Democrats Announce Health-Care Bill , Wash. Post , Oct. 29, 2009, ST2009102902154 " target="_blank" rel="noopener noreferrer">http://www.washingtonpost.com/wp-dyn/content/article/2009/10/29/AR2009102902240.html?sid= ST2009102902154 . ↩
• See, e.g. , id . (“It is with great pride and with great humility that we come before you to follow in the footsteps of those who gave our country Social Security and then Medicare and now universal, quality, affordable health care for all Americans.”) (statement of Rep. Nancy Pelosi); id. (“[W]e’re here at a historic time, when for over half a century a family elected by their citizens to come to this Congress have raised the banner of health care for all that they could afford.”) (statement of Rep. Steny Hoyer); id . (“47 million Americans who do not have health care will be grateful for this day . . . . This bill offer [sic] everyone, regardless of income, age, sex, health status, the peace of mind in knowing that they will have real access to quality, affordable health insurance when they need it.”) (statement of Rep. John Dingell). ↩
• Id. ; Who Are the Uninsured? , N.Y. Times , Aug. 23, 2009, http://prescriptions.blogs.nytimes.com/ 2009/08/23/who-are-the-uninsured . ↩
• E.g. , 155 Cong. Rec. H12 ,623, H12 ,848 (daily ed. Nov. 7, 2009) (“[T]his bill will do for America what we should have done 100 years ago: provide health care for all Americans as a matter of right, not as a matter of privilege.”) (statement of Rep. Braley); 155 Cong. Rec. H12 ,598, H12 ,619 (daily ed. Nov. 7, 2009) (“Every American deserves the promise of quality affordable health care, and this is our moment to fulfill that promise.”) (statement of Rep. Langevin); id. at H12 ,621 (“Let me be absolutely clear: every single American should have access to affordable and quality health-care coverage.”) (statement of Rep. Ackerman). ↩
• E.g. , 155 Cong. Rec. H12 ,623, H12 ,844 (daily ed. Nov. 7, 2009) (“We are creating a new health insurance marketplace and requiring everyone to have coverage, which I support.”) (statement of Rep. Frank); 155 Cong. Rec. H12 ,598, H12 ,611 (daily ed. Nov. 7, 2009) (“[I]t is clear that Congress needs to make reforms to expand health care coverage so that everyone in this great Nation has health insurance.”) (statement of Rep. Diaz-Balart); id. at H12 ,614 (“Six principles have guided my work and determined my vote on this legislation: health insurance reform must create stability, contain costs, guarantee choice, improve quality, cover everyone, and include a strong public option.  The Affordable Health Care for America Act delivers on each of these principles.”) (statement of Rep. Heinrich). ↩
• 155 Cong. Rec. H12 ,623, H12 ,851 (daily ed. Nov. 7, 2009) (“This bill cuts healthcare for our seniors by hundreds of billions of dollars while providing subsidized health care of illegal immigrants, which will draw more illegals into our country.”) (statement of Rep. Rohrabacher); id. at H12 ,870 (“As if that wasn’t enough, the bill opens the floodgates of taxpayer money for illegal immigrants to abuse the system and obtain free government health insurance—all on the backs of law-abiding Americans.”) (statement of Rep. Rogers). ↩
• Representative Holt stated, Another myth is that health reform would provide federal benefits for undocumented aliens. Undocumented immigrants currently may not receive any federal benefits except in specific emergency medical situations. There are no provisions in the House health reform bill that would change this policy. In fact, the legislation explicitly states that federal funds for insurance would not be available to any individual who is not lawfully present in the United States. ↩
• 155 Cong. Rec. H12 ,598, H12 ,620 (daily ed. Nov. 7, 2009) (emphasis added). ↩
• Id. at H12 ,615. ↩
• 155 Cong. Rec. H12 ,623, H12 ,899 (daily ed. Nov. 7, 2009). ↩
• Biden & Obama, supra note 2. ↩
• See Bryan J. Leitch, Comment, Where Law Meets Politics: Freedom of Contract, Federalism, and the Fight Over Health Care , 27 J.L. & Pol. 177, 178 (2011). ↩
• See Lance Gable, The Patient Protection and Affordable Care Act, Public Health, and the Elusive Target of Human Rights , 39 J.L. Med. & Ethics 340, 342 (2011). ↩
• See id. ; David U. Himmelstein & Steffie Woolhandler, Op-Ed, I Am Not a Health Reform , N.Y. Times , Dec. 15, 2007, http://www.nytimes.com/2007/12/15/opinion/15woolhandler.html (dis­cuss­ing President Nixon’s healthcare reform bill). ↩
• For example, see W. John Thomas, Play It Again, Hillary: A Dramaturgical Examination of a Repeat Health Care Plan Performance , 19 Stan. L. & Pol’y Rev. 283, 290 (2008), for a brief overview of the 1993 Health Care Reform Plan. ↩
• Adam Clymer, Hillary Clinton Courts Four Senators Backing Rival Health Care Proposal , N.Y. Times , Oct. 30, 1993, http://www.nytimes.com/1993/10/30/us/hillary-clinton-courts-four-senators-backing-rival-health-care-proposal.html . ↩
• See Health Care Reform May Leave Out Undocumented Aliens , 70 No. 35 Interpreter Releases 1195, 1195 (1993). ↩
• E.g. , 155 Cong. Reg. H12,598, H12 ,607 (daily ed. Nov. 7, 2009) (“Millions of illegal immigrants will receive taxpayer subsidies for enrollment in subsidized health care plans [under the initial House version of the ACA ].”) (statement of Rep. Posey); id. at H12 ,615 (“This massive government takeover of our health care still allows the 20 million people in this country that are illegally here to get one of those fake Social Security cards without benefit of even a photo ID and get some of that free government health care that everybody else has to pay for.”) (statement of Rep. Poe); 155 Cong. Rec. H12 ,623, H12 ,870 (daily ed. Nov. 7, 2009) (statement of Rep. Rogers); see also Dolgin & Dieterich, supra note 47, at 284. ↩
• 155 Cong. Rec. H12 ,623, H12 ,870 (daily ed. Nov. 7, 2009) (statement of Rep. Rogers). ↩
• See Julia Preston, Health Care Debate Focuses on Legal Immigrants , N.Y. Times , Nov. 3, 2009, http://www.nytimes.com/2009/11/04/health/policy/04immig.html . ↩
• Eduardo Porter, Illegal Immigrants Are Bolstering Social Security With Billions , N.Y. Times , Apr. 5, 2005, http://www.nytimes.com/2005/04/05/business/05immigration.html . ↩
• Nina Bernstein, Tax Returns Rise for Immigrants in U.S. Illegally , N.Y. Times , Apr. 16, 2007, http://www.nytimes.com/2007/04/16/nyregion/16immig.html . ↩
• Juliet Lapidos, Editorial, The 47 Percent , N.Y. Times (Sept. 18, 2012, 11:47 AM), http://takingnote.blogs.nytimes.com/2012/09/18/the-47-percent . ↩
• Brian Palmer, Exactly How Many Americans Are Dependent on the Government? , Slate (Sept. 18, 2012, 1:07 AM), http://www.slate.com/articles/news_and_politics/explainer/2012/09/romney_says_47_percent_of_americans_receive_direct_government_assistance_is_that_true_.html . ↩
• Cong. Budget Office, Immigration Policy in the United States 8 (2006) . ↩
• See Damien Cave, Better Lives for Mexicans Cut Allure of Going North , N.Y. Times , July 6, 2011, http://www.nytimes.com/interactive/2011/07/06/world/americas/immigration.html . ↩
• See , e.g. , Dayna Bowen Matthew, The Social Psychology of Limiting Healthcare Benefits for Undocumented Immigrants—Moving Beyond Race, Class, and Nativism , 10 Hous. J. Health L. & Pol’y 201, 204 (2010) (“[W]e know empirically that the sole or primary motivation to immigrate to the United States is not to participate in the healthcare system.”).  Matthew also posits a public health reason for extending health insurance coverage to all noncitizens: preventing the spread of treatable, communicable diseases.  See id. at 203. ↩
• See Michael Muskal, Illegal Immigration to U.S. Stays Down, Pew’s Latest Numbers Show , L.A. Times , Dec. 6, 2012, http://www.latimes.com/news/nation/nationnow/la-na-nn-pew-illegal-immigration-down-20121206,0,4267690.story (“The number of illegal immigrants in the U.S., which stood at about 8.4 million in 2000, peaked at about 12 million in 2007 and has been tapering since . . . .”). ↩
• Further, the Mexican economy has improved in the last few years, dissuading many Mexicans from leaving home to enter the United States.  See Cave, supra note 75.  Some, however, also credit increased enforcement efforts with the decrease in the U.S. undocumented population.  Matthew, supra note 76, at 202. ↩
• See Christopher M. Hughes, Op-Ed, Health Care for All: Expanding Medicaid Would Save Lives, Suffering and Money , Pittsburgh Post-Gazette (Oct. 4, 2012, 12:17 AM), http://www.post-gazette.com/stories/opinion/perspectives/health-care-for-all-expanding-medicaid-would-save-lives-suffering-and-money-656060 . ↩
• Ludden, supra note 46. ↩
• Patrick J. Glen, Health Care and the Illegal Immigrant 58 (Georgetown Pub. Law & Legal Theory Research Paper No. 12-024, 2012). ↩
• E.g. , James C. Capretta, Obamacare: Impact on Future Generations , Heritage Found. (June 1, 2010), http://www.heritage.org/research/reports/2010/06/obamacare-impact-on-future-generations . ↩
• See Ezekiel J. Emanuel, Op-Ed, Saving by the Bundle , N.Y. Times (Nov. 16, 2011, 7:55 PM), http://opinionator.blogs.nytimes.com/2011/11/16/saving-by-the-bundle ; see also Ann Weilbaecher, Immigrant Health Care: Social and Economic Costs of Denying Access , 17 Annals Health L. 337, 337–38 (2008); Ludden, supra note 46. ↩
• See, e.g. , 155 Cong. Rec. H12 ,598, H12 ,616 (daily ed. Nov. 7, 2009) (“[T]oo many people in America are uninsured, 47 million.  Well, subtract from that 47 million illegal aliens which will be funded under this bill, immigrants, those that qualify for Medicaid and other government programs, employer programs that make over ,000 a year, now you’re down to really only 12.1 million Americans who are without affordable options.  That is less than 4 percent of America.  And for that you would throw out the liberty of America, throw out the baby with the bathwater of the best health insurance industry in the world, the best health care delivery system in the world, destroyed by a desire to create a dependency society to steal our freedom.”) (statement of Rep. King). ↩
• For support of this theory, see Dolgin & Dieterich, supra note 47, at 312–13. ↩
• See supra note 52 and accompanying text. ↩
• See Biden & Obama, supra note 2. ↩
• See supra notes 63–65 and accompanying text. ↩
• See supra note 53 and accompanying text. ↩
• See John F. Manning, The New Purposivism , 2011 Sup. Ct. Rev. 113, 172 (cautioning against over-analyzing the breadth of a term used in the legislative history such as “substantially all”). ↩
• See supra note 84. ↩
• Dolgin & Dieterich, supra note 47, at 311–25. ↩
• Black-White Conflict Isn’t Society’s Largest , Pew Res. Ctr. (Sept. 24, 2009), http://www.pewsocialtrends.org/2009/09/24/black-white-conflict-isnt-societys-largest . ↩
• See Matthew, supra note 76, at 222 (discussing the “Us-Them dichotomy” espoused by many “in-group” Americans). ↩
• See id. at 201 (quoting Otis L Graham, The Unfinished Reform: Regulating Immigration in the National Interest , in Debating American Immigration, 1882–Present 89, 91 (2001)). ↩
• Dolgin & Dieterich, supra note 47, at 285 (“[I]mmigrants—especially undocumented, Hispanic immigrants—have become scapegoats on which social discontent and economic anxiety are displaced.”).  See generally Mark Hugo Lopez et al., Pew Hispanic Ctr., Illegal Immigration Backlash Worries, Divides Latinos (2010) (explaining how animosity towards the undocumented has led to Latinos fearing prejudice and discrimination based on their ethnic characteristics, regardless of their immigration status). ↩
• See, e.g. , Olga Popov, Note, Towards A Theory of Underclass Review , 43 Stan. L. Rev. 1095, 1099 (1991). ↩
• Matthew, supra note 76, at 202. ↩
• See Dolgin & Dietrich, supra note 47, at 312–14, for a discussion suggesting that the ACA ’s proponents neglected to include the undocumented in the bill because it would be “politically explosive.” ↩
• See supra note 58 and accompanying text identifying the dearth of legislative history regarding reasons for giving reduced protections for these two groups under the ACA . ↩
• Most conceptions of comprehensive immigration reform include a path to citizenship for at least some portion of the undocumented community.  See Understanding Immigration Reform , N.Y. Times , Dec. 9, 2012, http://www.nytimes.com/roomfordebate/2012/12/09/understanding-immigration-reform ; see also Preston, supra note 69 (“‘We are not trying to expand health care coverage to illegal immigrants through this legislation,’ said Senator Jeff Bingaman, Democrat of New Mexico.  ‘That will have to be dealt with through comprehensive immigration reform.’”). ↩
• See supra note 36. ↩
• See Editorial, Inching Toward Immigration Reform , Wash. Post , Nov. 30, 2012, http://www.washingtonpost.com/opinions/inching-toward-immigration-reform/2012/11/30/3a016b70-38e0-11e2-8a97-363b0f9a0ab3_story.html . ↩
• See, e.g. , supra note 43 and accompanying text. ↩
• See Matthew, supra note 76, at 225. ↩

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Understanding the American healthcare reform debate

• Related content
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• Donald M Berwick , president emeritus and senior fellow
• Institute for Healthcare Improvement, Cambridge, Massachusetts, USA
• dberwick{at}ihi.org

If you don’t understand American healthcare, join the crowd. Donald M Berwick explains US government attempts to repeal and replace the Affordable Care Act

Debates over the US healthcare reform law—the Affordable Care Act (ACA) or “Obamacare”—have raged for almost a decade, with new fury now in the “repeal and replace” initiatives of the Trump administration. The act is complex, the more so because its provisions build on an already tortuous non-system of financing and delivering care to the people of the United States.

Here I present a quick tour of that non-system, an explanation of the basics of the ACA, and an analysis of the present attempts to undo it. Although I have tried to be technically correct, I make no claim to be non-partisan. I was President Obama’s appointee as administrator of the US Centers for Medicare and Medicaid Services between July 2010 and December 2011, which provides insurance at a cost above $820bn (£640bn; €730bn) to over 100 million Americans and which was and is responsible for implementing and managing more than 70% of the provisions of the ACA. I am a fan of the ACA, and I strongly oppose its repeal.

Understanding the ACA and its critics requires an understanding of how the US funds its healthcare. There are seven main routes of funding (box 1).

Box 1: How the US funds healthcare

Employer sponsored insurance for about 160 million people—workers and their families—in which premium costs are shared between employers (usually 60%-80% of the costs) and employees

Medicare—the tax supported federal health insurance scheme established in 1965 for Americans over 65 years of age (about 50 million people) and some others with disabilities

Medicaid—tax supported insurance, also begun in 1965, managed through the states and funded by a sharing of costs between states and the federal government, covering the care of people with low income, including those in long term care facilities. (Each state determines eligibility criteria.) About 70 million people each year have Medicaid coverage at some time during the year, but it is an ever changing pool as people come into and out of poverty

Children’s Health Insurance Program—essentially a Medicaid-like federal programme for about 8 million children

Department of Defense’s healthcare system for service members and their families (8 million)

Veteran’s Health Administration for military veterans and their families (8 million)

The individual and small group market—consists of roughly 20 million people who do not qualify for any of the other forms of coverage and who either find insurance on their own or go without

The funds flowing through these channels now amount to about $3tr a year, 18% of the entire US economy. Healthcare costs account for more than 25% of the federal government’s budget and are by far the fastest growing component of public expenditure in the US.

Closing the coverage gap

When President Barak Obama took office, around 50 million Americans lacked any health insurance because they did not fit into any of the existing payment streams. Many were simply unable to find affordable insurance or, because they had pre-existing medical conditions, could not find any insurance company willing to cover them.

President Obama made closing that coverage gap his flagship domestic policy initiative (allegedly against the advice of many of his staff). With enormous political conflict and through a long list of compromises with stakeholder groups, he was able to get the Affordable Care Act passed by Congress in March 2010, 14 months after his inauguration.

The ACA is hard to summarise briefly. It has 10 “titles” (sections) and is well over 1000 pages long. It may be best understood as, in effect, two bills in a single package.

One major theme is to improve healthcare insurance by extending coverage to more people and by placing insurers under new requirements that effectively make coverage more comprehensive and robust. More people are covered through Medicaid by setting a single, national threshold for eligibility (anyone whose annual income is less than 138% of the federally defined “poverty” definition). The act also established either state or federal “exchanges” (now called marketplaces) in which individuals between 138% and 400% of the federal poverty level can find commercial policies and receive a subsidy from the federal government to help them buy that coverage. In its initial design, the ACA was estimated to cover 16 million more people in Medicaid and 16 million more people in the exchanges. The ACA also introduced a popular provision that made children eligible for coverage under their parents’ health insurance policies up to the age of 26 years.

To make this all work, the ACA introduced a range of requirements for the insurance industry. One—“guaranteed issue”—forbade insurers from denying coverage because of pre-existing conditions. Another—“community rating”—required pooling of well and ill beneficiaries in a common actuarial pool so that the premiums would be affordable to people with greater need for care.

Individual mandate

By far the most controversial requirement was the “individual mandate,” under which every American had to obtain health insurance or pay a penalty. Without that requirement, given the new guaranteed issue provision, a well person could choose not to buy insurance until he or she became ill, which would make the actuarial pools unsustainable—as if people could wait to buy fire insurance until their house was in flames.

The other main part of the ACA addressed delivery of care. It did this by introducing a wide range of payment mechanisms to create incentives for healthcare providers to work more closely together and to provide more integrated care. Among the best known of these were accountable care organisations (which could in theory unify the aims of hospitals and community based care) and “bundled payment” for episodes of care (such as total joint replacement) rather than elements of care (such as operating theatre time or physician fees). The ACA also created new forms of transparency, public reports, and antifraud enforcement, as well as a new Center for Medicare and Medicaid Innovation with $10bn of funds to support widespread trials of new designs of care.

The costs of the expanded coverage of the ACA—about $1tr over 10 years—were offset with projected savings from better care, some reductions in payments to hospitals and private insurers, and a series of new taxes facing mainly wealthier taxpayers.

Problems with Obamacare

The ACA achieved many of its aims. For example, by the time of President Trump’s January 2017 inauguration, more than 20 million additional people had health coverage, the rate of rise of healthcare costs had somewhat slowed, major innovations in care and payment were being widely tested, reductions in hospital complications and readmissions were well documented, and the quality of insurance had generally improved. Problems were developing in many of the exchanges because of instability in enrolments in the fraught individual and small group market, and drug costs—never targeted by the ACA—were rising rapaciously. And, during the Obama years, the US Supreme Court weakened the Medicaid expansion provision by denying the federal government the authority to require expansion. As a result, when Obama left office, 19 states had still not expanded Medicaid.

More to the point, the prominence of the ACA as ground zero for political attacks from the Republican party never abated during the seven years between the ACA’s passage and the election of Donald Trump as president. Their rhetoric was unremittingly negative, and the Republicans vowed that once in office they would repeal the law forthwith.

But despite Republicans getting control of the White House and Congress in 2016, the repeal of Obamacare has not gone to plan. Two headwinds developed.

Firstly, it has proved difficult, if not impossible, for the Republican party to agree internally on the exact terms of ACA repeal. Secondly, the American public has begun to experience and notice benefits from the ACA that most people are now reluctant to give up. People with pre-existing conditions feared loss of insurance if the ACA requirements were weakened. The 31 states that had expanded their Medicaid programmes (many of them Republican states) were enjoying newfound federal dollars to cover impoverished patients whose care would otherwise have to be paid for by states and their local charities. And hospitals found that the formerly “free care” populations they had to serve without payment now had insurance coverage.

It seemed politically unwise to wrench those improvements from the public, but the far right wing of the Republican Party—the Freedom Caucus—refused to support any repeal-and-replace bill that maintained the federal subsidies and requirements that would have been required to avoid that implosion.

Effect of repeal bill

The bill that finally passed the US House of Representatives on 4 May 2017, in a close vote (217 to 213), acceded to many of the Freedom Caucus’s demands. It in effect would end the Medicaid expansion support (taking coverage away from about 14 million poor people and nursing home residents), end income based subsidies for purchase of policies in the exchanges (substituting inadequate age based subsidies), weaken guaranteed issue requirements, weaken community rating (thus putting insurance premiums for sicker people out of reach for millions), weaken coverage requirements (by permitting policies without such formerly required benefits as maternity care and mental healthcare), and begin to move Medicaid from a federal state partnership to a “block grant” in which states would assume much more risk for coverage costs. The bill also would end the ACA’s investment in a crucially important Prevention Fund, intended to advance the work of the US Centers for Disease Prevention and Control and others on social determinants of health and the upstream causes of illness.

The non-partisan Congressional Budget Office determined that if the House bill became law about 23 million people would lose coverage, federal Medicaid contributions would fall by more than $800bn over 10 years, and Americans in higher income brackets (about $250 000 annual income) would experience about $1tr in lower taxes over 10 years. Compared with the ACA, the House bill thus amounts to a transfer of about $1tr over 10 years from older, sicker, and lower income Americans to those in the top 2% of the income distribution.

More hurdles

Each chamber in Congress has to come up with its own bill and then reconcile them. So the American Health Care Act (AHCA) being proposed will be substantially changed. The legislative ball has now shifted to the US Senate, where more moderate Republican voices tend to be heard than in the House. Republican Senate leaders have publicly stated that the House bill cannot pass the Senate, and are apparently shaping their own repeal-and-replace proposal. What that will be, and whether the Venn diagram overlaps at all with what could pass the House, is yet to be known.

In the meantime, a minor but important chorus has been developing, almost as a sideshow, not yet embraced by any visible bipartisan Congressional leaders, and not at all by the White House. That voice identifies a discrete set of technical problems with the ACA, such as in the details of the supports for the individual and small group market on the exchanges, ways to encourage young and healthy people to obtain insurance, and providing reinsurance and other supports to insurance companies who find themselves covering riskier populations than they had estimated.

In happier, less partisan times, an enterprise to improve an important and largely successful law based on empirical evidence and experience would seem obvious. And the wisest path would not only repair the ACA but also go on to address the needs of the people—over 20 million of them—that, even with the ACA, still lack insurance. But, for the present, that productive approach seems, sadly, out of reach.

It should not go unnoticed that a vocal minority of critics of the current American health insurance system argue persistently that the most straightforward remedy would be, not the amalgam of financing of the ACA, but rather a “single payer” system—essentially Medicare for all. That idea has not yet gained political traction, largely because of the opposition of powerful lobbying interests, most importantly the healthcare insurance industry, which would stand to lose the most.

Massive step backwards

Whatever the next act will be in the ACA drama, perhaps the most important fact of all is that the United States, despite its wealth, remains the only Western democracy that has not embraced universal healthcare, explicitly or implicitly, as a human right.

The Affordable Care Act, though imperfect, was the largest step towards that goal that the US has taken since the creation of Medicare and Medicaid in 1965. The AHCA in anything like the form the House approved would be a massive and immoral step backwards, leaving tens of millions of Americans once again to face needless risk, greater suffering, and, for many, destitution. The hope is that wiser heads and more compassionate hearts will prevail among the nation’s leaders.

Donald M Berwick, a paediatrician by background, is a global authority on healthcare quality and improvement and a former administrator of the US Centers for Medicare and Medicaid Services.

Competing interests: I have read and understood BMJ policy on declaration of interests and declare I was administrator of the US Centers for Medicare and Medicaid Services between July 2010 and December 2011.

Provenance and peer review: Commissioned; not externally peer reviewed.

Current debates in health care policy: A brief overview

Subscribe to the economic studies bulletin, matthew fiedler and matthew fiedler joseph a. pechman senior fellow - economic studies , center on health policy @mattafiedler christen linke young christen linke young deputy assistant to the president for health and veterans affairs - domestic policy council for health and veterans, former fellow - usc-brookings schaeffer initiative for health policy @clinkeyoung.

October 15, 2019

Issues in health care policy fall in two broad categories: those related to health care coverage and those related to the underlying cost of health care. Coverage policy addresses where Americans get health insurance, how it is paid for, and what it covers, while policies related to underlying costs seek to reduce overall health care spending by lowering either the price or utilization of health care.

A Closer Look

Health care is a major issue in American politics, with important debates related to health care coverage and the underlying cost of health care. The role of health care coverage is to insulate people from high health care spending burdens and facilitate access to health care. Policies related to coverage include those affecting how Americans get health insurance, how that insurance is paid for, and what insurance does and does not cover. Debates about how to reduce the number of people without health insurance, whether Americans should continue to get coverage through their jobs, if health insurance deductibles are too high, or how to change the premiums required under federal coverage programs all fall into this category.

Many coverage policies change how much families have to pay for health care, generally by changing what government programs pay on their behalf or by changing how health care spending burdens are shared between people with larger and smaller health care needs. But other proposals aim to reduce the underlying cost of health care, either by reducing how many health care services patients receive or by reducing the prices paid for those services. Policies like these have the potential to reduce overall health care spending throughout the system, but this is often easier said than done.

Policies related to health care coverage

More than 90% of Americans have health insurance. About half get coverage from an employer, and a third get coverage from a government program like Medicare or Medicaid. Another 5% buy coverage on the individual market, while 9% are uninsured. Different policymakers see different problems with the way people get coverage today and, correspondingly, propose different solutions.

Some policymakers believe that current federal programs that provide health care coverage are too generous and inappropriately burden taxpayers. These policymakers often support proposals that would narrow eligibility for or reduce the generosity of those programs, particularly Medicaid and programs that subsidize individual market coverage, even though fewer people would have coverage and some people’s coverage would become less generous. President Trump has supported proposals like these .

Other policymakers are primarily concerned with reducing the number of uninsured or reducing the burdens people face from premiums and cost-sharing. These policymakers often support proposals that would broaden eligibility for existing coverage programs or make those programs more generous, even though it would require additional federal spending. Many Democratic presidential candidates have supported approaches like these . Some proposals focus primarily on people who are currently uninsured or face particularly high health care spending burdens, while others support a program like Medicare for All that would commit a great deal more federal funds and insure all Americans through a single federal program.

Learn more about broad proposals related to health care coverage here . In addition to these broad proposals, some policymakers also support proposals that target specific problems with our existing health insurance system. One example is the fact that people with insurance can sometimes receive large “surprise” bills for health care services, discussed more here .  

Policies related to underlying health care costs

Health care spending is determined by two factors: how many health care services patients receive and the prices paid for each service. While there is broad agreement that some health care services are unnecessary and that the prices of some services are excessive, there is much less agreement about how to address these excesses.

Starting with the volume of services patients receive, the main challenge policymakers face is discouraging delivery of services that provide little health benefit without discouraging delivery of valuable services. One approach is to give health care providers financial incentives to eliminate unnecessary services by paying them based on the overall costs their patients incur rather than the number of services they personally deliver. Reforms like these can reduce utilization, seemingly without harming patients’ health, although total savings have been relatively modest so far.

Another approach is to require consumers to bear more of the cost of care themselves by increasing cost-sharing in hopes that they will become more cost-conscious and forgo low-value services. Research finds that this approach can also reduce service volume, but consumers often cut back on both high-value and low-value services rather than just low-value services. Increasing cost-sharing also reduces the effectiveness of health insurance in protecting against the costs of illness.

Policymakers may also be interested in lowering health care prices. A major cause of excessive prices is that health care provider markets—particularly hospital markets—are concentrated , with relatively few competitors in many parts of the country. In addition, many patients value a broad choice of providers. These and other features of health care markets allow many providers to demand prices from private insurers that substantially exceed providers’ costs of delivering health care services.

Policymakers have some options for addressing high prices. One is to make health care markets more competitive . This may include encouraging new entrants, blocking mergers, and aggressively policing anti-competitive behavior. Another approach is to take advantage of the fact that public insurance programs generally pay much lower prices than private insurers by introducing a “public option” or transitioning to a single payer system. Alternatively, policymakers could lower prices by regulating them directly. No matter how policymakers aim to reduce prices, they will need to balance the savings from lower prices against the risk of driving prices too low and jeopardizing access to or quality of care. Prescription drug prices raise somewhat different issues. In most cases, the main reason drugs are expensive is because the government grants a time-limited monopoly to inventors of new drugs via patents and related policies. That monopoly allows manufacturers to set high prices, with the goal of encouraging development of new drugs. Correspondingly, most approaches to lowering prices boil down to reducing the scope or duration of manufacturers’ monopoly or limiting the prices manufacturers can charge while the monopoly lasts. But, here too, there are tradeoffs: the benefits of lower prices on existing drugs must be weighed against the reduction in incentives to develop new drugs.

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I Studied Five Countries’ Health Care Systems. We Need to Get More Creative With Ours.

By Aaron E. Carroll

Dr. Carroll is the chief health officer of Indiana University and writes often on health policy.

Although we just experienced a pandemic in which over one million Americans died, health care reform doesn’t seem to be a top political issue in the United States right now. That’s a mistake. The American health care system is broken. We are one of the few developed countries that does not have universal coverage. We spend an extraordinary amount on health care, far more than anyone else. And our broad outcomes are middling at best .

When we do pay attention to this issue, our debates are profoundly unproductive. Discussions of reform here in the United States seem to focus on two options: Either we maintain the status quo of what we consider a private system or we move toward a single-payer system like Canada’s. That’s always been an odd choice to me because true single-payer systems like that one are relatively rare in the world, and Canada performs almost as poorly as we do in many international rankings.

Moreover, no one has a system quite as complicated as ours.

A more productive debate might benefit from looking around the world at other options. Many people resist such arguments, however. They think that our system is somehow part of America’s DNA, something that grew from the Constitution or the founding fathers. Others believe that the health care systems in different countries couldn’t work here because of our system’s size.

I think those are bad excuses. Our employer-based insurance system is the way it is because of World War II wage freezes and I.R.S. tax policy, not the will of the founders. And much of health care is regulated at the state level, so our size isn’t really an outlier. We could change things if we wanted to.

In the first half of the year, I was privileged to visit five other countries and learn about their health care systems. In February I traveled to Britain and France with Indiana University’s Kelley School of Business and, more recently, with the Commonwealth Fund and AcademyHealth to New Zealand, Australia and Singapore.

Australia and New Zealand are two other countries with single-payer systems out there, although their systems differ greatly from Canada’s and from each other’s. Unlike our neighbor to the north, they allow private insurance for most care, which can be applied to pay for faster access with more bells and whistles. In addition, Australia’s system has fairly high out-of-pocket payments, in the form of deductibles and co-pays.

France’s system is close to a single-payer one because almost everyone gets insurance from one of a few collective funds, mostly determined by employment or life situations. They also have out-of-pocket payments and expect most people to pay upfront for outpatient care, to be reimbursed later by insurance. That’s something even the United States system doesn’t do.

Britain , on the other hand, has no out-of-pocket payments for almost all care. Private insurance is optional, as it is in other countries, to pay for care that may come faster and with more amenities. Relatively few people purchase it, though.

As I’ve written about before , Singapore has a completely different model. It relies on individuals’ personal spending more than almost any other developed country in the world, with insurance really available only for catastrophic coverage or for access to a private system that, again, relatively few use.

America could learn a thing or two from these other countries. We could take inspiration from them and potentially improve access, quality and cost. However, it’s important to frame our examination correctly. Focusing on these countries’ differences misses the point. It’s what they have in common — and what we lack — that likely explains why they often achieve better outcomes than we do.

Universal coverage matters, not how we get there.

The pandemic should have been an eye-opener in terms of how much work we need to do to repair the cracks in our health care foundation. Unfortunately, we seem to have moved on without enough focus on where we fall short and what we might do about it. It’s outrageous that the health care system hasn’t been a significant issue in the 2024 presidential race so far.

Even if we did have that national conversation, I fear we’d be arguing about the wrong things. We have spent the last several decades fighting about health insurance coverage. It’s what animated the discussions of reform in the 1990s. It’s what led to the Affordable Care Act more than a decade ago. It’s what we are still arguing about. The only thing we seem able to focus on concerns insurance — who provides it and who gets it.

No other country I’ve visited has these debates the way we do. Insurance is really just about moving money around. It’s the least important part of the health care system.

Universal coverage matters. What doesn’t is how you provide that coverage, whether it’s a fully socialized National Health Service, modified single-payer schemes, regulated nonprofit insurance or private health savings accounts. All of the countries I visited have some sort of mechanism that provides everyone coverage in an easily explained and uniform way. That allows them to focus on other, more important aspects of health care.

But the United States can’t decide on a universal coverage scheme, and not only does it leave too many people uninsured and underinsured; it also distracts us from doing anything else. We have all types of coverage schemes, from Veterans Affairs to Medicare, the Obamacare exchanges and employer-based health insurance, and when put together, they don’t work well. They are all too complicated and too inefficient, and they fail to achieve the goal of universal coverage. Our complexity, and the administrative inefficiency that comes with it, is holding us back.

When I was younger, I was more of a single-payer advocate, until I realized how many systems perform better than Canada’s. More recently, I favored the tightly regulated, entirely private insurance system of Switzerland because it performs exceptionally well using a private scheme I thought would be more palatable to many Americans. Today, though, I really don’t care how we get to universal coverage.

If we could agree on a simpler scheme — any one of them — we could start to focus on what matters: the delivery of health services.

Public delivery systems are essential, but so are private options.

What separates the countries I traveled to from the United States is that they largely depend on public delivery systems. Most people get their hospital care from a government-run facility. However, each country also has a private system that serves as a release valve. If people don’t like the public system, they can choose to pay more, either directly or indirectly, through voluntary private health insurance, to get care in a different system.

The care delivered in these public systems is often just as good, in terms of outcomes, as what is delivered in the private system. The same doctors often work in both settings. What is different is the speediness of care and the amenities that come with it. If you choose to get care in a public system, you often have to wait in line. Most often, the wait doesn’t lead to worse outcomes, and people accept it because it’s much cheaper than paying for private hospital care. Those who don’t want to wait, or feel they can’t, can pay more to jump the queue.

In fact, explicit tiering is a feature, not a bug, of all of these other systems. Those who want more can get more, even in Singapore’s public system. But more isn’t better care; it’s more choice in terms of physicians, private rooms, fancier food and even air conditioning. (While many Americans see the latter as a necessity, most people in Singapore — where it’s much hotter — don’t agree.)

In the United States, on the other hand, most care is provided by private hospitals , either for-profit or nonprofit. Even nonprofit systems compete for revenue, and they do so by providing more amenity-laden care. This competition for more patient volume leads to higher prices, and while we don’t explicitly ration care, we do so indirectly by requiring deductibles and co-pays, forcing many to avoid care because of cost . Our focus on what pays — acute care — also leads us to ignore primary care and prevention to a larger extent.

I’m convinced that the ability to get good, if not great, care in facilities that aren’t competing with one another is the main way that other countries obtain great outcomes for much less money. It also allows for more regulation and control to keep a lid on prices.

I’m not arguing it would be easy to expand the number of public hospitals in the United States. It would be politically difficult to expand the government’s role in delivering health care, directly or indirectly. But allowing people to choose whether to accept cheaper care delivered by a public system or to pay more for care in a private system might make this much more palatable. By doing so, we could make sure that good care is available to all, even if better care is available to some.

Strong social policies matter.

I have been to Singapore twice now to learn about the country’s health care system, and twice I’ve watched my hosts spend significant time showcasing their public housing apparatus. More than 80 percent of Singaporeans live in public housing , which involves more than one million flats that were built and subsidized by the government. Almost all Singaporeans own their own homes, too, even publicly subsidized ones; only about 10 percent of them rent.

Because of government subsidies, most people spend less than 25 percent of their income on housing and can choose between buying new flats at highly subsidized prices or flats available for resale on an open market.

This isn’t cheap. It’s possible, though, because the government is only spending about 5 percent of G.D.P. on health care. This leaves a fair amount available for other social policies, such as housing.

Other social determinants that matter include food security, access to education and even race. As part of New Zealand’s reforms, its Public Health Agency, which was established less than a year ago, specifically puts a “greater emphasis on equity and the wider determinants of health such as income, education and housing.” It also seeks to address racism in health care, especially that which affects the Maori population .

In Australia I met with Adam Elshaug, a professor in health policy at the Melbourne School of Population and Global Health. When I asked about Australia’s rather impressive health outcomes, he said that while “Australia’s mortality that is amenable to or influenced by the health care system specifically is good, it’s not fundamentally better than that seen in peer O.E.C.D. countries, the U.S. excepted. Rather, Australia’s public health, social policy and living standards are more responsible for outcomes.”

Addressing these issues in the United States would require significant investment, to the tune of hundreds of billions or even trillions of dollars a year. That seems impossible until you remember that we spent more than $4.4 trillion on health care in 2022. We just don’t think of social policies like housing, food and education as health care.

Other countries, on the other hand, recognize that these issues are just as important, if not more so, than hospitals, drugs and doctors. Our narrow view too often defines health care as what you get when you’re sick, not what you might need to remain well.

When other countries choose to spend less on their health care systems (and it is a choice), they take the money they save and invest it in programs that benefit their citizens by improving social determinants of health. In the United States, conversely, we argue that the much less resourced programs we already have need to be cut further. The recent debt limit compromise reduces discretionary spending and makes it harder for people to get access to government programs like food stamps. As Mr. Elshaug noted, doing the opposite would lead to better outcomes.

We are already doing what other countries can’t.

These other countries’ systems are not perfect. They face aging populations, expensive new technologies and often significant wait times — just like ours. Those problems can make some people quite unhappy, even if they’re not more unhealthy.

When I asked experts in each of these countries what might improve the areas where they are deficient (for instance, the N.H.S. has been struggling quite a bit as of late), they all replied the same way: more money. Some of them lack the political will to allocate those funds. Others can’t make major investments without drawing from other priorities.

Singapore might, though. With its rapidly aging population, it likely needs to spend more than the around 5 percent of G.D.P . Jeremy Lim, the director of the country’s Leadership Institute for Global Health Transformation and an expert on its health care system, said that while Singapore will need to spend more, it’s very unlikely to go above the 8 percent to 10 percent of G.D.P. that pretty much all developed countries have historically spent.

That is, all of them except the United States. We currently spend about 18 percent of G.D.P. on health care. That’s almost $12,000 per American . It’s about twice what other countries currently spend.

With that much money, any of these countries could likely solve the issues it faces. But spending substantially more on health care is something they feel they cannot do. We obviously don’t have that issue, but it’s intolerable that we get so little for what we spend.

We cannot seem to do what other countries think is easy, while we’ve happily decided to do what other countries think is impossible.

But this is also what gives me hope. We’ve already decided to spend the money; we just need to spend it better.

Source photograph by Oli Scarff via Getty

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Aaron E. Carroll  is the chief health officer  for and a distinguished professor of pediatrics at Indiana University. His show and podcast on health research and policy is “ Healthcare Triage .” @ aaronecarroll

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Course info, instructors.

• Prof. Christopher Warshaw
• Leah Stokes

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• Urban Studies and Planning
• Political Science

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• American Politics
• Public Policy

Learning Resource Types

Making public policy, paper 1: health care reform.

In March 2010, Congress passed and President Obama signed the Patient Protection and Affordable Care Act (“ACA”). Imagine that you are a senior advisor to an interest group that is trying to figure out why the ACA passed and how to influence the law going forward. You can choose one of the following two interest groups to address:

• The Club for Growth, a large conservative interest group that opposes the ACA.
• MoveOn.org, a large liberal interest group that supports the ACA and wants to further expand access to affordable health care.

Please write a five-page essay in which you make and defend an argument about why the bill passed and what the group should do now. In the course of your essay, you should address the following questions:

• How did changes in the political landscape open a policy window in 2009–2010 that made it easier to pass health care reform?
• How was the ACA designed to minimize the opposition of health care interest groups such as insurers, doctors, and hospitals that previously had opposed health care reform in the U.S.?
• How did legislative coalition leaders use techniques of persuasion, procedure, and modification to win over enough members of Congress to pass the bill?
• In the conclusion of your essay, provide a brief recommendation to the interest group on the political strategy it should pursue to modify the ACA. Remember that the Club for Growth would like to repeal or scale back the ACA, while MoveOn would like to further expand it. Your recommendations should be tailored to whichever interest group you choose to address. Your recommendations could include advocacy at either the state or federal level. Be sure to consider the political feasibility of your recommendation.

Student Examples

The examples below appear courtesy of MIT students and are used with permission. Examples are published anonymously unless otherwise requested.

The Affordable Care Act: How It Passed and Where to Go from Here (PDF)

The True Costs of the Affordable Care Act (PDF)

The Passage of the Affordable Care Act (PDF)

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United States Health Care Reform Progress to Date and Next Steps

The Affordable Care Act is the most important health care legislation enacted in the United States since the creation of Medicare and Medicaid in 1965. The law implemented comprehensive reforms designed to improve the accessibility, affordability, and quality of health care.

To review the factors influencing the decision to pursue health reform, summarize evidence on the effects of the law to date, recommend actions that could improve the health care system, and identify general lessons for public policy from the Affordable Care Act.

Analysis of publicly available data, data obtained from government agencies, and published research findings. The period examined extends from 1963 to early 2016.

The Affordable Care Act has made significant progress toward solving long-standing challenges facing the US health care system related to access, affordability, and quality of care. Since the Affordable Care Act became law, the uninsured rate has declined by 43%, from 16.0% in 2010 to 9.1% in 2015, primarily because of the law’s reforms. Research has documented accompanying improvements in access to care (for example, an estimated reduction in the share of nonelderly adults unable to afford care of 5.5 percentage points), financial security (for example, an estimated reduction in debts sent to collection of $600–$1000 per person gaining Medicaid coverage), and health (for example, an estimated reduction in the share of nonelderly adults reporting fair or poor health of 3.4 percentage points). The law has also begun the process of transforming health care payment systems, with an estimated 30% of traditional Medicare payments now flowing through alternative payment models like bundled payments or accountable care organizations. These and related reforms have contributed to a sustained period of slow growth in per-enrollee health care spending and improvements in health care quality. Despite this progress, major opportunities to improve the health care system remain.

CONCLUSIONS AND RELEVANCE

Policy makers should build on progress made by the Affordable Care Act by continuing to implement the Health Insurance Marketplaces and delivery system reform, increasing federal financial assistance for Marketplace enrollees, introducing a public plan option in areas lacking individual market competition, and taking actions to reduce prescription drug costs. Although partisanship and special interest opposition remain, experience with the Affordable Care Act demonstrates that positive change is achievable on some of the nation’s most complex challenges.

Health care costs affect the economy, the federal budget, and virtually every American family’s financial well-being. Health insurance enables children to excel at school, adults to work more productively, and Americans of all ages to live longer, healthier lives. When I took office, health care costs had risen rapidly for decades, and tens of millions of Americans were uninsured. Regardless of the political difficulties, I concluded comprehensive reform was necessary.

The result of that effort, the Affordable Care Act (ACA), has made substantial progress in addressing these challenges. Americans can now count on access to health coverage throughout their lives, and the federal government has an array of tools to bring the rise of health care costs under control. However, the work toward a high-quality, affordable, accessible health care system is not over.

In this Special Communication, I assess the progress the ACA has made toward improving the US health care system and discuss how policy makers can build on that progress in the years ahead. I close with reflections on what my administration’s experience with the ACA can teach about the potential for positive change in health policy in particular and public policy generally.

Impetus for Health Reform

In my first days in office, I confronted an array of immediate challenges associated with the Great Recession. I also had to deal with one of the nation’s most intractable and long-standing problems, a health care system that fell far short of its potential. In 2008, the United States devoted 16% of the economy to health care, an increase of almost one-quarter since 1998 (when 13% of the economy was spent on health care), yet much of that spending did not translate into better outcomes for patients. 1 – 4 The health care system also fell short on quality of care, too often failing to keep patients safe, waiting to treat patients when they were sick rather than focusing on keeping them healthy, and delivering fragmented, poorly coordinated care. 5 , 6

Moreover, the US system left more than 1 in 7 Americans without health insurance coverage in 2008. 7 Despite successful efforts in the 1980s and 1990s to expand coverage for specific populations, like children, the United States had not seen a large, sustained reduction in the uninsured rate since Medicare and Medicaid began ( Figure 1 8 – 10 ). The United States’ high uninsured rate had negative consequences for uninsured Americans, who experienced greater financial insecurity, barriers to care, and odds of poor health and preventable death; for the health care system, which was burdened with billions of dollars in uncompensated care; and for the US economy, which suffered, for example, because workers were concerned about joining the ranks of the uninsured if they sought additional education or started a business. 11 – 16 Beyond these statistics were the countless, heartbreaking stories of Americans who struggled to access care because of a broken health insurance system. These included people like Natoma Canfield, who had overcome cancer once but had to discontinue her coverage due to rapidly escalating premiums and found herself facing a new cancer diagnosis uninsured. 17

Percentage of Individuals in the United States Without Health Insurance, 1963–2015

Data are derived from the National Health Interview Survey and, for years prior to 1982, supplementary information from other survey sources and administrative records. The methods used to construct a comparable series spanning the entire period build on those in Cohen et al 8 and Cohen 9 and are described in detail in Council of Economic Advisers 2014. 10 For years 1989 and later, data are annual. For prior years, data are generally but not always biannual. ACA indicates Affordable Care Act.

In 2009, during my first month in office, I extended the Children’s Health Insurance Program and soon thereafter signed the American Recovery and Reinvestment Act, which included temporary support to sustain Medicaid coverage as well as investments in health information technology, prevention, and health research to improve the system in the long run. In the summer of 2009, I signed the Tobacco Control Act, which has contributed to a rapid decline in the rate of smoking among teens, from 19.5% in 2009 to 10.8% in 2015, with substantial declines among adults as well. 7 , 18

Beyond these initial actions, I decided to prioritize comprehensive health reform not only because of the gravity of these challenges but also because of the possibility for progress. Massachusetts had recently implemented bipartisan legislation to expand health insurance coverage to all its residents. Leaders in Congress had recognized that expanding coverage, reducing the level and growth of health care costs, and improving quality was an urgent national priority. At the same time, a broad array of health care organizations and professionals, business leaders, consumer groups, and others agreed that the time had come to press ahead with reform. 19 Those elements contributed to my decision, along with my deeply held belief that health care is not a privilege for a few, but a right for all. After a long debate with well-documented twists and turns, I signed the ACA on March 23, 2010.

Progress Under the ACA

The years following the ACA’s passage included intense implementation efforts, changes in direction because of actions in Congress and the courts, and new opportunities such as the bipartisan passage of the Medicare Access and CHIP Reauthorization Act (MACRA) in 2015. Rather than detail every development in the intervening years, I provide an overall assessment of how the health care system has changed between the ACA’s passage and today.

The evidence underlying this assessment was obtained from several sources. To assess trends in insurance coverage, this analysis relies on publicly available government and private survey data, as well as previously published analyses of survey and administrative data. To assess trends in health care costs and quality, this analysis relies on publicly available government estimates and projections of health care spending; publicly available government and private survey data; data on hospital readmission rates provided by the Centers for Medicare & Medicaid Services; and previously published analyses of survey, administrative, and clinical data. The dates of the data used in this assessment range from 1963 to early 2016.

Expanding and Improving Coverage

The ACA has succeeded in sharply increasing insurance coverage. Since the ACA became law, the uninsured rate has declined by 43%, from 16.0% in 2010 to 9.1% in 2015, 7 with most of that decline occurring after the law’s main coverage provisions took effect in 2014 ( Figure 1 8 – 10 ). The number of uninsured individuals in the United States has declined from 49 million in 2010 to 29 million in 2015. This is by far the largest decline in the uninsured rate since the creation of Medicare and Medicaid 5 decades ago. Recent analyses have concluded these gains are primarily because of the ACA, rather than other factors such as the ongoing economic recovery. 20 , 21 Adjusting for economic and demographic changes and other underlying trends, the Department of Health and Human Services estimated that 20 million more people had health insurance in early 2016 because of the law. 22

Each of the law’s major coverage provisions—comprehensive reforms in the health insurance market combined with financial assistance for low- and moderate-income individuals to purchase coverage, generous federal support for states that expand their Medicaid programs to cover more low-income adults, and improvements in existing insurance coverage—has contributed to these gains. States that decided to expand their Medicaid programs saw larger reductions in their uninsured rates from 2013 to 2015, especially when those states had large uninsured populations to start with ( Figure 2 23 ). However, even states that have not adopted Medicaid expansion have seen substantial reductions in their uninsured rates, indicating that the ACA’s other reforms are increasing insurance coverage. The law’s provision allowing young adults to stay on a parent’s plan until age 26 years has also played a contributing role, covering an estimated 2.3 million people after it took effect in late 2010. 22

Decline in Adult Uninsured Rate From 2013 to 2015 vs 2013 Uninsured Rate by State

Data are derived from the Gallup-Healthways Well-Being Index as reported by Witters 23 and reflect uninsured rates for individuals 18 years or older. Dashed lines reflect the result of an ordinary least squares regression relating the change in the uninsured rate from 2013 to 2015 to the level of the uninsured rate in 2013, run separately for each group of states. The 29 states in which expanded coverage took effect before the end of 2015 were categorized as Medicaid expansion states, and the remaining 21 states were categorized as Medicaid nonexpansion states.

Early evidence indicates that expanded coverage is improving access to treatment, financial security, and health for the newly insured. Following the expansion through early 2015, nonelderly adults experienced substantial improvements in the share of individuals who have a personal physician (increase of 3.5 percentage points) and easy access to medicine (increase of 2.4 percentage points) and substantial decreases in the share who are unable to afford care (decrease of 5.5 percentage points) and reporting fair or poor health (decrease of 3.4 percentage points) relative to the pre-ACA trend. 24 Similarly, research has found that Medicaid expansion improves the financial security of the newly insured (for example, by reducing the amount of debt sent to a collection agency by an estimated $600–$1000 per person gaining Medicaid coverage). 26 , 27 Greater insurance coverage appears to have been achieved without negative effects on the labor market, despite widespread predictions that the law would be a “job killer.” Private-sector employment has increased in every month since the ACA became law, and rigorous comparisons of Medicaid expansion and nonexpansion states show no negative effects on employment in expansion states. 28 – 30

The law has also greatly improved health insurance coverage for people who already had it. Coverage offered on the individual market or to small businesses must now include a core set of health care services, including maternity care and treatment for mental health and substance use disorders, services that were sometimes not covered at all previously. 31 Most private insurance plans must now cover recommended preventive services without cost-sharing, an important step in light of evidence demonstrating that many preventive services were underused. 5 , 6 This includes women’s preventive services, which has guaranteed an estimated 55.6 million women coverage of services such as contraceptive coverage and screening and counseling for domestic and interpersonal violence. 32 In addition, families now have far better protection against catastrophic costs related to health care. Lifetime limits on coverage are now illegal and annual limits typically are as well. Instead, most plans must cap enrollees’ annual out-of-pocket spending, a provision that has helped substantially reduce the share of people with employer-provided coverage lacking real protection against catastrophic costs ( Figure 3 33 ). The law is also phasing out the Medicare Part D coverage gap. Since 2010, more than 10 million Medicare beneficiaries have saved more than $20 billion as a result. 34

Percentage of Workers With Employer-Based Single Coverage Without an Annual Limit on Out-of-pocket Spending

Data from the Kaiser Family Foundation/Health Research and Education Trust Employer Health Benefits Survey. 33

Reforming the Health Care Delivery System

Before the ACA, the health care system was dominated by “fee-for-service” payment systems, which often penalized health care organizations and health care professionals who find ways to deliver care more efficiently, while failing to reward those who improve the quality of care. The ACA has changed the health care payment system in several important ways. The law modified rates paid to many that provide Medicare services and Medicare Advantage plans to better align them with the actual costs of providing care. Research on how past changes in Medicare payment rates have affected private payment rates implies that these changes in Medicare payment policy are helping decrease prices in the private sector as well. 35 , 36 The ACA also included numerous policies to detect and prevent health care fraud, including increased scrutiny prior to enrollment in Medicare and Medicaid for health care entities that pose a high risk of fraud, stronger penalties for crimes involving losses in excess of $1 million, and additional funding for antifraud efforts. The ACA has also widely deployed “value-based payment” systems in Medicare that tie fee-for-service payments to the quality and efficiency of the care delivered by health care organizations and health care professionals. In parallel with these efforts, my administration has worked to foster a more competitive market by increasing transparency around the prices charged and the quality of care delivered.

Most importantly over the long run, the ACA is moving the health care system toward “alternative payment models” that hold health care entities accountable for outcomes. These models include bundled payment models that make a single payment for all of the services provided during a clinical episode and population-based models like accountable care organizations (ACOs) that base payment on the results health care organizations and health care professionals achieve for all of their patients’ care. The law created the Center for Medicare and Medicaid Innovation (CMMI) to test alternative payment models and bring them to scale if they are successful, as well as a permanent ACO program in Medicare. Today, an estimated 30% of traditional Medicare payments flow through alternative payment models that broaden the focus of payment beyond individual services or a particular entity, up from essentially none in 2010. 37 These models are also spreading rapidly in the private sector, and their spread will likely be accelerated by the physician payment reforms in MACRA. 38 , 39

Trends in health care costs and quality under the ACA have been promising ( Figure 4 1 , 40 ). From 2010 through 2014, mean annual growth in real per-enrollee Medicare spending has actually been negative , down from a mean of 4.7% per year from 2000 through 2005 and 2.4% per year from 2006 to 2010 (growth from 2005 to 2006 is omitted to avoid including the rapid growth associated with the creation of Medicare Part D). 1 , 40 Similarly, mean real perenrollee growth in private insurance spending has been 1.1% per year since 2010, compared with a mean of 6.5% from 2000 through 2005 and 3.4% from 2005 to 2010. 1 , 40

Rate of Change in Real per-Enrollee Spending by Payer

Data are derived from the National Health Expenditure Accounts. 1 Inflation adjustments use the Gross Domestic Product Price Index reported in the National Income and Product Accounts. 40 The mean growth rate for Medicare spending reported for 2005 through 2010 omits growth from 2005 to 2006 to exclude the effect of the creation of Medicare Part D.

As a result, health care spending is likely to be far lower than expected. For example, relative to the projections the Congressional Budget Office (CBO) issued just before I took office, CBO now projects Medicare to spend 20%, or about $160 billion, less in 2019 alone. 41 , 42 The implications for families’ budgets of slower growth in premiums have been equally striking. Had premiums increased since 2010 at the same mean rate as the preceding decade, the mean family premium for employer-based coverage would have been almost $2600 higher in 2015. 33 Employees receive much of those savings through lower premium costs, and economists generally agree that those employees will receive the remainder as higher wages in the long run. 43 Furthermore, while deductibles have increased in recent years, they have increased no faster than in the years preceding 2010. 44 Multiple sources also indicate that the overall share of health care costs that enrollees in employer coverage pay out of pocket has been close to flat since 2010 ( Figure 5 45 – 48 ), most likely because the continued increase in deductibles has been canceled out by a decline in co-payments.

Out-of-pocket Spending as a Percentage of Total Health Care Spending for Individuals Enrolled in Employer-Based Coverage

Data for the series labeled Medical Expenditure Panel Survey (MEPS) were derived from MEPS Household Component and reflect the ratio of out-of-pocket expenditures to total expenditures for nonelderly individuals reporting full-year employer coverage. Data for the series labeled Health Care Cost Institute (HCCI) were derived from the analysis of the HCCI claims database reported in Herrera et al, 45 HCCI 2015, 46 and HCCI 2015 47 ; to capture data revisions, the most recent value reported for each year was used. Data for the series labeled Claxton et al were derived from the analyses of the Trueven Marketscan claims database reported by Claxton et al 2016. 48

At the same time, the United States has seen important improvements in the quality of care. The rate of hospital-acquired conditions (such as adverse drug events, infections, and pressure ulcers) has declined by 17%, from 145 per 1000 discharges in 2010 to 121 per 1000 discharges in 2014. 49 Using prior research on the relationship between hospital-acquired conditions and mortality, the Agency for Healthcare Research and Quality has estimated that this decline in the rate of hospital-acquired conditions has prevented a cumulative 87 000 deaths over 4 years. 49 The rate at which Medicare patients are readmitted to the hospital within 30 days after discharge has also decreased sharply, from a mean of 19.1% during 2010 to a mean of 17.8% during 2015 ( Figure 6 ; written communication; March 2016; Office of Enterprise Data and Analytics, Centers for Medicare & Medicaid Services). The Department of Health and Human Services has estimated that lower hospital readmission rates resulted in 565 000 fewer total readmissions from April 2010 through May 2015. 50 , 51

Medicare 30-Day, All-Condition Hospital Readmission Rate

Data were provided by the Centers for Medicare & Medicaid Services (written communication; March 2016). The plotted series reflects a 12-month moving average of the hospital readmission rates reported for discharges occurring in each month.

While the Great Recession and other factors played a role in recent trends, the Council of Economic Advisers has found evidence that the reforms introduced by the ACA helped both slow health care cost growth and drive improvements in the quality of care. 44 , 52 The contribution of the ACA’s reforms is likely to increase in the years ahead as its tools are used more fully and as the models already deployed under the ACA continue to mature.

Building on Progress to Date

I am proud of the policy changes in the ACA and the progress that has been made toward a more affordable, high-quality, and accessible health care system. Despite this progress, too many Americans still strain to pay for their physician visits and prescriptions, cover their deductibles, or pay their monthly insurance bills; struggle to navigate a complex, sometimes bewildering system; and remain un-insured. More work to reform the health care system is necessary, with some suggestions offered below.

First, many of the reforms introduced in recent years are still some years from reaching their maximum effect. With respect to the law’s coverage provisions, these early years’ experience demonstrate that the Health Insurance Marketplace is a viable source of coverage for millions of Americans and will be for decades to come. However, both insurers and policy makers are still learning about the dynamics of an insurance market that includes all people regardless of any preexisting conditions, and further adjustments and recalibrations will likely be needed, as can be seen in some insurers’ proposed Marketplace premiums for 2017. In addition, a critical piece of unfinished business is in Medicaid. As of July 1, 2016, 19 states have yet to expand their Medicaid programs. I hope that all 50 states take this option and expand coverage for their citizens in the coming years, as they did in the years following the creation of Medicaid and CHIP.

With respect to delivery system reform, the reorientation of the US health care payment systems toward quality and accountability has made significant strides forward, but it will take continued hard work to achieve my administration’s goal of having at least half of traditional Medicare payments flowing through alternative payment models by the end of 2018. Tools created by the ACA— including CMMI and the law’s ACO program—and the new tools provided by MACRA will play central roles in this important work. In parallel, I expect continued bipartisan support for identifying the root causes and cures for diseases through the Precision Medicine and BRAIN initiatives and the Cancer Moonshot, which are likely to have profound benefits for the 21st-century US health care system and health outcomes.

Second, while the ACA has greatly improved the affordability of health insurance coverage, surveys indicate that many of the remaining uninsured individuals want coverage but still report being unable to afford it. 53 , 54 Some of these individuals may be unaware of the financial assistance available under current law, whereas others would benefit from congressional action to increase financial assistance to purchase coverage, which would also help middle-class families who have coverage but still struggle with premiums. The steady-state cost of the ACA’s coverage provisions is currently projected to be 28% below CBO’s original projections, due in significant part to lower-than-expected Marketplace premiums, so increased financial assistance could make coverage even more affordable while still keeping federal costs below initial estimates. 55 , 56

Third, more can and should be done to enhance competition in the Marketplaces. For most Americans in most places, the Marketplaces are working. The ACA supports competition and has encouraged the entry of hospital-based plans, Medicaid managed care plans, and other plans into new areas. As a result, the majority of the country has benefited from competition in the Marketplaces, with 88% of enrollees living in counties with at least 3 issuers in 2016, which helps keep costs in these areas low. 57 , 58 However, the remaining 12% of enrollees live in areas with only 1 or 2 issuers. Some parts of the country have struggled with limited insurance market competition for many years, which is one reason that, in the original debate over health reform, Congress considered and I supported including a Medicare-like public plan. Public programs like Medicare often deliver care more cost-effectively by curtailing administrative over head and securing better prices from providers. 59 , 60 The public plan did not make it into the final legislation. Now, based on experience with the ACA, I think Congress should revisit a public plan to compete alongside private insurers in areas of the country where competition is limited. Adding a public plan in such areas would strengthen the Marketplace approach, giving consumers more affordable options while also creating savings for the federal government. 61

Fourth, although the ACA included policies to help address prescription drug costs, like more substantial Medicaid rebates and the creation of a pathway for approval of biosimilar drugs, those costs remain a concern for Americans, employers, and taxpayers alike— particularly in light of the 12% increase in prescription drug spending that occurred in 2014. 1 In addition to administrative actions like testing new ways to pay for drugs, legislative action is needed. 62 Congress should act on proposals like those included in my fiscal year 2017 budget to increase transparency around manufacturers’ actual production and development costs, to increase the rebates manufacturers are required to pay for drugs prescribed to certain Medicare and Medicaid beneficiaries, and to give the federal government the authority to negotiate prices for certain high-priced drugs. 63

There is another important role for Congress: it should avoid moving backward on health reform. While I have always been interested in improving the law—and signed 19 bills that do just that—my administration has spent considerable time in the last several years opposing more than 60 attempts to repeal parts or all of the ACA, time that could have been better spent working to improve our health care system and economy. In some instances, the repeal efforts have been bipartisan, including the effort to roll back the excise tax on high-cost employer-provided plans. Although this provision can be improved, such as through the reforms I proposed in my budget, the tax creates strong incentives for the least-efficient private-sector health plans to engage in delivery system reform efforts, with major benefits for the economy and the budget. It should be preserved. 64 In addition, Congress should not advance legislation that undermines the Independent Payment Advisory Board, which will provide a valuable backstop if rapid cost growth returns to Medicare.

Lessons for Future Policy Makers

While historians will draw their own conclusions about the broader implications of the ACA, I have my own. These lessons learned are not just for posterity: I have put them into practice in both health care policy and other areas of public policy throughout my presidency.

The first lesson is that any change is difficult, but it is especially difficult in the face of hyperpartisanship. Republicans reversed course and rejected their own ideas once they appeared in the text of a bill that I supported. For example, they supported a fully funded risk-corridor program and a public plan fallback in the Medicare drug benefit in 2003 but opposed them in the ACA. They supported the individual mandate in Massachusetts in 2006 but opposed it in the ACA. They supported the employer mandatein Californiain 2007 but opposed it in the ACA— and then opposed the administration’s decision to delay it. Moreover, through inadequate funding, opposition to routine technical corrections, excessive oversight, and relentless litigation, Republicans undermined ACA implementation efforts. We could have covered more groundmore quickly with cooperation rather than obstruction. It is not obvious that this strategy has paid political dividends for Republicans, but it has clearly come at a cost for the country, most notably for the estimated 4 million Americans left uninsured because they live in GOP-led states that have yet to expand Medicaid. 65

The second lesson is that special interests pose a continued obstacle to change. We worked successfully with some health care organizations and groups, such as major hospital associations, to redirect excessive Medicare payments to federal subsidies for the uninsured. Yet others, like the pharmaceutical industry, oppose any change to drug pricing, no matter how justifiable and modest, because they believe it threatens their profits. 66 We need to continue to tackle special interest dollars in politics. But we also need to reinforce the sense of mission in health care that brought us an affordable polio vaccine and widely available penicillin.

The third lesson is the importance of pragmatism in both legislation and implementation. Simpler approaches to addressing our health care problems exist at both ends of the political spectrum: the single-payer model vs government vouchers for all. Yet the nation typically reaches its greatest heights when we find common ground between the public and private good and adjust along the way. That was my approach with the ACA. We engaged with Congress to identify the combination of proven health reform ideas that could pass and have continued to adapt them since. This includes abandoning parts that do not work, like the voluntary long-term care program included in the law. It also means shutting down and restarting a process when it fails. When HealthCare.gov did not work on day 1, we brought in reinforcements, were brutally honest in assessing problems, and worked relentlessly to get it operating. Both the process and the website were successful, and we created a playbook we are applying to technology projects across the government.

While the lessons enumerated above may seem daunting, the ACA experience nevertheless makes me optimistic about this country’s capacity to make meaningful progress on even the biggest public policy challenges. Many moments serve as reminders that a broken status quo is not the nation’s destiny. I often think of a letter I received from Brent Brown of Wisconsin. He did not vote for me and he opposed “ObamaCare,” but Brent changed his mind when he became ill, needed care, and got it thanks to the law. 67 Or take Governor John Kasich’s explanation for expanding Medicaid: “For those that live in the shadows of life, those who are the least among us, I will not accept the fact that the most vulnerable in our state should be ignored. We can help them.” 68 Or look at the actions of countless health care providers who have made our health system more coordinated, quality-oriented, and patient-centered. I will repeat what I said 4 years ago when the Supreme Court upheld the ACA: I am as confident as ever that looking back 20 years from now, the nation will be better off because of having the courage to pass this law and persevere. As this progress with health care reform in the United States demonstrates, faith in responsibility, belief in opportunity, and ability to unite around common values are what makes this nation great.

Disclaimer: The journal’s copyright notice applies to the distinctive display of this JAMA article, and not the President’s work or words.

Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. The author’s public financial disclosure report for calendar year 2015 may be viewed at https://www.whitehouse.gov/sites/whitehouse.gov/files/documents/oge_278_cy_2015_obama_051616.pdf .

Additional Contributions: I thank Matthew Fiedler, PhD, and Jeanne Lambrew, PhD, who assisted with planning, writing, and data analysis. I also thank Kristie Canegallo, MA; Katie Hill, BA; Cody Keenan, MPP; Jesse Lee, BA; and Shailagh Murray, MS, who assisted with editing the manuscript. All of the individuals who assisted with the preparation of the manuscript are employed by the Executive Office of the President.

Universal Health Care: Arguments For and Against

Introduction, works cited.

The constant debates around the health care system in the United States, recently heated by the president’s health care reforms proposal, is a direct indication that the issue of health care in the United States is a painful subject. On the one hand, there is a support for the health care owned by the private sector, in which the medical treatment should be paid for ensuring higher efficiency, and on the other hand there are supporters of the opinion that health care is a right that should be accessible to everybody. The mutual point of intersection between the two groups is that both of them acknowledge that the current system needs reform (Roberts). Taking the position of the health care as a right accessible to everyone, “Sicko”, a 2007 documentary film by Michael Moore, outlined the effectiveness of such system – universal health care, showing and comparing the implementation of this system in practice in other developed countries such as Canada and France, and accordingly, pointing to the deficiencies of the current, based on insurance, health care in the United States. In that regard, this paper takes the position for universal health care, outlining the supportive arguments, as well as the arguments used by its opposition.

In the majority of universal health care system, the government’s involvement is the main approach in providing health care. In that regard, the sources of government coverage stem from general and dedicated taxation, and social insurance (McDougall, Duckett and Manku). Accordingly, it can be seen that the reliance on universal health care will lead the creation of more government positions.

Such point can be seen through Moore’s film, where the example of France is showing the social services provided by the government. Accordingly, it can be assumed that the necessity for such positions in any country adopting a universal health care system will lead to the creation of more government jobs.

Nevertheless, it should be stated that such positions imply limiting health care providers to the government, rather than that the payment methods will be regulated. In the example of France indicated in the film, the “The state sets the ceiling for health insurance spending, approves a report on health and social security trends and amends benefits and regulation”.

Following the previous argument, it can be said that government regulations will lead to a decrease in the doctors’ payment within a universal health care system. One point of controversy, which is held by the opposition of universal health care, is the possibility of health care quality reduction due to regulation of payments by the government and “enslaving the doctors”.

Looking at the representation of the doctors working in universal health care systems in Moore’s film, the doctors in Britain are paid by the government, and accordingly the system of commission implemented in Britain implies that the doctors are paid more when there are documented improvements in patients’ conditions. In such way, the doctors are interested in providing the best treatment for their patients, and at the same time the patient is sure that the aid he is receiving is not dependable on such factor as the doctors’ income.

Taking a look at other countries with universal health care such as France, where the fees are negotiable with the government, Switzerland, where the government negotiates rates with doctor organizations, and Netherlands, where insurers negotiate rates (McDougall, Duckett and Manku), it can be seen that such approach is definitely will not deprive the doctors of their rights, especially considering that negotiating imply a more flexible approach for the doctors, rather than regulation, where payments are regulated in government programs, as seen in the United States (Organization for Economic Development and Cooperation, The Commonwealth Fund and Henry J. Kaiser Family Foundation).

Finally, the most important argument, which can be considered as the criterion, based on which the health care system should be evaluated is the effectiveness seen through the results. In that regard, one of the arguments used in Moore’s film, in addition to the accessibility of the health care to everyone, is the results of such implementation on the overall health of the population. Taking the example of Great Britain in the film, a report from the AMA (American Medical Association) into the health of 55- to 64-year-olds says Brits are far healthier than Americans. That was only one example of the way the universal health care is more effective.

Taking life expectancy as a measure, the United States is the behind the such countries as Great Britain, United Kingdom, New Zealand, Italy, Canada, Sweden, Austria and France (McDougall, Duckett and Manku). Accordingly, in infant mortality rate as of 1999, the United States is ranked the last among the previously mentioned countries. In fact, the health care in the United States might have positive results in some areas, taking various positions surpassing the position of some of the countries in the list. However, it should be stated that considering the fact that “the U.S. spends far more per capita on health care than any other nation,” (Organization for Economic Development and Cooperation, The Commonwealth Fund and Henry J. Kaiser Family Foundation) it is not the leader in health among other developed countries.

Opposing the universal health care system, the arguments used vary in their effectiveness and accuracy, although some of them can be considered logical. Taking the example of the insurance company, one argument that might used can be seen in the statement that private insurance companies will go out of business. The as arguments is stemming from the fact that the current health system in the United States is largely operated by the private sector, either in provision of medical services or the insurance, where in terms of the latter the percentage of people covered by private health insurance was 67.5 as of 2007 (DeNavas-Walt et al.). Nevertheless, it can be stated that the universal health care system implies the option for private insurance companies, where taking the example of Switzerland the health system comprises of universal coverage, a mandate that everyone buy insurance and a major role for private insurance companies (McManus).

Omitting such factor as less payment for doctors, as previously explained in the example Britain, another important argument is overcrowded hospitals in universal health care systems. Such argument seems reasonable, where the examples of hospitals being overcrowded can be seen in such countries as Japan, Australia and others. In the case of Australia, Australian Medical Association stated that “there are 1500 unnecessary deaths in Australia due to overcrowding in public hospitals” (SHEPHERD). In that regard, such argument has sense, but nevertheless, it cannot be generalized on universal health care systems everywhere, rather than examples of funding issues might have led to such consequences in specific cases. Taking such factor as performance effectiveness, measured based on average length of stay, it can be seen that there are countries with universal health care that are leading with such indicators, which generally can imply that the type of health care system is not influencing such factor. Accordingly, such variables as the number of beds can be resulted from ineffective funding programs, rather than general health deficiencies.

It can be concluded that the universal health system is an option to hold to, specifically measuring such factors as costs and outcomes. Generally speaking, separate examples do not indicate the superiority of the system or its failure, while general trends examined through several developed countries shows the perspectives of such system. Universal health care is a step forward toward confirming the statement that health care is a right that is accessible to everyone.

“The State of Affairs in 16 Countries in Summer 2004”. World Health Organization . Eds. Grosse-Tebbe, Susanne and Josep Figueras. Web.

DeNavas-Walt, Carmen, et al. “Income, Poverty, and Health Insurance Coverage in the United States: 2007”. 2008. Census.gov . U.S. Government Printing Office. Web.

McDougall, Ashley, Paul Duckett, and Manjeet Manku. “International Health Comparisons”. National Audit Office . Web.

McManus, Doyle. “Switzerland’s Example of Universal Healthcare”. 2009. LA Times .Web.

“Sicko”. Dir. Moore, Michael. DVD. 2007.

Organization for Economic Development and Cooperation, The Commonwealth Fund, and Henry J. Kaiser Family Foundation. “Compare International Medical Bills”. 2008. National Public Radio . Web.

Roberts, Joel. “Poll: The Politics of Health Care”. 2007. CBS News . Web.

SHEPHERD, TORY. “Needless Hospital Deaths”. 2008. News Limited . Web.

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If you’re a nursing student, then you know how important it is to choose Great Healthcare argumentative essay topics.

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Strong Healthcare argumentative essay topics

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• Is there a nurse shortage in the United States? If so, what are the causes, and what can be done to mitigate it?
• What are the benefits and drawbacks of various types of Nurse staffing models?
• What are the implications of the current opioid epidemic on nurses and patients?
• Are there any ethical considerations that should be taken into account when providing care to terminally ill patients?
• What are the most effective ways to prevent or treat healthcare-acquired infections?
• Should nurses be allowed to prescribe medication? If so, under what circumstances?
• How can nurses best advocate for their patients’ rights?
• What is the role of nurses in disaster relief efforts?
• The high cost of healthcare in the United States.
• The debate over whether or not healthcare is a human right.
• The role of the government in providing healthcare.
• The pros and cons of the Affordable Care Act.
• The impact of healthcare on the economy.
• The problem of access to healthcare in rural areas.
• The debate over single-payer healthcare in the United States.
• The pros and cons of private health insurance.
• The rising cost of prescription drugs in the United States.
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There is no shortage of controversial healthcare topics to write about. From the high cost of insurance to the debate over medical marijuana, there are plenty of issues to spark an interesting and thought-provoking argumentative essay.

Here are some Controversial healthcare argumentative essay topics to get you started:

1. Is healthcare a right or a privilege?

2. Should the government do more to regulate the healthcare industry?

3. What is the best way to provide quality healthcare for all?

4. Should medical marijuana be legalized?

5. How can we control the rising cost of healthcare?

6. Should cloning be used for medical research?

7. Is it ethical to use stem cells from embryos?

8. How can we improve access to quality healthcare?

9. What are the implications of the Affordable Care Act?

10. What role should pharmaceutical companies play in healthcare?

11. The problems with the current healthcare system in the United States.

12. The need for reform of the healthcare system in the United States.

Great healthcare argumentative essay topics

Healthcare is a controversial and complex issue, and there are many different angles that you can take when writing an argumentative essay on the topic. Here are some great healthcare argumentative essay topics to get you started:

1. Should the government provide free or low-cost healthcare to all citizens?

2. Is private healthcare better than public healthcare?

3. Should there be more regulation of the healthcare industry?

4. Are medical costs too high in the United States?

5. Should all Americans be required to have health insurance?

6. How can the rising cost of healthcare be controlled?

7. What is the best way to provide healthcare to aging Americans?

8. What role should the government play in controlling the cost of prescription drugs?

9. What impact will the Affordable Care Act have on the healthcare system in the United States?

Hot healthcare argumentative essay topics

Healthcare is always a hot-button issue. Whether it’s the Affordable Care Act, single-payer healthcare, or something else entirely, there’s always plenty to debate when it comes to healthcare. Here are some great healthcare argumentative essay topics to help get you started.

1. Is the Affordable Care Act working?

2. Should the government do more to provide healthcare for its citizens?

3. Should there be a single-payer healthcare system in the United States?

4. What are the pros and cons of the Affordable Care Act?

5. What impact has the Affordable Care Act had on healthcare costs in the United States?

6. Is the Affordable Care Act sustainable in the long run?

7. What challenges does the Affordable Care Act face?

8. What are the potential solutions to the problems with the Affordable Care Act?

9. Is single-payer healthcare a good idea?

10. What are the pros and cons of single-payer healthcare?

Argumentative topics related to healthcare

Healthcare is always an ever-evolving issue. It’s one of those topics that everyone has an opinion on and is always eager to discuss . That’s why it makes for such a great topic for an argumentative essay . If you’re looking for some fresh ideas, here are some great healthcare argumentative essay topics to get you started.

1. Is our healthcare system in need of a complete overhaul?

3. Are rising healthcare costs making it difficult for people to access care?

4. Is our current healthcare system sustainable in the long term?

5. Should we be doing more to prevent disease and promote wellness?

6. What role should the private sector play in providing healthcare?

7. What can be done to reduce the number of errors in our healthcare system?

8. How can we make sure that everyone has access to quality healthcare?

9. What can be done to improve communication and collaboration between different parts of the healthcare system?

10. How can we make sure that everyone has access to the care they need when they need it?

Argumentative essay topics about health

There are many different stakeholders in the healthcare debate, and each one has their own interests and perspectives. Here are some great healthcare argumentative essay topics to get you started:

1. Who should pay for healthcare?

2. Is healthcare a right or a privilege?

3. What is the role of the government in healthcare?

4. Should there be limits on what treatments insurance companies must cover?

5. How can we improve access to healthcare?

6. What are the most effective methods of preventing disease?

7. How can we improve the quality of care in our hospitals?

8. What are the best ways to control costs in the healthcare system?

9. How can we ensure that everyone has access to basic care?

10. What are the ethical implications of rationing healthcare?

Medical argumentative essay topics

• Is healthcare a fundamental human right?

2. Should there be limits on medical research using human subjects?

3. Should marijuana be legalized for medicinal purposes?

4. Should the government do more to regulate the use of prescription drugs?

5. Is alternative medicine effective?

6. Are there benefits to using placebos in medical treatment?

7. Should cosmetic surgery be covered by health insurance?

8. Is it ethical to buy organs on the black market?

9. Are there risks associated with taking herbal supplements?

10. Is it morally wrong to end a pregnancy?

11. Should physician-assisted suicide be legal?

12. Is it ethical to test new medical treatments on animals?

13. Should people with terminal illnesses have the right to end their lives?

14. Is it morally wrong to sell organs for transplantation?

15. Are there benefits to using stem cells from embryos in medical research?

16. Is it ethical to use human beings in medical experiments?

17. Should the government do more to fund medical research into cancer treatments?

18. Are there risks associated with genetic engineering of humans?

19. Is it ethical to clones humans for the purpose

Argumentative essays on mental illness

• Should there be more focus on mental health in schools?
• Are our current treatments for mental illness effective?
• Are mental health disorders more common now than they were in the past?
• How does social media impact mental health?
• How does trauma impact mental health?
• What are the most effective treatments for PTSD?
• Is therapy an effective treatment for mental illness?
• What causes mental illness?
• How can we destigmatize mental illness?
• How can we better support those with mental illness?
• Should insurance companies cover mental health treatments?
• What are the most effective treatments for depression?
• Should medication be used to treat mental illness?
• What are the most effective treatments for anxiety disorders?
• What are the most effective treatments for OCD?
• What are the most effective treatments for eating disorders?
• What are the most effective treatments for bipolar disorder?
• How can we better support caregivers of those with mental illness?
• What role does stigma play in mental illness?

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