美国医疗改革步履维艰——从其内生的两难境地切入
Introduction
In a White House ceremony on March 23,2010, President Barack Obama capped a year-long uphill battle by signing into law the Patient Protection and Affordable Care Act （“Affordable Care”）.David Leonhardt, a New York Times columnist, characterized this legislation as“the federal government's biggest attack on economic inequality since inequality began rising more than three decades ago, ”because it trims tax breaks and business subsidies and taxes the wealthy to pay for benefits that“flow mostly to households making less than four times the poverty level—$88,200 for a family of four people.”
Before 2010, powerful entrenched interests had defeated reform in America for almost one hundred years.The first attempt at broad health insurance was in the 1910s, but it was scotched by the insurance companies and the American Medical Association（AMA）.The second opportunity came in the 1930s, when President Roosevelt considered including health insurance in the Social Security legislation.It was left out because the AMA again mobilized against it.Harry Truman's effort to pass“compulsory health insurance”—probably not the best label—was derided as socialism.The next effort was in the 1960s, when reformers decided to start on universal insurance by introducing a bill that provided coverage for the elderly.This bill faced less opposition because the insurance companies did not really want to cover expensive, older, sick people—but Medicare did not lead to insurance for everyone.In fact, it pulled a major voting bloc, seniors, out of the fight for reform and gave conservatives a new scare tactic, convincing the elderly that Medicare might be cut back to pay for other people.In the 1970s, under Nixon and Carter, Democrats refused to accept a better deal than they would get now.And then there was the spectacular failure in 1993-1994 under Hillary and Bill Clinton that led to a Republican takeover of the Congress.
Struggling to this century of failed reform, the United States has been left with a health care system that is very unusual by international standards.Between the late 1800s and the end of World War Ⅱ, most other advanced, industrial nations created systems of universal health-insurance coverage.In America, a patchwork of policies leaves more than 46 million Americans uninsured.Most working-age people get their health insurance through their employers, while federal programs provide coverage for the elderly, military veterans, the poor, and families making incomes a little above the poverty line.Our nation pays an enormous premium for this inefficient, piecemeal system.The United States spends about twice as much per person as other major industrial countries do on average, and more than fifty percent more than the next-biggest spender, Switzerland.
In terms of the relationships between U.S.health care reform with politics, economic recession, financial support, shareholders and so on, The comment will focus on analyzing the instinctive dilemmas in the core of health care reform pushed up by Barack Obama and behind him, the Democratic Party and addressing proper innovative suggestions or landscapes, in order to speculate a promising approach to the on-going health care reform.
Dilemma:Pre-election or Mid-election
In terms of the popular vote, unlike the two presidential elections prior to 2008 which were not won decisively, Obama won presidential elections quite handily.His margin over the presidential runner-up, John McCain, was 53%to 46%in the total popular vote, and 365 to 173 in the Electoral College.At the same time, Congressional Democrats strengthened their margins in both the House and the Senate—carrying forward a partisan shift that started in 2006.Eventually, midway through 2009, when the protracted court battles in Minnesota were finally settled, the Democrats plus two Independents ended up with what the media trumpeted as a“filibuster proof”supermajority in the Senate.
The 2008 election was also marked by the mobilization of new blocs of voters into greater participation, as well as enhanced support for the Democratic Party.Younger voters raised their level of engagement; African-Americans turned out in droves to vote for the first African-American presidential candidate; and Latino voters increased their level of participation and shifted toward a greater margin of support for Democrats.
Obama also enjoyed an advantage that has been underlined in the research of political scientist Stephen Skowronek.Obama arrived at the presidency at a juncture when most Americans of all political persuasions were disillusioned with his predecessor, George W. Bush, and soured on the economic and foreign policy directions the country had taken under the sway of the Republican Party（which controlled both Congress and the Presidency from 2000 through 2006）.For a change-oriented president, this is the ideal situation:to come to office backed by his own party after the country has repudiated his predecessor.
In addition, it is good for a president who wants to use federal power vigorously to come to office during a deep economic downturn, when businesses and people are more open to government help.During the original New Deal, President Franklin Roosevelt and the Democratic Party were able to achieve immense social policy victories amidst the massive Great Depression.President Barack Obama took office just as the country plunged into the deepest economic downturn since the 1930s, as a result of an epochal financial meltdown.The advent of current downturn crisis helped President Obama and the Democrats build their margins of electoral victory against Senator McCain and the Republicans in the 2008 election.
Finally, Obama came to office after being unusually straightforward with the public about seeking to change the direction of federal social and fiscal policies, which I am willing to elaborate on.
Even at the height of speculation over a possible“New New Deal, ”some of the fundamental findings of American political science suggested caution.Electoral outcomes tend to swing back and forth, especially in midterm Congressional elections when one party has control of the presidency and both Houses of Congress.Unfortunately the survey shows up the demographics least enamored of Barack Obama.It has long been well documented that Americans are ideologically cautious about strong government or governmental activism.Americans have long been philosophical conservatives and operational liberals.This remains true and means that, even if the public may approve of many steps taken by President Obama and the Democrats, the reflexive anti-government worries of Americans can also be invoked by the political opponents of new measures.
Obama started out with sky-high public approval ratings, and quickly persuaded Congress to pass the American Recovery and Reinvestment Act（the so-called“Stimulus”）.The Stimulus was not as large or as bold as progressives wanted to see, but nevertheless inj ected nearly a trillion dollars into the economy and included“down payments”on new policy initiatives in education, clean energy production, and health care. With the national economy plunging into recession, the Republican Party nevertheless decided to mount vigorous opposition to President Obama's leadership.The White House devoted a major portion of the original Stimulus legislation to tax cuts for businesses, but in return got virtually no votes from Congressional Republicans, even as their home states clamored for fiscal relief.
Almost a year to the day after he was inaugurated, Obama watched his nominal supermajority disappear, Apparently, the“New New Deal”that appeared possible in early 2009 was dead in its tracks by early 2010.This included comprehensive health care reform, which had been debated in Congress for nine months and was on the verge of final enactment.
Dilemma:Incremental Shift or Radical Redirection
Early During the general election and the interminable Democratic Party primaries, Obama had spoken about redistributive issues in a way highly unusual for any Democratic presidential nominee in recent memory.He talked quite frankly about the need to do more to help average Americans, and he did not even back off from the proposition that rich families, making more than $250,000 a year, should pay higher taxes.No Democratic presidential candidate since the ill-fated Walter Mondale has been willing to talk so openly about raising taxes.
After inspecting the health policy developments, we come to understand quite a bit about what it takes to shift U.S.public policies in the direction of enhancing security for lower-income and lower-middle-income Americans.Furthermore, we will look forward, pinpointing the obstacles remaining to the full implementation of Obama's Affordable Care Act in a U.S.polity racked with partisan polarization and public anxieties about a prolonged economic downturn.“The New New Deal—What Barack Obama can learn from FDR—and what Democrats need to do”was the feature story in the November 24,2008 issue of Time magazine, which hit the newsstands not long after the historic 2008 elections.A striking mock picture appeared on the magazine cover—showing Obama wearing a fedora and riding FDR-style in an open convertible car, a cigarette in a silver holder dangling from his grinning lips.The cover story caught the mood of the moment, as many commentators suggested that the nation's first African-American president might have the potential to redirect U.S.public policies in a way comparable to the shift in direction marked by the New Deal of the 1930s.Put another way, it seemed that the Obama administration and the Democratic Party might begin to use public programs and tax measures to mitigate and reverse trends toward greater inequality that have marked American society in recent decades.Obama's presidency could be pivotal in the same way as FDR and Ronald Reagan before him, shifting the role of government in U.S.life.
Dilemma:Constitutional and Nullification or not
In response to the federal government's strong push toward national health care reform; as many as thirty-six state legislatures have taken steps to“Just Say No”to the federal health care overhaul package.the Utah State Legislature passed a bill that prohibits Utah state agencies from“implementing any part of federal health care reform‘unless'the Legislature...passes legislation specifically authorizing...the state's compliance.”In Arizona, the November 2010 ballot included a proposed amendment to the state constitution that would render any potential national health insurance mandate inapplicable to Arizona citizens and employers.States pushing back against federal health care reform（whether by resolution, bill, or state constitutional amendment）are making two independent arguments against such reform.First, states assert that current federal health care proposals constitute an unconstitutional infringement on state sovereignty as protected under the Tenth Amendment of the Constitution.[FN5]States argue that they retain power under the Tenth Amendment to regulate health care within their respective borders—a power that states contend was never ceded to the federal government.States are therefore vowing to legally challenge the constitutionality of federal health care reform as violative of the Tenth Amendment.
Second, in enacting measures to prohibit the implementation of federal health care reform within their borders, states are also asserting that they possess authority, independent of Supreme Court jurisprudence, to invalidate federal health care reform as it would apply to each state's respective citizens, employers, and agencies.This effort by states to independently invalidate federal health care reform is referred to as the doctrine of nullification.Generally, the nullification doctrine—and its close cousin“interposition”—hold that states are independent interpreters of the federal Constitution and that states can therefore declare federal laws unconstitutional and inapplicable within their respective borders.It is important to highlight that state nullification of federal law is completely independent from whether the federal judiciary（including the Supreme Court）considers the law constitutional.Under the theory of nullification, states themselves are independent interpreters and protectors of the federal Constitution and can therefore decide which federal laws are constitutional.
Current state opposition to national health care reform thus presents two important and independent legal questions:（1）whether federal health care reform is constitutional under current Supreme Court jurisprudence despite state claims that such reform violates the Tenth Amendment, and（2）whether states have authority to nullify or invalidate federal health care reform if they independently deem such legislation unconstitutional, regardless of Supreme Court precedent.
The first question concentrates on the constitutionality of federal health care reform under current Supreme Court jurisprudence, Most of these scholars conclude that the Supreme Court's broad interpretation of Congress's power under both the Commerce Clause and the Taxing and Spending Clause, combined with the Court's rather narrow view of the Tenth Amendment, suggest that federal health care reform is constitutional.
The second question is whether the doctrine of nullification allows states to independently invalidate federal health care reform within their respective borders.The doctrine of nullification traces back to Thomas Jefferson and James Madison who challenged unconstitutional federal action.By Using Jefferson's and Madison's arguments, states at various points throughout U.S.history have asserted their right to independently invalidate federal law within their borders.
Right or wrong being void of constitutional authority to nullify federal legislation, nullification can be employed by states as a powerful political tool in opposing federal legislation.As the majority of states move to nullify federal health care reform, state legislatures signal to the federal government that implementing such reform will be a difficult task as states will be sluggish to give effect to national health care reform within their borders.Not to mention that Widespread state opposition to national health care reform also places intense political pressure in an election year on those congressional leaders who voted for such reform.While maintaining the issue's political salience, it potentially enables conservatives to use the negativity surrounding health care reform to their benefit at the voting booth.
Dilemma:an Employer-based System or a Consumer Driven System
High expenditure, low efficiency and lack of fairness are the three major disadvantages of the U.S.health care system, long-standing abuse.The core of the health care reform proposed by Obama is to achieve“full coverage”and“low cost”, that is, by the way of the appropriate government intervention to achieve universal coverage, improve the health care system as the fairness of public goods; by adjusting the structure of Medicare spending to cut unnecessary expenses and improve the efficiency of health care system.
As health care premiums continue to rise, more and more businesses are cutting health care coverage for their employees.While 160 million Americans are insured under the current employment based system，the number of employers sponsoring coverage and the proportion of employees taking benefits when they are offered are being reduced.It has resulted in“job-lock”as employees are unwilling to change jobs out of fear of losing their employment-based health insurance.
Under a consumer driven system, the cost will be driven down as the patient are twenty percent more likely to follow treatment regimes very carefully.Employers have a limited role, only participating if they wish to contribute to the employee's Health Savings Accounts（MSA）, Flexible Spending Accounts（FSA）, or Health Reimbursement Arrangements（HRA）.All the programs push up patients to cut back in areas where there is presumed to be a lot of waste and to substitute less expensive treatment options for more expensive ones.However, since any employer contribution to one of these programs is taxdeductible, it is essentially a government subsidy, which reduces cost-effectiveness.It is estimated that by implementing a consumer driven health care system, Americans would pay about two-thirds what they pay today for health insurance.This is mainly due to the idea that when patients are paying for the health care services on their own, they are much more conscious of cost and will weigh the value of the service against the cost.However, critics claim that the system will result in high premiums for the elderly and ill individuals since they do not have the negotiating clout that businesses have under group plans.
Despite the complexities and costs of the existing private and public patchwork that makes up the nation's health care system, Democrats were committed to modifying the system rather than replacing it.
Democratic presidents and elected officials may agree that such a system would be more efficient and less costly in principle, but in practice they are not prepared to disrupt existing arrangements between employers and private insurance companies（which are major employers in their own right）.So Democrats since the 1970s have advocated reforms in existing arrangements.But preserving the employer core of the system also means taking a very mature system and simultaneously trying to improve its efficiency while expanding its reach.It means trying to squeeze out the resources to cover the uninsured, while readjusting existing institutions to operate more effectively and at lower cost.
Dilemma:Expanding the Reach or Providing Limited Financial Resource
The complex system referring to the health care disguises high risks.For doctors, getting paid requires filling out thousands of forms, without the certainty that an insurer will agree to pay.Hospitals have to cope with an unpredictable influx of uninsured people who appear in their emergency rooms.Many Americans, even those who are insured, face the risk that an illness can wipe out the family savings.In fact, catastrophic health care costs are the leading cause of bankruptcy in America.
We must keep in mind that this is a heavy lift politically.Most Americans do not believe that you can pay for 46 million more people and save money at the same time.No health care economists will convince them otherwise.Moreover, many powerful groups and economic interests have a stake in the current broken system—where one person's waste is another's cherished benefit or corporate profit.
When it came to financing health reform, Obama was quite specific in his recommendations.The first Obama budget, released at the end of February 2009, included more than $600 million in new taxes and cost-cutting measures, intended as a“down payment”on health care reform.In June 2009, Obama sent a letter to Senate Committee Chairmen Max Baucus and Edward Kennedy, in which he spoke in the broadest terms about what benefits should be included in health care reform, but explicitly outlining the budget cuts and tax increases he would recommend to pay for the bill.Focusing on the financing side of health care reform had important strategic consequences.First, the costcutting provisions helped identify up front which entrenched interests were going to lose out to make health care reform affordable.Second, Obama's advocacy on the funding sources also provided Democrats in Congress with support in the face of heavy industry lobbying, and cleared the way for negotiations.Third, and perhaps more important, Obama set a benchmark in terms of savings that created the room for some significant expenditures, and therefore expanded the scope of possible reform.
Conclusion
Regardless of how the future implementation struggles play out, the passage of the Affordable Care legislation in 2010 is a remarkable achievement, enough to support a claim that President Obama and the Democrats in Congress from 2009 to 2010 have fashioned parts of another New Deal.In a highly partisan atmosphere, in the midst of a burgeoning economic crisis, and with a smaller majority compared to other Democratic presidents who have pushed through major social reforms, President Obama piloted through a sea of entrenched interests and secured a wide-ranging and remarkably progressive health reform bill that draws resources from the privileged in order to spread access to affordable health insurance to most of the U.S.citizenry.
The enactment of the new laws in March 2010 marked a beginning, not an end, a promise of accomplishment, not a fait accompli.We believe that no perfect solution for the United States health care system, it is best to reform our current system as opposed to completely changing it.Though Hillary Clinton advocate for the more government involvement as a possible reformation, it's a distinct advantage around here to keep a cool head with that the increased government involvement leads to price controls and ultimately a reduction in services provided.America is a country built on choice and increased government involvement limits that choice.A better solution for America is to open state borders and to allow consumers to purchase health care, while Costs would be lowered“without imposing a large cost on taxpayers and without creating a new government bureaucracy.”By opening state borders, there is an increase in competition between the state health care markets, resulting in lower prices.
By opening borders, small businesses employing half the nation's workforce, which are discouraged from providing employee health care since they are subj ect to state mandates dealing with health insurance coverage, will be able to shop for lower premiums, and thus more businesses will be able to provide employees with coverage since they will be able to get the lowest premium coverage.
The United States should also establish more effective tort reform to help lower the cost of health care, considering malpractice lawsuits result in increased costs to consumers since physicians are forced to practice defensive medicine as well as purchase medical malpractice insurance.Simply reforming tort law could reduce medical care expenditures by 70 billion to 140 billion dollars per year.The major part of those savings would be to simply reduce unreasonable awards for non-economic damages, estimated to be between$60 and $108 billion dollars a year.This would ultimately reduce health care premiums and allow“an additional 2.4 to 4.3 million Americans to obtain insurance.”An open state border policy, fewer states mandates, and tort reform are expected to solve most of America's employer based health system problems.