Conclusion

As the twenty-first century dawned, the evolution of health insurance in the United States and elsewhere had reached a point where significant new public policy decisions were increasingly demanded by the consumer groups, business, politicians, and health professionals (see Rashi Fein's work).

In all industrial nations, the rates of growth in total expenditures for healthcare were creating economic strains and social concern (see the report of the Government Committee on Choices in Healthcare). Particularly in the United States—with the highest percentage of its GNP devoted to healthcare—business, government, and consumer groups insisted on effective control of total healthcare expenditures. Some argued that the solution had to come from submitting healthcare to a competitive market. Others preferred government regulation through global budgets, delivery system reforms, and limitations on services that qualify for collective financing. Most reformers insisted that health insurance had to stop fueling uncontrolled growth in healthcare spending.

Expenditure control has major consequences for the social insurance aspect of health insurance schemes. Many European nations and Canada have sought to control total expenditures without sacrificing the healthcare component of their social insurance commitments. In the United States, many providers, social reformers, and the general public have demanded explicit commitment to the social insurance dimension of health insurance: a universal system that would guarantee a decent minimum of healthcare to every citizen. Reformers were particularly concerned to have the nation address the equity issue. During a thirty-two-month period in 1990-1992, one-fourth of the entire population outside of institutions were without health insurance for at least one month; more than one-third of the African-American population and nearly one-half of the Hispanic population found themselves excluded from coverage (Pear).

Growing public awareness of the size of the uninsured population and the vulnerability of the middle class to loss of job-related health insurance have led to growing dissatisfaction with the system and sparked a renewed interest in health insurance reform. Dozens of proposals emerged in the late 1980s and 1990s driven by several key questions. Should America continue its multiple payer, public-private system, or embark on a new path with a streamlined single-payer system? Should the single payer be the federal government or each state? If there were to be multiple payers, who would conduct the negotiations needed to coordinate their practices so that universal coverage would be achieved and maintained?

The multiple-payer approach continues the path of adapting casualty insurance and free-market forces to serve the social insurance function. In the mid-1990s, President Bill Clinton proposed a market-structuring, multiple-payer solution (White House Domestic Policy Council; Zelman), and was immediately criticized by sponsors of competing market proposals for interfering too much with market forces and not trusting them to achieve efficient allocations (Enthoven and Singer). Single-payer advocates, arguing that Clinton was fundamentally mistaken and that the private health insurance market was simply the wrong vehicle for achieving universal coverage and cost control, invoked the social insurance model, abandoning market pluralism in favor of uncomplicated universality and administrative efficiency achievable through centralized financing.

Finally, the Clinton proposal failed politically. Backing away from universal coverage, the Clinton Administration launched a special program to increase children's access to coverage in 1997 (Title XXI of the Social Security Act, the State Children's Health Insurance Program). By 1999, all fifty states had approved programs that either created a special program for children, an expansion of Medicaid, or some combination of the two. Despite success in reaching children, the percentage of Americans without health insurance has grown, costs have not come under control, and the critics of the status quo remain unable to attract sufficient political consensus to bring about universal coverage.

Health insurance in the United States continues to evolve. The tension between the casualty insurance practices and social insurance ideals frustrate reformers in both camps. The enduring challenge is to formulate policies that can control total expenditures while allocating resources fairly and promoting the common good.

MICHAEL J. GARLAND MERWYN R. GREENLICK (1 995) REVISED BY AUTHORS

SEE ALSO: Conflict of Interest; Corporate Compliance; Economic Concepts in Healthcare; Genetic Discrimination; Healthcare Institutions; Managed Care; Medicaid; Pharmaceutical Industry; Profit and Commercialism; Race and Racism; Sexism

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