Home Political Science & Law Journal Issue Article


2011/4 (No 143)

  • Pages : 224
  • ISBN : 9782707170071
  • DOI : 10.3917/her.143.0137
  • Publisher : La Découverte

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In 2001, the World Health Organization (WHO) ranked the health care systems of 191 countries. The United States placed 37th behind nearly all European countries, Oman, and Costa Rica. While this study’s methodology has since been questioned, its findings no less align with later comparative studies. For instance, a study published in June 2010 by the Commonwealth Fund ranked the United States behind Australia, Canada, Germany, New Zealand, and Great Britain in terms of health care access and quality. This low ranking is primarily due to the fact that many Americans cannot access health care because they are uninsured. According to the Census Bureau, 47 million people were uninsured in 2011. In addition to not being accessible to all, the quality of health care services is not the same for those who can access them. The quantity and quality of health care services vary greatly by geographical location, type of insurance policy, and the hospital dispensing care. The United States has neither a “universal” nor “standardized” public health care system. In addition, health care spending [1]  Annual health care spending is estimated at 2.5 trillion...[1] has risen sharply in recent decades and is straining the federal budget (16.2 percent of GDP in 2008 versus 11 percent in France in 2010). The public health care system is a complex and confusing network of insurance companies, hospitals, public and private laboratories, lobbies, independent doctors, and private charities, in a political context where many suspect the federal government of using health care reform to gain more control than is warranted. From its inception, the idea of a single-payer system, in which the federal government pays for and regulates public health care, sparked outcry. In effect, many assume that Americans will never accept so-called “socialized medicine,” although no serious study corroborates this assumption. The fact is that unequal access to care and rising costs remain urgent yet unresolved problems that have seriously worsened in recent years. As early as in 1910, this topic was addressed by Theodore Roosevelt during his presidential campaign under the Bull Moose Party and by the American Association for Labor Legislation. It resurfaced later during the New Deal, under Franklin R0osevelt, and had succeeding President Harry Truman, at the end of World War II, advocating for mandatory health insurance coverage for all. It again emerged during the presidencies of John Kennedy, Richard Nixon, Jimmy Carter, and, more recently, Bill Clinton, who, in 1993-1994, argued that health care was a universal right.


Since World War II, all industrialized countries have made health care a universal right except the United States, where “reformers” (as advocates of universal health care coverage are called) have faced such staunch opposition that most attempts to give all Americans health care coverage have failed. Reformers have, however, won some key victories, including the 1965 Social Security Act, which created two public insurance plans, Medicaid and Medicare, managed by the US Department of Health and Human Services (DHHS). Medicare [2]  Medicare covers some 44 million people (2008) at a...[2] covers seniors (over age 65) and Medicaid [3]  Medicaid covers some 40 million people (2007) at a...[3] the poor. However, the system remains a jumble of insurance plans and of public and private hospitals, without any overarching strategy. The system has worked well enough for enough people to avoid the threat of reform on multiple occasions. Today, it has become a massive and highly profitable industry.


Since Clinton’s failed attempt at reform in the early 1990s, no serious political discussion on health care reform has occurred in the United States. However, the over-crowding of emergency rooms – open to all, even the uninsured – and the astronomical costs of care without doubt point to a major systemic problem. The Congressional Budget Office (CBO) predicts the cost of federal health care programs like Medicaid and Medicare will rise from 5.5 to 12 percent of the GDP between 2011 and 2050. Reasons for this include the ever-rising costs of health insurance premiums and of private sector care. Inflation in this sector threatens the country’s economy, and reform is now unavoidable. In March 2010, Congress passed the Patient Protection and Affordable Care Act (PPACA, also referred to as the “Affordable Care Act”). Signed by President Obama on March 23, 2010, the Affordable Care Act extended Medicaid benefits to uninsured working-aged individuals and their children. The act also increased the number of services Medicare covers for the elderly, including preventive care. The reform also created a so-called marketplace, run by the states, for small companies, wherein health insurance companies compete for subscribers. Lastly, for the 176 million Americans already with health insurance (through employer or private plans), the new law mandates that, from 2014, private insurance companies may no longer deny coverage due to preexisting conditions. Today, companies use such conditions to vet potential subscribers and to set their risk load. Moreover, since autumn 2010, insurance companies have had to cover all children regardless of their health status and to allow children to remain on their parents’ plans until the age of 26. The reform also offers subsidies to people with incomes between 100 and 400 percent of the federal poverty level (e.g. a family of four with household income under 88,000 USD) to enable their purchase of health insurance.


It is now mandatory for each person to purchase insurance or else face fines. Companies with over 50 employees not offering medical coverage will also be fined, according to the number of uninsured employees they have. Small companies will receive tax credits to help pay for health insurance for their employees.


So tinged was health care reform with political ideology that the outcome of the congressional vote remained uncertain until the last minute. Heated disagreements about abortion threatened to derail the reform at any moment. Supporters of the reform were haunted by President Clinton’s earlier failed attempts. However, this time, it felt like the time was ripe: the health care system had become especially monstrous and unfair; Obama, a Democratic president, had a Democratic majority in Congress; the costs of health care had reached new summits and medical coverage for the middle classes and the poor had declined significantly with millions of Americans uninsured. The reform was a critical step in the history of the country’s social legislation much like the establishment of social security in 1935 by President Roosevelt, the civil rights laws signed in 1964 by President Johnson, or the creation of Medicare in 1965.


Due to the country’s federal structure, significant geographical differences exist in health care spending and social redistribution. According to the federal Constitution, public health is a matter for state governments, leaving the federal government with very limited authority in this area. In addition, health care is not subject to macroeconomic regulation. The activities of the DHHS and the federal agencies it oversees are limited to regulating product safety, fighting epidemics, conducting medical research, assisting with quality-control and assessments, and managing pensions and health insurance covered by the federal budget via the Center for Medicare and Medicaid Services (CMS). The only health care institution the federal government runs is under the US Department of Veteran Affairs for the military – the Veterans Health Administration – (VA). It has no authority over institutions or health care professionals. No single system of American health care exists since each state makes and enforces its own regulations regarding health care. The country is a composite of systems of coverage and benefits run by individual states. Numerous models exist, from Texas with the costliest health care system and one of the highest percentages of uninsured people, to Massachusetts, which has had a universal and mandatory health care system since 2006. However, in all states, the health care sector was privatized in the early twentieth century. This shaped the overall construct and it became a given. According to the country’s capitalist ideology, the best type of social insurance is full-time employment. Federal administrations always sought to sustain economic growth and to lower unemployment instead of strengthening social welfare. President Obama’s reform was bold enough to tackle inequality in health care by creating a system to make health insurance mandatory and to regulate the rising cost of care, which was bankrupting families. A study by Harvard Medical School in five states found that, in 2001, 46.2 percent of bankruptcies were due to health care expenses. That proportion rose to 62.1 percent in 2007. In order to understand the reform under way, we must examine the current state of the health care system and its history. Disparities in terms of the health standard among different ethnic groups and of services available in different geographic areas have been rising since 1983. These certainly constitute an additional challenge to implementing this reform, which was a key topic in the 2012 elections.

How Did We Get Here?


One of the first companies devoted exclusively to insurance services was Lloyds of London. It was created in the late seventeenth century to protect the interests of traders of the British Empire and served as a model for many other companies. In the United States, the first private insurance company was born much later, during the colonial period when Benjamin Franklin created a company that insured the houses of Philadelphia against fires. Not until the early twentieth century did the idea of medical insurance emerge. At the time, the development of sanitation techniques to prevent infections, deeper knowledge about opiates as pain-killers, and greater mastery and wider practice of surgery had turned hospitals from places where people had a slim chance at survival to places where people came to be healed. All these factors ushered in the modern era of medicine. Meanwhile, doctors had created formal training programs and protocols for official certification, which gave them legitimacy and priority over healers from earlier days. As medicine advanced, new costs emerged. Doctors and hospitals began charging higher fees to compensate for their investment in training and supplies. In the 1920s, health care costs had risen so high that many Americans could no longer afford the fledgling institutionalized health care system. The Great Depression only worsened the situation. It cost more to spend a week in the hospital than most Americans made in a month. The idea that people assume collective responsibility for each other’s medical costs – like earlier traders had done for other things – began circulating, and health insurance was born. Some European industrialized countries began offering health insurance to all citizens through governmental organizations or entities funded by the government, thereby distributing the financial burden of medical costs across the entire population. Health care was becoming a right. This right became official in 1948 when the WHO was created. Reformers from California and New York urged the United States to follow suit, but were met with staunch political opposition. Large companies feared that making the government responsible for public health would lead to federal interference in other areas, namely the economy, which they firmly opposed. Private insurers were not ready to give up a highly promising market and even doctors rejected the idea of government interference in their practices. Doctors formed a lobby so powerful in the first half of the twentieth century that Franklin Roosevelt withdrew the provision on health insurance from the law on social security in 1935 to avoid upsetting the American Medical Association (AMA). Had he not, it would have quashed the entire bill. Hospitals were also struggling with inflation. During the economic boom leading up to the crisis, hospitals had improved, grown, and acquired the most modern equipment, which now had to be paid for by being made profitable. In 1929, on the brink of bankruptcy in the middle of the economic recession, Baylor Hospital in Dallas, Texas, hired a new administrator, Justin Kimball, who had recently obtained a degree in public administration. Kimball suggested this to his colleagues: for all teachers willing to pay a monthly fee of 50 cents, up to 20 days of hospitalization and complete care. Seventy-five percent of teachers in the region subscribed to the plan. On the first day of the Christmas holidays in 1929, a teacher broke an ankle and went to the emergency room at Baylor, becoming the first American whose health care costs were covered by modern hospitalization insurance. Soon after, Baylor was being copied by other hospitals, which improved on the original model. In Sacramento, California, and then in New Jersey, hospitals began coming together to offer plans whereby the insured could receive care in any of the hospitals in the group. This was the first multi-hospital insurance plan. In 1934, the founder of a health insurance company in Saint Paul, Minnesota, decided to place a blue cross on his advertising posters. The symbol had a significant impact. Four years later in 1938, 2.8 million people had subscribed to “Blue Cross,” which had opened offices throughout the country. For the sake of financial viability, Blue Cross and Baylor tailored their plans to groups of employees in companies instead of to individuals. They sometimes offered plans through local associations like the Elks Club. [4]  The Elks Club (full name, The Benevolent and Protective...[4] Just before World War II, for-profit insurers entered the health insurance market, directly competing with hospitals. During the war, tax credits for employers offering social benefits incited employers struggling with a scarcity of qualified workers to offer health insurance to their workers and employees. Health insurance thus became tied to employment and companies assumed responsibility for the well-being of their human resources.


As the economy grew, health insurance was a way for companies to secure the trust and loyalty of their employees and to silence calls for federally-run, universal, health insurance. The National Labor Relations Board – an independent agency with the task of holding union elections and investigating illegal practices in the workplace – even ruled, with unions’ approval, that health insurance could be subject to collective bargaining, thereby making it negotiable. However, the idea of national health insurance was not left by the wayside. In the late 1940s, President Truman, supported by the AFL-CIO, [5]  The American Federation of Labor and Congress of Industrial...[5] formally proposed universal medical coverage. When McCarthyism took hold during the Cold War, “Truman’s socialized medicine” became a target for the crusade against the threat of communist influence. Some unions withdrew their support for public health care, including the powerful United Mine Workers, which feared losing the benefits its members were already receiving at the time. Without support, Truman’s initiative failed. In the next 20 years, the economy prospered and social benefits increased. Companies were generous and the vast majority of Americans with full-time employment received health insurance from their employers. During this period, most Americans had access to health care, which, while helping to improve medical technology, also caused hospitals to incur debt, thereby driving up health care costs. Moreover, economic growth concealed an undercurrent of inflation. Eventually, the economy faltered and prosperity ended. In the 1980s, corporations, as the cornerstones of the American economy, had to face foreign competitors able to produce at lower cost, and they were forced to cut spending. The so-called negotiable social benefits were the first to go. Due to the rising costs of premiums, more and more workers opted for work contracts without health insurance, even when their company offered it. In the 1990s, companies like Wal-Mart (which now employs 1.4 million people [6]  Wal-Mart employs 2.1 million people in the world and...[6]) began cutting the social benefits for people who had worked for the company full-time for at least two years. In 2005, less than half of Wal-Mart employees had health insurance, well below the national average. Companies under contract with unions were forced to pay such high premiums that health insurance became a scapegoat for all economic woes. In 1993, for instance, General Motors announced that health insurance for its employees added over 700 USD to the cost of each car, or roughly the cost of installing air-conditioning in a Chevrolet. In 2004, it was even rumored that health insurance had driven American society to the brink of bankruptcy.


In the name of profitability, insurance companies always prioritized comprehensive plans for large employers, leaving freelancers and small companies struggling to find reasonably priced health insurance plans. In the 1990s, insurance companies began screening future members. When Blue Cross offered its first plans in 1930, its goal was to make health insurance affordable to as many as people possible without discrimination. To reach its goal, it charged reasonable premiums that were the same regardless of age, sex, or current health status (although the premiums of individual subscribers were slightly higher than those of people covered by company plans). Blue Cross thus implemented an insurance system whereby people in good health covered costs of the sick, in line with the 1932 recommendation of the Committee on the Costs of Medical Care. Blue Cross, however, was a private company and, while its founders were humanists on a mission to extend health insurance to everyone, its primary goal was to serve the interests of the hospitals that created it. Plans from Blue Cross were exempt from taxation. In fact, politicians not only appreciated its improving the well-being of their constituents, they also saw it as a safeguard against calls for national health insurance: in 1950, over 20 million people had subscribed to Blue Cross, which strengthened the private insurance sector while silencing calls for universal national insurance. Over the years, for-profit insurers broadened their offer, including disability coverage: if a subscriber fell ill and was unable to work, the insurance company would cover the insured’s salary. Initially, these disability policies only covered certain types of sicknesses and accidents, but they were soon expanded to cover nearly all instances in which hospitalization or surgery was required. Soon after, insurers raised premiums across the board to cover the cost of these policies since the people most likely to buy them already had serious health problems or worked dangerous jobs. A vicious cycle began, which the insurance industry called “adverse selection,” a term referring to the tendency of voluntary insurance systems to attract the greatest financial risks. In effect, increasing premiums partly discouraged people in good health from buying health insurance, which left companies with subscribers who were already sick or working dangerous jobs.


Until this point, adverse selection had been a great enough risk to keep large insurers like Prudential off the individual health insurance market. However, once Blue Cross had demonstrated that health insurance was a profitable activity when offered through companies to large groups of employees, for-profit insurers were quick to move into the market. In the 1950s, Prudential, Aetna, Metropolitan Life of New York and of Connecticut, and General Life Insurance Company (later Cigna) flocked to this burgeoning market. Their arrival sparked a drastic change: it took ethics out of the industry. Unlike Blue Cross, for-profit insurers did not strive to serve the public interest or even the interests of hospitals. Their objective was to maximize profits. For this reason, they began vetting their subscribers and restricting plans to healthy people. They created individual rates based on subscribers’ health status, which could be adjusted yearly, and implemented selection criteria like age, sex, profession, and even race. Many for-profit insurers withdrew from insuring individuals, which they considered too costly and risky. For-profit insurance companies determined access to their plans and premium amounts according to the risk presented by subscribers, thereby abolishing the principle of an egalitarian ethos – at the heart of European national health care plans – and the communitarian and cooperative nature of Blue Cross in its early years. When subscriptions to these for-profit plans outnumbered those of Blue Cross in the 1950s, the company gradually had to forgo its founding principles. In 1986, Congress voted to revoke its tax-exempt status, thus forcing it to prioritize profit over its founding philosophy. However, the creation of Medicare and Medicaid in the 1960s relieved Blue Cross of a burden by allowing it to drop individual subscribers with the highest risks, namely the elderly and the very poor, with a clear conscious. For-profit insurance providers became increasingly aggressive on this now competitive market. In 1968, Odin Anderson (1971), [7]  Anderson is Professor of Sociology in the Graduate...[7] a leading American expert on health insurance, noted that the basic concepts of community and solidarity had simply vanished. Due to the economic decline in the early 1970s, employers backed away from the role of managing social benefits (retirement and health insurance plans) for their employees. Less concerned than in the past with gaining their employees trust, American companies gradually came to reject this role. As a result, the management of financial assets (retirement and health insurance funds) fell to third-party companies. The scandal of the car manufacturer Studebaker, in which many workers lost their retirement, led to the introduction of regulations to prevent the misuse of retirement funds. The Employment Retirement Income Security Act (ERISA), enacted in 1974, legislated federal authority to regulate social benefits plans, including health insurance. ERISA set standards for the social benefits offered by companies, without, however, requiring companies to provide health insurance to their employees. Thus companies, only had they to comply with the statute if chose to do so. With this federal law, any remaining hope for universal national insurance evaporated. Whereas close relations between the medical world, politicians, and business leaders have today given the United States cutting-edge medicine, they also turned health care into a major market with few regulations and safeguards. The ambiguity of a complex law that allowed companies to reject the heaviest and costliest risks left millions of Americans with limited health care coverage or none at all.

A Complex System for a Plural America


In the twenty-first century, public health in the United States is maintained by a patchwork of commercial vendors. The degree of respect they show subscribers and their needs is determined by the ethical values of businesspeople who are overseen to some degree by federal, state, and local government attempts at regulation of a system over which they have very little authority. In fact, the principal regulations are imposed by the market itself and are microeconomic: supply control, certain constraints placed on the insured and limits to the services covered in integrated care networks, and pricing schemes based on sickness type or homogenous groups of sick people in hospitals (Duhamel 2002). In the labyrinth of institutions, laws, and regulations, researchers in the social sciences often struggle to make sense of this complex system, and experts in population geography have a hard time drawing up public health maps. In addition to having a complex medical care delivery system, the United States is also a diverse country with many races, socioeconomic environments, and lifestyles.


In an article in the New Yorker, Gawande (2009) highlighted the diversity of care across regions and the difficulty of assessing quality. He took the example of McAllen, Texas (Hidalgo County), to show the abuses and backwardness of the system; and the example of the Mayo Clinic in Rochester, Minnesota, to show how free enterprise can, in fact, stimulate creativity and produce effective models. Located on the border with Mexico, McAllen has one of the lowest average household income levels in the country, although the commercial shipping industry keeps the unemployment rate below 10 percent. McAllen also has one of the country’s highest per capita health expenditures. In 2006, Medicare spent 15,000 USD per recipient, twice the national average. McAllen’s average per capita income is 12,000 USD; 38 percent of the population is obese; and due to poverty, alcoholism, and greasy Tex-Mex food, McAllen’s population is not in good health. The same applies to other cities along the Mexican border, which share similar populations and behaviors. In McAllen, however, health care providers are more active than anywhere else, and Gawande claimed that medical services are being used excessively. One surgeon interviewed for his study explained that, “Before [1990], it was about doctors doing good work [...]. Now, it’s about bringing money in.” Between 2005 and 2006, patients from McAllen received many more ultrasounds and underwent more blood, urine, and other tests than inhabitants from the neighboring counties; biopsies, knee and hip replacements, and pacemakers were commonplace. Yet the population’s health remained low. Gawande reported that too many doctors in McAllen have become businessmen. They own laboratories, surgical centers, hospitals, and even shopping centers and rental properties, and know how to protect their own interests as much if not more than those of their patients. McAllen is an extreme example of a wider phenomenon broadly present in different regions that is driving up the cost of care. In 2011, an article in the New York Times by Bogdanich and McGintry corroborated Gawande’s findings. It underscored the growing concern of Medicare and radiologists over the excessive use of scanners. The article argued that hundreds of hospitals are needlessly exposing patients to radiation from scanners – for economic rather than medical reasons. In 2006, for instance, US doctors conducted 60 million surgical procedures, or one for every six Americans (Cullen et al. 2009). No other country uses the blade so liberally. One sixth of the federal budget goes to health care expenses (doctors, hospitals, medications, treatments, tests, etc.). In fact, in a speech at the White House in March 2011, President Obama announced that the greatest threat to the US budget was neither security nor economic bailouts, but, by far, the drastic and uncontrolled rise in health care spending. His reform aims to make health insurance universal and to implement price controls. In McAllen, the absence of strict local regulation has led to the emergence of a “for-profit culture” that gradually eroded the ethics of the medical profession and drove up prices. Woody Powell, a sociologist at Stanford who specializes in this topic, argues that companies or powerful organizations can influence the development trajectories of cities and determine their “economic culture.” For example, Genentech made south San Francisco a hub for the biotech industry. The same phenomenon is occurring elsewhere. All it takes is for one well-known laboratory to start paying doctors for referrals. Before long, doctors refer all patients to the same laboratory.


This economic culture phenomenon can also work in the other direction and ethical practices can also become normative when influential actors endorse them. In the relatively unregulated US system, effective approaches that are mindful of the quality of care and of keeping costs down do exist. One example is the Mayo Clinic, whose slogan, “putting patients first,” is written on the walls to remind staff members of the values of the clinic’s founder, Dr. William Worrall Mayo, and of his commitment to those who are ill. At the clinic, doctors, nurses, and other staff (including security guards and cleaning crew) meet regularly and work together to find ways to improve the clinic. The clinic encourages all initiatives aimed at improving services, and the quality of care is constantly being discussed. Its doctors are salaried and the quantity of treatments or tests has no impact on how much they earn. The ethics of the clinic, the values of its staff, and the quality of its treatments have attracted many doctors. Two new Mayo Clinics were opened in 1986, in Florida and then in Arizona. Employing over 55,000 doctors, nurses, and medical personnel, it is today one of the cheapest hospitals, yet the quality of its services remain well above average. Independent doctors have taken other initiatives, such as creating an association that combines ethics and price controls in the Grand Junction region of Colorado. They standardized their prices in order to avoid vetting patients. Whether the patient has Medicare, Medicaid, or a private plan, the cost of care is the same. At the request of the city’s largest insurer, an HMO, [8]  A health maintenance organization (HMO) is a health...[8] they regularly meet in small groups to discuss patients’ files, diagnoses, and the best treatment options to minimize costs while maximizing the quality of care. In 2004, doctors from the Grand Junction association and the HMO group joined forces in creating a shared regional information network – a digitized local system doctors use to compare notes, test results, and other information about patients. This approach has been copied by other HMOs and associations of doctors, such as Geisinger Health System in Danville, Pennsylvania; the Marshfield Clinic in Marshfield, Wisconsin; Intermountain Health Care in Salt Lake City, Utah; and Kaiser Permanente in California and Hawaii. All operate according to similar principles: they are non-profit organizations that supply quality health care to all their subscribers.


Effective programs do exist locally, yet, overall, the US public health system is inequitable and outcomes are unequal. In too many regions, the Hippocratic Oath has been supplanted by a profit-driven logic that has turned health care into a service and sometimes even a luxury, thus gradually moving away from the WHO founding principle of health care as a fundamental right of every human being.


Further, since 1974, ERISA, as we saw earlier, regulates from the negative, not mandating that employers provide health insurance to their employees. This law also groups insurance plans together and divides their various components into categories that fall under varying jurisdictions (ERISA/state governments/federal government). Its stipulations on health care are ambiguous, complicated, and confusing. With distinctions not always clear, much is left to interpretation, as evidenced by the high number of lawsuits. The act is bandied about whenever a county creates a program to offer its residents medical coverage. In 2006, for example, the Golden Gate Restaurant Association (GGRA) claimed that the city of San Francisco’s “Healthy San Francisco” (HSF) program violated ERISA. Spearheaded by Mayor Gavin Newson in 2005, HSF provides universal access to health care to all city residents without insurance or Medicaid, regardless of immigration and job status or preexisting conditions. All city residents with annual income levels below 300 percent of the poverty line, who are not covered by Medicaid (or individuals earning 32,670 USD yearly or families of four earning 67,050 USD yearly), are eligible. HSF is managed by the San Francisco Department of Public Health. It is not an insurance provider, but a program that allows and encourages residents to seek preventive health care and some basic health care services within a specified network of providers. It is funded by the city, individual taxpayers, income-dependent premiums and co-payments, and contributions from companies with over 25 employees not already paying into insurance plans or sickness funds. In 2010, the HSF had over 534,000 members and a budget of 140 million USD. Legally speaking, HSF is not an insurance plan, which is what protected it from GGRA’s suit. Programs created in Maryland (Maryland Fair Share Health Care Fund Act), and in Suffolk County, New York (Suffolk County’s Fair Share for Health Act), met a different fate. Both were created in 2005 as an indirect way to counteract measures taken by Wal-Mart to cut employees’ social benefits. Both programs were stopped when the Supreme Court ruled they violated ERISA. Due to the decentralized nature of health care policy, each state or even county must fight alone and any victories are confined to the local level. In May 2011, the Vermont House of Representatives passed a law to create a universal health insurance system. The state Senate approved it and it was signed by Governor Shumlin in June of that year. The law (Act 48 – H.202) introduced a single payer system. However, the state must enact certain reforms for the law to succeed, such as drawing up a funding plan and proving that the single payer system costs less and is thus economically viable. The creation of reforms and the introduction of Vermont’s public health care plan should be monitored closely. Already, lobbies are joining with the corporations IBM and Dealer in seeking ways to demonstrate the plan violates ERISA (Chagnon 2011). Hawaii, however, is unaffected by ERISA, because its health care system was created prior to 1974. Ninety percent of Hawaii’s residents had health coverage in 2009 (Gardiner 2009). The state’s system requires companies to provide insurance to any employees working more than 25 hours per week. State regulations on insurance companies keep the amounts employers have to pay relatively low. Due to strong incentives to seek preventive care, Hawaiians receive less treatment and fewer hospitalizations than other Americans, and the state’s total health care expenditure (measured as a percentage of Hawaii’s GDP) is slightly below the national average. Other plans have been created for specific ethnic groups. The Indian Health Service (IHS) serves the 565 federally recognized Native American tribes, or roughly 5 million people. The IHS is a branch of the DHHS and operates on a yearly budget of 4 billion USD, which corresponds to a health expenditure per capita well below the national average (www.ihs.gov; Trahant 2009). IHS is significantly underfunded. It was created in 1955 to improve the health of this unhealthy population, which has a life expectancy 5.2 years shorter than the rest of the US population, from lack of education, endemic poverty, and ongoing discrimination. Tuberculosis, diabetes, alcoholism, homicides, and suicides are devastating this small population, which has been abandoned and neglected.


Thus we see that a complicated and diversified system of health insurance and care providers – characterized by heterogeneous practices and highly variable health outcomes and types of illness from state to state – operates in a multi-ethnic America where levels of health vary greatly among ethnic groups.

A Complex System for a Multi-Ethnic America


It is difficult to map all variations in quality and cost in the US health care system. The picture becomes even more complicated if that map is overlaid with one showing health levels of population groups. Health disparities have been researched extensively. A study published in 2006 by researchers at the Harvard School of Public Health (Murray et al.) showed that while the average life expectancy of Americans is longer than in the past, life expectancy is strongly affected by ethnicity, income level, and place of residence. The authors studied the ethnically diverse US landscape and identified sub-groups based on sociodemographic and geographical indicators such as race, place of residence and local population density, average annual income, and the homicide rate in county of residence. The authors identified “eight Americas.”


The study compared life expectancy, risks of mortality from specific illnesses, and access to health insurance and medical care among the eight groups. Findings included a life expectancy gap of up to 33 years between those with the best and poorest health. For example, between 1997 and 2001, Native American men in South Dakota had a life expectancy of 58 years whereas Asian women in New Jersey had a life expectancy of 91 years. In 2001, the life expectancy gap was 20.7 years between the 3.4 million high-risk black men living in cities (risk of heart disease after 35 and of homicide between 15 and 50) and the 5.6 million women of Asian descent (a “healthy minority”) due to the latter group’s genetic make-up, more balanced lifestyle, healthier diet, and access to health care in their communities (US Census 2009). In terms of sex differences, the widest gap in life expectancy among men was 15.4 years (between Asians and black men living in urban areas) and 12.8 years among women (the longest being among women of Asian descent and the shortest among black women living in rural areas of the South). Significant disparities also existed between age groups. The widest gaps were observed between the group aged 15-44 and the group aged 45-59. Given that many studies have demonstrated that mortality correlates closely with access to care, income, education, and genetic endowment, one would expect the life expectancy of the Hispanic population to be comparable to the black population, and thus lower than the white population. However, a 2010 study by the National Center for Health Statistics found otherwise, referring to the mortality paradox in the Hispanic population. This study found that people of Hispanic origin live longer than whites despite having much poorer socioeconomic conditions. In 2006, the life expectancy at birth of Hispanics was 80.6 years whereas it was 78.1 for whites, 72.9 for blacks, and 77.7 for the general population. This study did not take Asians into account. Researchers struggle to account for this anomaly, which contradicts many studies on population groups. Studies on the Hispanic paradox claim “social bonds” are a factor of longevity. The tight social bonds between members of this population, combined with low rates of alcohol and tobacco consumption, and the fact that people in good health are more likely to migrate, likely account for this paradox. Roughly two-thirds of the 48 million Hispanics are from Mexico. The National Institutes of Health (NIH) undertook a study of Latino populations to examine differences between sub-groups because the study also found significant differences in mortality rates and life expectancies within this population based on geographical origins.

Table 1 - Population Groups by Income Level

Unfortunately, the ranking of life expectancies and the differences in absolute value between ethnic groups changed very little between 1986 and 2001. Compared to other developed countries, the disparities among the eight sub-groups – each of which includes millions or even tens of millions of Americans – are massive. Murray’s study concluded that a minority comprising 10 million Americans have the best health in the world and access to the highest quality of care. This group has one of the highest life expectancies in the world (three years longer than Japanese women and four years longer than Icelandic men). However, tens of millions of Americans have levels of health comparable to those of middle- and even low-income people in developing countries. This unhealthy segment of the US population exists throughout the country, but is more prevalent in the South and among black and Native American populations. In these two sub-groups, Native Americans living in western regions of the country (group 5) have the lowest access to individual health insurance, followed by blacks in rural areas of the South (group 7). Individual health insurance plans are most common among whites in the North (group 2) and Asian populations (groups 3 and 1). Another study (Murray et al. 2011) found that the average life expectancy at birth between 2000 and 2007 was 75.6 for men and 80.8 for women, which ranks the United States 37th in the world. This study also highlights disparities among counties of residence, with life expectancy varying from 65.9 to 81.1 years for men and from 73.5 to 86 years for women. The shortest life expectancies for both sexes were found in counties of Appalachia, the Deep South (Alabama, Georgia, Louisiana, Mississippi, and South Carolina), and north Texas. The counties with the longest life expectancies were located in the Northern Plains, the Pacific Coast, and the East Coast. In addition to these significant geographic disparities, regional anomalies also exist. For instance, some counties, although located in the West, still have low life expectancies due to being isolated and having a high Native American population. Equally, there are counties where the life expectancy is unusually high for the region. Such “islands of wealth” are found in Colorado, Minnesota, Utah, California, Washington, and Florida. Another important point from this study is that between 2000 and 2007, life expectancy in the United States (nationally and regionally) dropped below the average life expectancy of other developed countries, and this gap is widening in over 85 percent of counties despite the fact that the United States had the highest per-capita health expenditure over the same period.


Too often, public health economists make the mistake of not drawing a correlation with the socioeconomic levels of individuals and communities. Since many studies do not consider such inequalities as factors of health, no policy exists to reduce them. Instead, public health strategies tackle consequences they see as causes – such as risk factors of chronic diseases, most often blamed primarily on lifestyle factors like smoking, drinking, obesity, high blood pressure, high cholesterol, poor diet, and lack of exercise – without viewing economic context as a major factor. However, the impact social integration has on health has been clearly demonstrated. For instance, Cassel’s (1976) “social support” theory highlights the causal relationship between psychosocial processes like social support and the etiology of illnesses. Poverty, as the outcome of socioeconomic inequality in a society, is detrimental to the health of the population, and health performance indicators (life expectancy, mortality/morbidity rate) are all directly influenced by a given population’s standard of living. Moreover, lack of income is not what matters most, rather it is the relative distribution of income (Wilkinson 1992). Various studies like the one Kennedy conducted in 1996 even prove the relationship between income inequality and the mortality rate of a given population. According to Kennedy, strategies to reduce the growing inequalities in terms of wealth distribution could have a real impact on the health of populations. However, the debate presently under way about the health care system avoids this topic and is restricted by a liberal economic structure that is both dogmatic and peremptory, because the interests at stake are so great. No sooner than he had signed it, President Obama’s reform came under fire. While there is nothing “socialist” about it (since it involves the private sector), a brutal war has been declared by the free-market fundamentalists and their supporters. Many states have already filed suit against it, claiming it is unconstitutional and demanding the reform be repealed. Of course, the Affordable Care Act was a key topic in the 2012 presidential election.

Health Care at the Core of Political Debate in 2012


A period of high polarization is dawning. Many Republicans have already announced their intention to seek their party’s nomination in the 2012 presidential election, and many seats are up for grabs in the House of Representatives and the Senate. Republican and Democratic candidates will spend the months preceding the elections underscoring their differences, and health care reform will be a decisive topic. All are more or less aware that, in addition to the social tragedy caused by the inequality and unfairness of the public health system, the health of the nation’s budget hinges more than ever on controlling health care spending. The country’s economic and social situation could indeed worsen if nothing is done to stem the tide of rising costs. According to many polls, Mitt Romney, former governor of Massachusetts, leads the race for the Republican nomination. However, the GOP [9]  Grand Old Party, nickname of the Republican Party.[9] base is wary of him and disapproves of the health care reform he created in Massachusetts in 2006, which gave health care coverage to 400,000 people by requiring all state residents to have health insurance. In February 2007, immediately after the law passed, Romney made this statement in a speech in Baltimore: “I’m proud of what we’ve done. If Massachusetts succeeds in implementing it, then that will be the model for the nation.” Now, however, in an attempt to attract Republican voters, he says that, if elected, he will fight against President Obama’s health care reform, despite the fact that it is modeled on the reform he enacted in Massachusetts. In 2008, when it came time to decide on the direction that reform to the public health care system would take, the single-payer option, which would have replaced the majority of large private insurers with a government system, was quickly dismissed. It would have demanded considerable effort without much chance of success due to staunch political opposition. Instead, Obama used the Massachusetts reform as a model and, like Romney in 2006, felt compelled to make the reform mandatory in order for it to achieve significant impact. During his presidential campaign, he had voiced opposition to making health insurance mandatory and penalizing those without it. He and Hillary Clinton, had some heated exchanges on the subject. Today, it is precisely the mandating of health insurance coverage that concerns most opponents of Obama’s reform. They claim this violates individual freedom and is an abuse of federal power. Whereas the only goal of Romney’s initiative was to extend medical coverage to all, a key aspect of Obama’s reform is to introduce price-control mechanisms. He argues that cutting health care spending must be a cornerstone of growing the economy. Five years after being signed into law, the system created in Massachusetts has succeeded in extending health insurance to virtually all residents of the state. However, from the outset, the reformers in Massachusetts separated access to care from the cost of care. Their priority was ensuring health insurance for all without worrying about price controls. As could be expected, costs continued to rise and these now threaten the plan. The current governor, Deval Patrick, is now seeking solutions and has threatened to impose regulations on insurers and health care providers if they cannot effectively self-regulate. Experts in health care policy agree that the system in place leaves enough wiggle room for companies to find ways around certain measures, thereby weakening the legitimacy of the state’s authority in this area.


The Massachusetts plan and PPACA also differ in terms of funding. Romney’s reform was paid for primarily by federal funds, whereas Obama’s relies on a combination of higher income taxes and spending cuts in Medicare to free up 940 billion USD (700 billion EUR) over the next 10 years. Other than price controls and funding sources, the basic structure of the two reforms is the same. However, Republicans see so-called Obamacare as an aberration that, if not repealed, will erode the fundamental freedoms of an ill-informed American population desperate to fix the current system. In February 2007, Romney, proud of the success of his reform in Massachusetts, hoped to win the Republican presidential nomination. However, the party selected John McCain, who chose Sarah Palin, not Romney, as his running mate. Over the next few months, the financial markets collapsed, the Bush administration bailed out the banks, and Obama won the presidency. Obama allocated nearly 800 billion USD to bail out more banks along with the automobile industry. He then proposed his health care reform law, to cost close to 1 trillion USD. The defeated Republican party reacted by falling back on the most extreme capitalist ideology. By summer 2009, conservative intellectuals had ceased debating the topic of public health. Libertarians, who support maximum personal and economic freedom and as minimal government as possible, had won. Even the Heritage Foundation, which had played an active role in designing and implementing the Massachusetts reform, turned against the law. Its spokesperson issued this statement in August 2009: “Requiring every American to buy health insurance is a violation of the fundamental values of personal freedom.” Newt Gingrich, running for the Republican nomination in 2012, also withdrew support for the law. Today, many conservative groups throughout the country argue that Obamacare violates the Constitution. The constitutionality of the mandate will be decided by the Supreme Court.


Although Congress passed the Affordable Care Act, it will encounter problems during implementation. The funding sources to provide a greater majority of Americans with health care coverage remain unspecified. The fact is that the US political system offers significant leverage to the wealthy (well-organized and pragmatic). Opponents of reform have many ways to escape the higher taxes needed to fund the reform and to promote their ideology. They devote substantial funds to media campaigns and legions of influential lobbyists. Since 2010, their task has been made easier by the US Supreme Court’s Citizens United decision. This ruling cited First Amendment rights in preventing government from placing limits on independent political expenditures by corporations. With substantial resources, opposition groups will continue to weigh in heavily on decisions regarding federal regulations on funding for the reform. While Obama’s reform is a big step forward, it merely outlines the system and the rules that will govern it, and puts in place a five-year plan, leaving the resources needed for implementation still to be approved. Some PPACA provisions are already in effect. Children can now stay on their parents’ plans until they are 26. There is help for seniors paying for medications. People with chronic or serious illness are able to secure health insurance. The most important provisions will not be implemented until 2014 and beyond. The federal government, state governments, and the District of Columbia will be responsible for measures needed to enforce new directives. Congress will also have to approve the essential clauses of the act in its future yearly budgets. Most likely, all these steps toward implementation will occur in a climate of political tension and ill-will, since 26 states have already challenged the reform in court. Insurers and companies are also forming lobbies to influence Congress and the federal and state administrators charged with drawing up procedures. The partial or complete survival of the reform initiative directly hinges on future political decisions and the next elections will seal its fate. The federal Medicare and Medicaid programs are also in danger due to the uncontrolled rise of costs. In 2010, 12 percent of the federal budget was spent on Medicare. In addition to being the preferred target of conservatives, the ongoing rise of medical-care costs and a growing population of people over age 65 cast doubt on the future of Medicare. The number of people receiving Medicare is projected to go from 27 million to 80 million between now and 2030 and the contributor-to-beneficiary ratio to be 3.5 to 2.3 (Kaiser Family Foundation 2010).



Healthy populations are precious assets to countries. Along with education, health strengthens nations in the long-term. Not only does it ensure a healthier economy and more social balance, it also helps countries move towards real, inclusive, and sustainable progress. Despite leading the world in medical research, pioneering modern medicine, and spending ever-growing amounts on health care (now 2.5 trillion USD annually), the United States has failed to lengthen the average life expectancy of its citizens. Domestic disparities in terms of social benefits, access to care, quality of care, and the health status of various sub-groups of the population are widening the gap between those who benefit from the progress of medicine and the advantages of the free-market economy and those who are sliding backward due to having lost a fundamental right: the right to health care. The US health care system is sick and in very serious condition. The country is a prisoner of an inflationist spiral. The proliferation of cutting-edge technologies and the excessive use of medical procedures are undoubtedly driving up prices in a health care system based on free-market principles, and not on the principle of universal coverage or the idea of public funding through taxation (although the contribution of US taxpayers is significant). The lack of efficiency of a too complex network of public and largely private providers combined with a tremendous waste of resource has plunged the entire system into a dangerous economic situation, with dramatic social consequences. The domestic debate and the ideological conflicts between Republicans and Democrats over the last 20 years have solved nothing. Right after Congress signed the health care reform bill into law, some were already seeking a constitutional basis for its repeal. While the crux of the reform is to create a large competitive market (although regulated, a market nonetheless), conservatives and many Americans believe that federal involvement in this market will bring about what they fear the most and see as “socialism” in public health. While conservatives are uniting to defeat the reform, the American Medical Association (AMA) and several large medical groups are fully aware of the urgency and gravity of the situation and are working to keep Obama’s initiative alive. Utah Intermountain Health care, Aetna, Humana, Wellpoint, and Blue Cross Blue Shield are among the progressive groups that have already designed strategies to cut costs and to prioritize quality over quantity of care. Certainly, the 2012 elections will deepen the ideological divide. In early April, President Obama announced his intention to seek reelection. For the health care reform signed into law in 2010 to be implemented fully and stand the test of time, he must be reelected, yet, most likely, even that will not be enough to guarantee the success of the reform.


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[1] Annual health care spending is estimated at 2.5 trillion USD.

[2] Medicare covers some 44 million people (2008) at a yearly cost of 432 billion USD, or 3.2 percent of GDP (2007).

[3] Medicaid covers some 40 million people (2007) at a yearly cost of 330 billion USD, or 2.4 percent of GDP (2007).

[4] The Elks Club (full name, The Benevolent and Protective Order of the Elks) is a charitable organization founded in 1868 in New York. Today, it is a major organization with local chapters throughout the country.

[5] The American Federation of Labor and Congress of Industrial Organizations is the largest national union (11 million members in June 2008). It was created when AFL and CIO merged in 1955.

[6] Wal-Mart employs 2.1 million people in the world and 1.4 million in the United States. It is one of the largest employers in the United States and Canada and the largest in Mexico.

[7] Anderson is Professor of Sociology in the Graduate School of Business and Associate Director of the Center for Health Administration Studies, at the University of Chicago.

[8] A health maintenance organization (HMO) is a health care management organization offering guaranteed medical coverage. However, unlike traditional insurance, HMOs only cover care dispensed by doctors, hospitals, or service providers contracted to do so. The Health Maintenance Organization Act of 1973 required employers with 25 or more employees that offer health insurance plans to include certified HMO options.

[9] Grand Old Party, nickname of the Republican Party.



The American health care system is sick and its prognosis is poor. This system is a complex network of public and private entities, charities, and lobbies, operating in a context of a strong political ideology that distrusts the federal government. In this capitalist health care system, the proliferation of technologies and the excessive use of medical procedures are driving up costs. Inefficiencies have plunged the entire system into a dangerous economic situation with dire social consequences. In March 2010, Congress approved the Patient Protection and Affordable Care Act, a bill that aims to implement universal health coverage and price controls over a five-year period. However, the act is being aggressively challenged, with 26 states already having filed suit against it, claiming that a health insurance mandate is unconstitutional since it violates personal freedom and is an abuse of federal power. President Obama’s health care reform will be a key issue in the 2012 presidential campaign.


  1. How Did We Get Here?
  2. A Complex System for a Plural America
  3. A Complex System for a Multi-Ethnic America
  4. Health Care at the Core of Political Debate in 2012
  5. Conclusion

Translated from the French by JPD Systems

To cite this article

Michelle Bertho-Huidal, “ Santé et territorialité aux États-Unis, la réforme du président Obama ”, Hérodote 4/2011 (n° 143) , p. 137-161
URL : www.cairn.info/revue-herodote-2011-4-page-137.htm.
DOI : 10.3917/her.143.0137.

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