• if the family pays the cost they should decide
• we need to accept that death is inevitable
  
• we value individual freedom more than fairness
• are we willing to accept that studies show this treatment is worthwhile and that treatment is not
• are we ready for: government or insurance will only pay for best practices
• the system should pay for basic costs, if you want more you pay
  

• Ted Kennedy was an advocate for universal health care his whole career, proposed a single payer system like Medicare, but the problem is if government-funded this requires a 7-10% tax increase
  
• opposition was insurance companies and doctors who feared regulation and price controls
  
• Wilbur Mills (D-Arkansas) was the key committee chair in the House of Representatives--had some interest in universal health care but was very concerned about the cost
• Nixon was conservative but was pushed by the times into concern about the public good (didn't want the Democrats to be able to use health care as a campaign issue)
• The main thing he accomplished was requiring insurance companies to offer the option of Health Maintenance Organizations (HMOs), which had earlier been called Pre-paid Group Practices
  

Questions any proposal needs to answer

• Should doctors be paid for services delivered or a fixed amount per patient or per diagnosis (DRG)?
• there is always going to be a tension between care and business
• it is always going to be an uncomfortable compromise
• we don't realize the risks of too much care
  
• should patients have the right to treatments unlikely to do any good?
• should patients have the right to see any doctor they want?

Nixon proposals in 1971 and 1974:

• Nixon proposed a program that required employers to provide private health insurance (play or pay)
  
• subsidized insurance for poor families
• 1971 plan had no subsidies for those not eligible for welfare but the 1974 plan included everyone who wasn't offered a plan by their employer
  
• 1971 plan had 25% coinsurance, limited to 30 days in the hospital per year, but with an out of pocket maximum of $5000, 1974 plan had co-insurance that rose from 10% to 25% by income and a maximum cost sharing (out of pocket) that rose from 3% of income to $1500
• 1971 plan did not cover prescriptions, 1974 plan did
  
• what do you do about people who are not covered by their employer and chose not to purchase insurance even if they can get it at a reasonable price?  Nixon's plan did not require people to purchase insurance (no individual mandate)
• the 1974 Nixon plan almost came to a compromise with Kennedy's plan, but they wouldn't quite compromise
• various scandals got in the way of any bill getting very far

Clinton proposal

• a new approach: managed competition.  The government organizes a market-place in which people can choose a plan, employer funded or subsidized if their situation warrants
  
• health care costs were rising, a problem for consumers, businesses and government
• Clinton wanted a program that would required no increase in taxes, pay for greater coverage by making the system more efficient and by raising the cigarette tax
• cost control worried doctors and hospitals
• Clinton thought the Republicans would compromise but they decided they could stand firm on this one and win
• managed competition was too new an idea too quickly

what are the components that the different proposals to expand access to health care can choose among

• single payer: expand Medicare
• require employers to provide insurance
• who get the free or low cost for the poor
• do you subsidize people who aren't very poor but can't afford insurance
• do you allow insurance companies to charge some people more
• do you include cost control
• does the government organize how you buy health insurance
• do you require everyone to buy insurance
• how much do you take away from individual choice to provide everyone with a safety net