• we never come up with the best plan, new policies grow step by step
• people create changes by lots of different routes--there are many ways to get things done
  

• the government did not define or enforce that part of the law for 24 years
  
• until a young lawyer started winning lawsuits in 1970
  
• the courts put requirements on hospitals to provide free care and inform patients, but the decision that said individuals had a right to care was reversed on appeal
• the Department of Health, Education and Welfare (HEW) issued regulations in 1979 requiring hospitals to provide a minimum amount of care to those who could not pay

Medicare:

• only 38% of the elderly had any health insurance in 1958
• hospitals wanted help with the burden of caring for people without insurance
• Kerr-Mills bill in 1960 provided federal matching funds for state that developed their own program, but few did so effectively
  
• when it became inevitable the Republicans, particularly Wilbur Mills, combined three rival bills into one that would be hard for the supporters of any of the three to oppose, which became law in 1965
  

Philosophical questions:

• should your insurance cost depend on your health?  Your income?  Your habits?
• what is the proper role of the federal government?
• should the system be financed by premiums or taxes
  
• should a government program (state or federal) apply only to the poor?
• Are we willing to support a system where many people pay for more than they get?

How to increase coverage without increasing taxes:

• 1988 expansion covering catastrophic coverage and medications introduced different rates depending on income to pay for more of the costs via premiums was passed and then repealed
• cover children only, with funding from an increased cigarette tax--SCHIP in 1997
• one proposal was to change Medicare to a premium support program--you get a fixed amount of money to buy your own insurance

Prescription benefit

• 1998-2002 drug costs increased 13% a year--what wasn't a problem in the 1960s became a large problems in 2000s
  
• 2003 MMA encouraged private options within Medicare but cost a lot of tax money
  

Controlling costs

• why do costs rise so fast?
• DRG system of fixed payments by diagnosis
  
• cost-effectiveness analysis is used in some countries but would not be accepted in the US
• comparative effectiveness research has more potential
• why are US costs higher?
• US doctors earn higher salaries, cost of medical education is very high
  
• doctors use more expensive procedures
• drugs and devices cost more
• administrative costs

Why has the cost of health care increased so much in the last 50 years?

• improved technology
• companies are inventing machines to do more accurate treatment because they can make money selling the machines
• people don't put in the effort--some insurance plans now reward better behavior
• why does it cost $140 to go to the doctor for a quick problems, not $40
• cost of buildings and maintenance
• expensive technology
• managing billing and insurance is very expensive
• do extra tests, sometimes to make more money, sometimes because they might get sued if they don't, sometimes because it is most efficient to do it all at once
  
• people are unhealthier because they live longer
• more treatments, people live with chronic diseases instead of dying of them
• pharmaceutical companies keep inventing drugs that are a little bit better and a lot more expensive
• research is very expensive because of government regulation
• advertising increases the cost and use of expensive medications
• lack of preventative care
• more solutions to problems that people used to live with (companies know this is a way to make money)