• What are the historical causes of our present-day health care crisis in the United States?  Discuss two or three causes, at least one of which goes back before 1945, using material from the reading.  Given your analysis of causes, how do we need to change our system?
• For each change give at least 2 or 3 steps of how it developed historically, with specific examples
  
• Four to five pages double spaced, may be based on assigned reading, be careful to avoid plagiarism.

• care is too unfairly distributed
• people are dying from lack of basic care
• cost of health care has become a serious drag on our economy
• cost of health care drives an unsustainable budget deficit
• we pay more for care with worse outcomes than elsewhere in the world
• poor health behaviors
• people who can't afford care
• over-treatment
• many people say we aren't going to have enough doctors
• too many people are bankrupting themselves to pay for health care--Affordable Care Act helps but doesn't cover everyone and it doesn't cover the cost of long term care
  

• too much government interference (or fear of government interference)
  
• technological progress makes health care more and more expensive
• more scientific knowledge means there is more we can treat and so more health care costs
  
• resistance to higher taxes
• individualism--we don't want pay for other people
• dislike of socialism (government providing services to everyone)
  
• hospitals becoming the primary way to deliver acute care (expensive)
• unhealthy behaviors and the desire for medical quick fixes instead of changes in behavior
• we think what is important is getting the best possible care and we shouldn't have to worry about the cost or even if we have to pay the cost we want the best rather than looking for good deals (if this is true, increasing competition will not reduce costs)
  
• medical care is often emergency and we can't take the time to make good choices
• doctors went into medicine with the understanding that they would make a high income and will fight any reform that changes that, so they oppose a social insurance system
• aging population, more people live long enough to develop chronic diseases
• we developed a system where most people got health insurance through their employer but that insurance wasn't available to people who didn't have decent full time jobs (and there aren't enough decent full time jobs to go around)
  
• doctor's care has changed from a luxury to a basic necessity
  

• Cost for assisted living in this area is $2,000 to $3,000 a month, for a nursing home $5,000 to $7,000.  In major urban areas it can be $10,000 a month.
• A person who needs assistance typically lives another four years--about 80% of these people are cared for at home
• but more people are living with more intense medical needs
  

• current system: when you have spent all your money Medicaid will pay
• private long term care insurance is available but expensive: so few people have it that it only pays for 10% of long term care services
• made sure that Medicaid will also pay for home care, which is much less expensive than a nursing home
  
• include long term care in Medicare?  This would increase the cost of Medicare by about 20% if usage stayed the same
  
• unpaid family members?  currently the value of such care is estimated to be $300 billion a year, compared to $135 billion for residential care and paid assistance
  
• useful tables
• hospice rather than hospital for those at the end of life can reduce costs

Costs of the Affordable Care Act

• primary new costs are Medicaid expansion (paid for by the federal government) and subsidies to low income people buying insurance on the exchanges
• these costs are to be paid 45% by program savings: mostly decreasing the extra payment Medicare Advantage plans got
  
• 55% by new revenue: an increase in the Medicare tax for high income people and new fees for the health care industry
• will public support grow?  not clear yet

• Britain:
  
• single, government run health care system: the government pays and sets policy for doctors and hospitals, though private insurance is also available
  
• 75% paid for from taxes
• Canada:
• government run insurance system but most people have private insurance for drugs and dental care
• run by each province
• private insurance for basic medical services is not allowed
• Germany
• citizens choose among non-profit sickness funds
• the system recently changed so everyone pays a standard amount as part of their taxes, paid for by the welfare system if the person cannot afford it
• private insurance is allowed but rare
• family practitioners do not serve as gatekeepers
• co-payments have been added recently to try to reduce the growth in costs
  

• will new technology reduce or increase costs?
• will the Affordable Care Act survive?
• future of health care delivery
• alternative