Where does the road to reform lead?

No matter who you ask about reform, you will never get quite the same answer. Whilst most may agree the current system is broken, there's no real agreement on how to fix it. It's all controversial and highly political. But there is some common ground. Health care costs are out of control. Premiums have been rising faster than inflation for some years now and even the middle class is beginning to find coverage difficult to afford. The result is a rapidly increasing number of people uninsured. The quality of care is also under pressure with fewer people prepared to work as nurses and physicians preferring to work as surgeons rather than general practitioners out in the community. Put all these together and the opposition that stopped the reform movement under President Clinton is losing its power to prevent reform today. The only question is what the reform should look like.

President Obama has called for a comprehensive package by the end of this year. The most obvious place to start is with health care for children. There's a new slice of money for the State Children's Health Insurance Program - a mere $33 billion. The aim is to bring another four million uninsured children into a health plan. The second likely change is to see more money targeting preventative care. At present, most money is spent at the treatment end of the system when people fall ill. The uninsured wait until there's emergency before going to a hospital for treatment. By then, their illnesses are more difficult to treat. But with proper care early on, more serious conditions could be avoided and long-term costs reduced. This would be combined with regulations preventing insurance companies from discriminating against people with pre-existing conditions and new requirements on employers to pay more to insure their employees. There will also have to be new regulations dealing with the pricing of drugs and medical devices. At present, the government is the biggest buyer of medications but is limited in its power to negotiate discounts for volume.

So where's the controversy? Well, it all depends whether the federal government decides to introduce a single-payer system for some or all the people. This would be a public health plan to compete with private health insurance. In time, the US might move over to a more european health care system with only a small percentage of the population on private health insurance to top up what the state provides. But that is some time in the future. Trying to go there now would cause such ideological disagreement that nothing might get done. So, for now, whatever public provision is introduced to deal with the almost 50 million US citizens who are uninsured will run alongside the private sector. If the government plan proves a success, it could encourage more to opt out of the private sector and a slow shift could change the culture. Until then, we will have to wait and see what the politicians on Capitol Hill decide to recommend to President Obama.