As I wrote in yesterday's blog, the federal government is now responsible for about 35% of total national health expenditures. But the public sector's contribution is actually much larger: today, almost one out of every two dollars spent on health care comes from federal, state and local governments. In 2008, combined spending by the public sector (federal, state and local governments) represented 47.3% of the total national expenditures (all sources, public and private, combined). Governments' share has grown over the years: in 2000, 44% of the total national health care bill was paid by public funds, up from 42% in 1980 and 37.6% in 1970.
Another way to look at this is how many people are covered by government or private sources. The Census Bureau reports that in 2008, 84.6% of U.S. residents had health insurance coverage. Of these, 66.7% had private insurance and 29% government insurance. In 1999, 72.5% were covered by private insurance and 24.5% by government programs.
(I wonder if those who argue that the U.S. has the best health care in the world realize that they are talking about a system where more than 87 million people already depend on the government for coverage, and where one out of every two dollars spent on health care already comes from government funds.)
How much would the House and Senate bills expand the government's role?
The Congressional Budget Office estimates that over the next 10 years, the Senate bill would add 15 million more people to the Medicaid and SCHIP programs compared to current law. Four million fewer people would be covered by employers, and five million fewer by the individual insurance market. Twenty-six million people would get coverage through insurance plans offered by a state health exchange, and most of these people would get subsidies from the federal government to help them afford the plans. The House bill too would add 15 million more to Medicaid/SCHIP, but it would actually increase by 6 million the number of persons covered by private insurance offered by an employer. Twenty-one million would get coverage through a national health exchange, which would include private health insurers as well as a public option. (The public option is not expected to be in the final House-Senate bill.) Under the House bill, the number of people who buy individual insurance would decline by 6 million people.
Under both the House and Senate bills, the vast majority of Americans - in excess of 160 million - would get their coverage from employer-sponsored private health plans.
I understand that there is a serious case to be made from the right against the further expansion of the government, just as there is a serious argument to be made from the left that the proposed reforms should do more to expand government's role.
But an honest debate would at least start by acknowledging the fact that the government already is involved in health care, big-time, and its role will continue to expand, with or without health reform, just as it has for more than forty years now. (No politician that I know of - other than maybe Ron Paul - is proposing to keep government out of health care, since this would mean eliminating or at least rolling back Medicare, Medicaid, the Children's Health Insurance Program, the VA, military medicine, and Tri-Care - not to mention eliminating NIH research, funding for graduate medical education, and a whole host of other popular programs.)
An honest debate would also begin by acknowledging that the House and Senate bills would further increase the government's role in health care by enrolling more people in government programs, subsidizing the purchase of private insurance, and regulating insurance companies, but most people would still get coverage from private insurance offered by their employer. You may believe that this is a good or bad thing, but let's not pretend that the current debate is really about keeping government out of health care (it is already there) or creating of a government-run health system (the bills don't).
Today's questions: What do you think the role of government will be in health care, without or without health care reform? What do you think its role should be?