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An Analysis of the Current State of and Prospects for Healthcare Reform in the United States
Sophia Dilworth An Analysis of the Current State of and Prospects for Healthcare Reform in the United States Edited by Mariana Furneri
The current political climate is one in which even a moderate approach to healthcare reform becomes highly controversial as each party is unwilling to concede any ground.
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ABSTRACT Although Democrats and Republicans agree that the American healthcare system must be modified, consensus is difficult to achieve. While Republicans advocate for increased market competition to lower costs and improve efficiency, Democrats advocate for a “public option” in which the government acts as a low-cost insurance provider alongside the market. This paper demonstrates that these positions are not as incompatible as they appear and that a compromise plan incorporating aspects of both parties’ plans is, in theory, attainable. Both parties recognize that proposed plans will require concessions. At the same time, both parties are hesitant to support any healthcare reforms proposed by the other, as the polarized political system has transformed accepting compromise into concession, and concession into failure. This issue is further complicated by concerns of stakeholders, namely the healthcare industry. As such, prospects for healthcare reform, which, in a bipartisan system, is possible only through compromise, appear dire.
INTRODUCTION: THE NEED FOR REFORM
The unique debate surrounding healthcare in the United States is both a product of and reinforced by American Exceptionalism. Thus, the United States remains not only as the single Western nation lacking universal healthcare, but the only nation in which, for many, this lack of coverage is a product and source of pride. Nonetheless, the emergence of Social Security, Medicare and Medicaid throughout the 20 th century has demonstrated that the American commitment to libertarian values may not pose an insurmountable barrier to the extension of healthcare. However, whether such an extension would treat healthcare solely as a privilege to be made accessible to a larger share of the population, or as a right that must be provided to all by the government, remains a contentious and mainly partisan issue. The debate is further complicated by the fact that the dispute extends beyond concerns regarding healthcare’s legitimacy as a right. In recent decades, the rising influence of stakeholders has also served to undermine and shape healthcare reform, maintaining a careful balance between mollifying the public and maintaining profits. As the stakeholder and partisan debate reinforce each other and must thus both be simultaneously resolved, the prospects for healthcare reform, be it universal or otherwise, seem dire. As such, the progress towards fundamental healthcare reform is likely to be slow and arduous, focusing on reshaping national ideology concerning health and responsibility in addition to exerting and maintaining pressure on powerful stakeholders.
In light of these complications, it may be surprising that healthcare reform remains on the agenda at all. Indeed, the Constitution, from which rights in America are generally derived, contains no direct provisions for the protection of health. 1 Thus, the health-related policies and programs that have emerged are a product of Article 1 of the Constitution, which authorizes Congress to “regulate interstate commerce” and to “make all laws which shall be necessary and proper to … provide for the general Welfare.” 2 Nonetheless, the system remains largely privatized; insurance companies are the main providers, though coverage is
generally purchased by employers as incentivized by the tax system. 3, 4 However, privatization has somewhat decreased through public assistance programs such as Social Security, Medicare and Medicaid. Most recently, President Obama signed the Patient Protection and Affordable Care Act of 2010, which extended healthcare to more Americans by increasing government regulations. 5 However, these various programs have not achieved, nor have intended to achieve, universal healthcare. For the purpose of this paper, universal healthcare will be defined as a system in which every citizen, from birth, is provided coverage under a certain level of uniformity. 6 Thus far, such extensive coverage in the United States has hardly received consideration, at least not from within the party “establishment.” That said, the inclusion of universal healthcare as a priority in Elizabeth Warren’s and Bernie Sanders’ campaigns for the Democratic nomination for the 2020 presidential elections signals that the idea of universal healthcare may be gaining ground. Nonetheless, for most Democrats, the issue of reform is not one of achieving universal healthcare but is rather more pragmatic in nature: correcting existing inefficiency. Since the 1980s, U.S. healthcare expenditure has increased to 16% of GDP, as compared to the 5–11% reached by its peer countries. Most distressingly, this higher expenditure has resulted in comparably lower quality healthcare. 7 Therefore, due to inefficiency and lack of coverage, healthcare has resurfaced as an issue that can no longer be left on the fringe of the national policy agenda. Both the Democratic and Republican parties have incorporated the issue into their platforms, though, as is to be expected, the extent of reform and the values stressed in implementing any changes vary greatly between the two.
THE PARTISAN DEBATE
The Ideological Debate: The Value of Health Policy discrepancies between the Democratic and Republican parties is derived in part from traditional party ideologies into which the notion of health has been incorporated. Republicans, in abiding by their libertarian principles, have generally integrated health as a negative right, that is a right which the government may not infringe upon, but has no duty to enforce. 8 Under this conception, the delegates responsible for drafting the proposed Constitution intended that all rights be negative. This is exemplified by, for example, the First Amendment, which protects free speech from government interference but does not mandate a necessity for the government to provide a platform for such speech. 9 In the same way, though the government may not infringe upon your health, it has no duty to protect it as a positive right through, for example, providing healthcare. Furthermore, this notion of negative rights reinforces individualism and liberty by reducing reliance on the government. 10 From this ideological standpoint, universal healthcare would encourage dependency on hand-outs, thereby inhibiting individualism, and would give the government a mandate to infringe upon our freedoms. 11 This infringement would be further compounded by the fact that such an endeavor would likely be funded by taxes. 12 As a result, universal healthcare would reward those who cannot provide for themselves and unjustly penalize those who can. Therefore, healthcare must be a privilege, not a positive
right, which must be earned by merit.
Yet this argument appears to stand only if it is agreed that liberty and individualism are more important than life. This is certainly not a view held by Democrats, who assert that healthcare, as a fundamental requirement for life itself, must be a positive right. 1314 Indeed, this is not incompatible with libertarian values held by Republicans. After all, a sick person’s capabilities are often compromised, resulting in their inability to pursue goals, to assume individual responsibility, and to enjoy liberty. 15 The interpretation that individuals only have negative rights ignores how it is in fact through positive rights that the ability to pursue “life, liberty, and happiness” emerges. 16 Therefore, healthcare may be, in itself, compatible with libertarian values. Indeed, without health, the right to be exempt from government interference becomes meaningless. Thus, the disparity between the Democrats’ and Republicans’ perception of healthcare may not be a product of inherently different values towards the concept of health itself but rather an entrenched conception that the adversarial party’s ideas, by virtue of belonging to the political opponent, must be irreconcilable with their own.
The Practical Debate: Economic Implications of Healthcare Reform Regardless of its origin, the perceived conflict between party ideologies has also resulted in a disparity in the perception of the cause of healthcare inefficiency, the goals that healthcare reform must achieve, and the methods chosen to pursue healthcare reform. As such, the Republican Party (GOP) has identified the reduction of costs, rather than the treatment of healthcare as a right, as the primary focus of reform. Cost inflation, it maintains, is a product of overregulation, “over-insurance,” and lack of individual responsibility. 17 The solution is a libertarian one: the free market and increased competition. In order to achieve the benefits of a free market, the party asserts that it will deregulate the healthcare market by reducing the various mandates that insurance companies have to abide by. 18 Such mandates, the GOP argues, price millions out of the insurance market by increasing the costs for insurers. 19 These increased costs force firms to either increase premiums for consumers, or to leave the market entirely. 20 The latter option, too, increases premiums as the remaining firms finding themselves facing less competition, thus reducing the need to keep prices competitive. Furthermore, the party will allow insurance companies to compete across state boundaries, thus increasing competition and incentives to improve the quality of healthcare whilst reducing costs. 21 The necessity to do so will be reinforced by phasing out employer-based insurance. This is intended to encourage consumers to analyze a wider variety of insurance plans, thus requiring insurance companies to offer better premiums. 22 Thus, the impact of the free market on costs will be twofold: consumers will spend less as they assume individual responsibility for their healthcare, whilst companies, as required by competition, will reduce prices and aim to minimize their expenditures.
Yet the GOP also recognizes a need to make healthcare “more accessible.” 23 For example, it stresses that it does not intend to eliminate protection for individuals with preexisting conditions. 24 Moreover, the party’s plan includes a provision for tax credits to assist those who do not qualify for public assistance but cannot
fully afford to purchase insurance. 25 Such policies are certainly not libertarian. Yet rather than indicating a change in fundamental party ideology, such amendments indicate that to a certain extent, the Republican Party has realized that its libertarian values must be adapted to modern principles that no longer fully reject social responsibility. Nonetheless, this merely grants that the party is willing to extend the privilege of healthcare because it is politically viable to do so. In other words, these concessions should not be mistaken for a genuine commitment to include every member of society in its revised healthcare plan. Instead, it is likely that in abiding by its libertarian principles, the GOP will limit this increased accessibility to only those members of society who are deemed most vulnerable, and thus “worthy,” by key constituencies. As such, some members of the public will continue to be excluded from the privilege of healthcare.
Critics argue that in addition to the intended failure to provide universal coverage, the plan will also result in an unintentional failure to reduce costs. Under this conception, increased reliance on the free market and competition will propagate cost inflation rather than combat it. Though Republicans may argue that competition inevitably lowers costs, in reality insurance companies compete in additional ways that limit their incentives to attract customers merely through competitive pricing. For example, firms spend a combined $420 billion on managing, designing, and marketing various plans to appeal to customers and distinguish themselves from competitors. 26 As a result, in contradiction to what the GOP claims, pricing is not necessarily the decisive factor in firm competition. Furthermore, competitive firms aim to maximize their profits and are thus more likely to increase rather than reduce premiums. This is exacerbated by “cost-shifting,” which maintains that insurance firms will charge higher premiums to the insured as the number of uninsured rises. This occurs as the uninsured represent foregone profits for which the insured have to compensate, resulting in a cycle of ever-increasing premiums. 27 As a result, it is argued that the Republican plan to proliferate competition is likely to promote rather than combat cost inflation.
By drawing on these criticisms and the libertarian values underlying the Republican model, it may be logical to assume that the Democrats’ model for reform would stress the elimination of competition. This is only partially the case. Indeed, the so-called “single-payer option” maintains that the government, funded by taxes, would provide all of its citizens with insurance, which would eliminate all competition in the healthcare market. 28 However, although the single-payer option, by definition, provides for the Democrats’ stated goal of universal healthcare, the party has, for the most part, distanced itself from the policy. Instead, it advocates for a “public option,” in which the government acts as a low-cost insurance provider alongside, rather than in the place of, the current private and employer-based market. 29 Though this would likely extend coverage by making it more affordable, it would also increase competition, thereby producing aforementioned fears of ever-increasing premiums and costs. 30 As is the case with the Republican plan, this appears to be not a fundamental change in principles, but rather a reaction to a political climate in which its “pure strategy,” in this case single-payer healthcare, may be too drastic. As such, the goal of
achieving near-universal coverage and thus a significant extension of the right to healthcare must, at least in the interim, suffice. That this is a political necessity is indicated by the fact that even this less intrusive public option has nonetheless produced substantial opposition. For instance, Republicans argue that whilst private health plans aiming to maximize profits have strong incentives to prevent fraud, government programs do not as strongly pursue such measures, resulting in widespread and unnecessary inefficiency. 31 Furthermore, even the expectation that the government would be able to keep costs low is deemed questionable as it relies on the assumption that powerful interest groups affected by such cost-cutting measures will idly stand by. 32 Thus, a public option, it is maintained, would increase costs for both the government and consumers, thereby exacerbating the issue at hand.
As such the fiscal soundness of both the Republicans’ and Democrats’ proposals remains rather speculative. In essence, each party’s claim that only its respective plan can both increase access and reduce costs is an assertion that only their ideology and conception of health can offer a viable solution. As a result, the acceptance of the other party’s plan becomes a validation of their ideology. Thus, the critique of the economic validity of each plan is in fact a manifestation of the ideological debate. Nonetheless, as indicated by the moderation of each party’s “pure strategy” to accommodate the current political climate, the parties are willing to make concessions within their own plans. The over-arching goal of each party, however, remains the implementation of their own plan and the defeat of their adversary’s. The partisan debate thus appears to produce a hostile environment for reform in which each party refuses to accept its adversary’s plan, regardless of how many concessions it contains.
A THIRD PLAYER: THE IMPORTANCE OF STAKEHOLDERS It may thus appear that the path towards cooperative healthcare reform lies in resolving the ideological hostility between the two parties. However, the fact that the United States is a democracy means that the debate surrounding healthcare reform, which impacts a wide myriad of stakeholders such as consumers, healthcare providers and insurance companies, extends far beyond the concerns of politicians. Such stakeholders generally have little interest in discerning health’s legitimacy or illegitimacy as a right, and instead advocate for policies that promote their narrow interests.
As such, a prominent inhibitor to the resolution of the debate is the general populace; though the majority generally supports the idea of healthcare reform, it is wary of the fundamental changes that such reform inevitably requires. 33 This is largely a product of the general satisfaction with the prevailing system; approximately 88% of insured Americans, who comprise the vast majority of the population, are satisfied with their coverage. 34 Despite this general satisfaction, the public generally sees the healthcare industry, with its “fraud, greed and inefficiency,” as the source of rising costs. Thus, the public supports reform only in so far as it intervenes in the industry to correct these malpractices, whilst keeping the prevailing delivery system itself intact. 35 This results in a political climate in which any taxation, limitation of choices, or reduction of employer insurance
is seen as an unjust imposition on the “innocent” public. This is further compounded by a change-resistant sentiment found amongst “guilty” healthcare providers and insurance companies, both of whom hold considerable power in Washington. As the contributor of 18% of GDP, 36 the healthcare industry holds not only political importance but also economic significance. 37 Thus, when healthcare corporations resist both significant changes to the healthcare system as well as the lowering of prices, they create a significant political barrier. 38 Politicians, in attempting to enact reform, find resistance on multiple and conflicting fronts, thereby significantly reducing the policy options available.
Yet politicians have good reason to avoid antagonizing stakeholders, as exemplified by Bill Clinton’s failed healthcare reform efforts in 1993. Clinton’s plan aimed to achieve universal coverage by replacing the privatized employer-based system through “managed competition” by regional health alliances established by each state. 39 However, Clinton’s failure to consult stakeholders resulted in substantial opposition. 40 Healthcare companies and small businesses spent over $140 million in measures to defeat the initiative. 41 Furthermore, various health industry groups extended the debate to the public through public relations campaigns in which they portrayed the plan as an overextension of government bureaucracy and unnecessary risks. 42 The Clinton Plan became associated with a reduction in insurance status, which propagated fears that the removal of the employer-based system would adversely affect the public. 43 In reality, the plan was not quite as imposing as portrayed, but the average citizen was unable to discern this because of the plan’s undue complexity. 44 As a result, the public, though a dissenter in its own right, also became a malleable resource to be used by powerful opponents to defeat the plan.
Clinton’s failure thus serves as a warning that ignorance towards stakeholder influence, or false optimism towards public sentiment, is largely misplaced. As such, any successful healthcare reform is, by necessity, likely to be a result of deliberation with various stakeholders. However, this produces a serious impediment to change. As neither consumers nor affected corporations accept responsibility in the escalating healthcare crisis, the acceptance of the reduction of the employer-based system as advocated by Republicans, or the acceptance of the public option as advocated by Democrats, would appear to require altruistic actions with insurmountable costs. As a result, unless they provide substantial concessions elsewhere, both plans are unlikely to secure stakeholder support. Thus, the stakeholder debate serves to further reduce the possible scope of reform as each party is forced to make further concessions.
THE DEBATE APPLIED: THE PATIENT PROTECTION AND AFFORDABLE CARE ACT The importance of not only acknowledging but also allowing the partisan and stakeholder debates to shape healthcare reform is particularly evident in President Obama’s Patient Protection and Affordable Care Act (PPACA) of 2010. The plan aimed to extend coverage to millions of Americans and was a product of extensive compromise. As a result, the act overcame opposition to provide the first extensive federal healthcare reform in decades. At the same time, the
concessions have also made it highly controversial amongst not only conservatives, but also liberals who perceive it as too moderate. In principle, the PPACA did intend to abide by liberal principles with a key aim of extending coverage. Although it maintained the employer-based model of insurance, the PPACA included an “employer mandate” requiring all employers to provide insurance to their employees or pay a fine should they fail to do so. The act also included an individual mandate that made a similar requirement of citizens to purchase a healthcare plan, 45 and offered subsidies to people with an income of up to 400% of the federal poverty level to make plans more affordable. 46 Additionally, the PPACA attempted to expand the uniformity of Medicaid by reducing the income eligibility requirement in all states. 47 Despite these changes, the PPACA did not fundamentally alter the prevailing system through a public option, but simply modified existing institutions to grant greater access. Though the PPACA was in no way insignificant, its scope, as compared to liberal aspirations, was rather limited.
In part, this appears to be a product of the concern to not only get a plan passed, but to ensure that such a plan would be viable. Indeed, as Democrats controlled Congress and held a filibuster-proof majority in the Senate, Republican support was not explicitly required to ensure that the act would pass. 48 It was however, required to ensure that the plan would not be repealed in the future. Thus, the plan could not be overly rooted in ideological principles. The passage of the PPACA was therefore presented not as an affirmation of health as a right but rather as an implementation of Congress’s authority to regulate interstate commerce in order to improve American lives. 49 The resolution of ideological disparities was thus not encouraged. The plan further sought to reduce Republican opposition by including libertarian provisions such as private insurance, individual responsibility, and consumer choice. 50 The Democrat’s recognition of the need to reduce the partisan divide, though largely unsuccessful in assuring long-term Republican support, was partially responsible for the deviation from a more assertive plan.
Such moderation also served to ameliorate possible stakeholder resistance. The Obama administration quickly recognized that universal healthcare, even in the form of a public option, would not receive necessary stakeholder support. The public option was controversial even within the Democratic Party itself; several conservative Democrats threatened to filibuster any plan containing it. 51 This did not bode well for the stakeholder debate where it quickly found vehement opposition, led by the most powerful voice of the debate: the healthcare industry. The healthcare industry comprised the third most important source of corporate donations to Obama’s 2008 presidential campaign, spent more on lobbying than any other industry, and had contributed nearly $16 million in campaign contributions to 23 members of the Senate Finance Committee. 52 It thus held considerable political power in voicing concerns regarding the public option, which it subsidized with a campaign aimed at putting pressure on specific members of Congress. 53 Thus, the public option was easily defeated. The healthcare industry’s interests were instead promoted in the administration’s alternatives for the extension of healthcare, which took the form of the individual mandate
and government subsidization, since these provisions guaranteed both healthcare providers and insurance companies tens of millions of new customers. In exchange, these corporations agreed to provide insurance to clients with pre-existing conditions. 54 Though it is impossible to quantify the exact extent of industry influence on the final plan, many of the provisions and limits of the PPACA appear to have been included to serve these corporations.
Overall, the PPACA appears to represent the type of policy-making necessitated by the current political climate. In this climate, the goal of getting a healthcare reform passed must be prioritized over getting the optimal plan passed, which necessitates concessions. Ideally, a progression of such plans would work to alter public and partisan conceptions of healthcare, thus resulting in fewer concessions with every passing plan. Eventually, perhaps, fundamental healthcare reform would be achieved. Yet, at the same time, this method of “progression” transforms each plan, regardless of the concessions that it contains, into a success for the party that passed it. This may explain the continued hostility of the GOP towards the PPACA, which has become a considerable threat in signaling a progression towards the Democratic healthcare agenda. As a result, the current political climate is one in which even a moderate approach such as the PPACA becomes highly controversial as each party is unwilling to concede any ground. Indeed, after Republicans gained control of the House of Representatives in the 2010 mid-term elections, the House passed a series of motions to undermine the PPACA. However, with Democrats controlling the Senate and Obama in the White House, these motions were not existential threats to the Act itself. 55 The PPACA was more significantly challenged in 2011, when a District Court deemed that the plan’s individual mandate, which penalized individuals for failing to purchase health insurance, was beyond the purview of Congress. Further, the Court decided that the individual mandate could not be severed from the PPACA such that the plan was deemed unconstitutional. This ruling was overturned in 2012, when the Supreme Court decided that the individual mandate was reconcilable with Congressional taxation power. However, the Court’s ruling in NFIB v. Sebelius also mandated that the federal government could not exist Medicaid funding from states that did not cooperate with the PPACA’s expansion of Medicaid. Instead, the federal government would have to rely on financial incentives. 56 This decision exposed a key weakness in the PPACA: it relies on states to carry out its policies. As such, NFIB v. Sebelius enabled states governed by Republicans to refrain from expanding Medicaid in the way that the PPACA had intended. 57 States also proved reluctant to set up their own insurance marketplaces, a key aspect of the PPACA intended to increase accessibility to health insurance. As such, when President Trump took office in January 2016, only 32 states had expanded their Medicaid programs, while only 12 had implemented state-based insurance marketplaces. 58 This did not bode well for the PPACA, which soon became the Trump administration’s prime target; Trump vowed in his first address to a Republican-dominated Congress that they would “repeal and replace Obamacare.” 59 Throughout 2017, House Republicans introduced a series of proposals seeking to repeal the PPACA, including the American Health
Care Act, the Senate’s Better Care Reconciliation Act and the Cassidy-Graham amendment. 60 These proposals failed despite Republican control over the House and the Senate, due to “ideological divisions within the Republican party” rather than the “self-reinforcing policy legacies and vested interests” created by the PPACA. 61 As such, Senate leaders introduced the Obamacare Repeal Reconciliation Act, which sought to appeal to both Senate conservatives and moderate Republicans. Yet this bill, too, failed. As a last effort, Republicans launched the “skinny repeal” which would repeal only the most unpopular aspect of the PPACA - the individual mandate. Though this repeal also failed, Republicans eventually succeeded in eliminating the penalties imposed by the mandate by including this provision into the 2017 Tax Cuts and Jobs Act. 62 These failed attempts at repealing the PPACA demonstrate that the Democrats’ decision to pursue relatively conservative market-based reform has succeeded in fracturing Republican support for its repeal. 63 Moreover, these failures also reflect the PPACA’s relative popular support, which reached a peak of 50% in 2017, as well as the healthcare industry’s opposition to further reform. 64 While this suggests that the compromise that shaped the PPACA has contributed to its survival, the repeal of the individual mandate reflects a broader pattern of PPACA retrenchment, as Republicans have become increasingly adept at undermining the act through indirect means. For example, Trump has used executive authority to cut funding, withhold payments to insurers, and reduce the window for open enrolment. 65 Furthermore, the administration has reinterpreted Section 115 of the Social Security Act to allow states to tighten eligibility requirements for Medicaid. 66 Though Republican options are limited through the PPACA’s coalition-building, its erosion continues to form a key aspect of the Republican agenda. Most fundamentally, the Trump administration has “refused to intervene” when the constitutionality of the PPACA was again challenged in Texas v United States in 2018. At present, the Supreme Court is considering whether it should hear the case. There would be grave consequences if the PPACA were judicially invalidated, since states lack the legislative and institutional foundations to uphold aspects of the PPACA should it be repealed. 67 In other words, the PPACA is not yet self-reinforcing which leaves it vulnerable to partisan attacks. The passage of the PPACA did not mark the end of the healthcare debate, nor of antagonistic partisanship. The question of the survival of the PPACA is further complicated by the fact that, as Republicans seek to repeal it, several Democrats, most notably Bernie Sanders, are focused on expanding healthcare outside of the PPACA’s framework. 68 Thus, while the compromise that made the passage of the Act possible has helped to uphold it, it has also fractured the Democratic side. Meanwhile, though this compromise has limited Republican options at repeal, the PPACA’s market-based approach has not succeeded in garnering Republican support. Instead, the Act appears guilty by association with the Obama administration. Thus, the continued survival of the PPACA is precarious.
CONCLUSION The prospects for further healthcare reform appear dire, as the only consensus
throughout the debate lies in the assertion that healthcare reform is necessary. As a result, though the partisan debate has its origin in the question of health’s legitimacy as a right, and this conception has influenced each party’s plan, the debate has extended far beyond this question. In fact, it appears that even if health is agreed upon as a fundamental right, each egocentric constituency, be they a political party or stakeholder, would attempt to enforce this right in “their” way, thus antagonizing each other and eventually failing to enforce the right at all. Thus, the debate becomes a question of costs and benefits and how these factors will be allocated amongst political and public stakeholders. The answer to this question, if it is ever to be achieved, will likely be a product of continued debate and an increased readiness for compromise, but will nonetheless fail to satisfy everyone. For the time being, more limited interim plans, such as the Patient Protection and Affordable Care Act which continues to be controversial and lack bipartisan consensus, have likely reached the current capacity for compromise and change.
NOTES 1 Katherine L. Record, “Litigating the ACA: Securing the Right to Health Within a Framework of Negative Rights,” American Journal of Law & Medicine 38 (2012), 540. 2 Carolynne Shinn, “The Right to the Highest Attainable Standard of Health: Public Health’s Opportunity to Reframe a Human Rights Debate in the United States,” Health and Human Rights 4, no. 1 (1999): 114-133, http://www.jstor.org/stable/4065170, 122. 3 Jill Quadagno, “Institutions, Interest Groups, and Ideology: An Agenda for the Sociology of Health Care Reform,” Journal of Health and Social Behavior 51, no. 2 (2010): 125-136, DOI: 10.1177/0022146510368931, 128. 4 Employers are exempted from paying taxes on employee health insurance premiums, and employees are allowed to exclude such health benefits received from their taxable income (See Quadagno, “Institutions, Interest Groups, and Ideology,” 128). 5 Daniel Béland, Philip Rocco, and Alex Waddan, “Obamacare and the Politics of Universal Health Insurance Coverage in the United States,” Social Policy & Administration 50, no. 4 (2016): 428 - 451, DOI: 10.111/spol.12237, 429. 6 Béland et al., “Obamacare and the Politics of Universal Health Insurance Coverage in the United States,” 430. 7 In fact, Americans do not have a greater life expectancy than their counterparts in peer countries, and boasts an infant mortality rate of 6.3 per 1000 births, which is substantially higher than that found in most of the European Union (See Shaw and Magaldi, Analyzing the Politics of Health Care, 34). 8 Andrew Bradley, “Positive Rights, Negative Rights and Health Care,” Journal of Medical Ethics 36, no. 12 (2010): 838-841, http://www.jstor.org/stable/25764330, 838. 9 Bradley, “Positive Rights, Negative Rights and Health Care,” 839. 10 Shinn, “The Right to the Highest Attainable Standard of Health,” 116. 11 Paul Menzel and Donald W. Light, “A Conservative Case for Universal Access to Health Care,” The Hastings Center Report 36, no. 4 (Jul-Aug. 2006): 36-45, http://www.jstor.org/stable/4625655, 36. 12 Andrew Bradley, “Positive Rights, Negative Rights and Health Care,” 838. 13 Democratic Platform Committee (Orlando, 2016). 2016 Democratic Party Platform. Issued by the Democratic Platform Committee, 2016, 31. 14 Bill Shaw and Jessica A. Magaldi, “Analyzing the Politics of Health Care: Let’s Buy Ourselves Some Civilization,” Journal of Business Ethics 92, no. 1 (March 2010): 33-47, http://www. jstor.org/stable/25621542, 36. 15 Menzel and Light, A Conservative Case, 38. 16 Efrat Ram-Tiktin, “The Right to Health Care as a Right to Basic Human Functional Capabilities,” Ethical Theory and Moral Practice 15 (2011): 337-351. DOI: 10.1007/s10677-011- 9322-7, 339. 17 Thomas Bodenheimer, “The Political Divide in Health Care: A Liberal Perspective,” Health
Affairs 24, no. 6 (2005): 1426-1435, DOI 10.1377/hlthaff.24.6.1426, 1433. 18 Republican National Convention (Cleveland, 2016). Platform of the Republican Party 2016. Issued by the Republican National Convention, 2016, 36. 19 Republican National Convention, Platform of the Republican Party 2016, 36. 20 Eric D. Schansberg, “Envisioning A Free Market in Health Care,” Cato Journal 31, no. 1 (Winter 2011): 27-58. 21 Michael Schwartz and Kevin Young, “How Corporate Power Shaped the Affordable Care Act,” New Labour Forum 23, no. 2 (Spring 2014): 30-40, http://www.jstor.org/stable/24718508, 36-7. 22 Republican National Convention, Platform of the Republican Party 2016, 37. 23 Republican National Convention, Platform of the Republican Party 2016, 36. 24 Republican National Convention, Platform of the Republican Party 2016, 36. 25 Schansberg, “Envisioning A Free Market in Health Care,” 32. 26 Menzel and Light, “A Conservative Case for Universal Access to Health Care,” 40. 27 Menzel and Light, “A Conservative Case for Universal Access to Health Care,” 39. 28 David DeGrazia, “Single Payer Meets Managed Competition: The Case for Public Funding and Private Delivery,” The Hastings Center Report 38. no. 1 (2008): 22-33, http://www.jstor.org/stable/25165289, 28. 29 Scott E. Harrington, “The Health Insurance Reform Debate,” The Journal of Risk and Insurance 77, no. 1 (March 2010) 5-38, http://www.jstor.org/stable/20685289, 24. 30 Harrington, “The Health Insurance Reform Debate,” 24. 31 Harrington, “The Health Insurance Reform Debate,” 27. 32 Ezekiel J. Emanuel, “The Problem with Single-Payer Plans,” The Hastings Center Report 38, no. 1 (Jan-Feb. 2008): 38-41, http://www.jstor.org/stable/25165292, 41. 33 Susan Adler Channick. “Will Americans Embrace Single-Player Health Insurance: The Intractable Barriers of Inertia, Free Market, and Culture,” Law & Inequality: A Journal of Theory and Practice 28, no. 1 (2010): 1-50, h0p://scholarship.law.umn.edu/lawineq/vol28/iss1/1, 33. 34 Channick, “Will Americans Embrace Single-Player Health Insurance,” 32. 35 Daniel Yankelovich, “The Debate That Wasn’t: The Public and The Clinton Plan,” Health Affairs (1995): 8-23, http://courses.phhp.ufl.edu/hsa6152/articles/debatethatwasnt.pdf, 14. 36 Kevin Young and Michael Schwartz, “Healthy, Wealthy, and Wise: How Corporate Power Shaped the Affordable Care Act,” New Labour Forum 23, no. 3 (Spring 2014): 30-40, http://www. jstor.org/stable/24718508, 35. 37 Young and Schwartz, “Healthy, Wealthy, and Wise,” 35. 38 Shaw and Magaldi, “Analyzing the Politics of Health Care,” 40. 39 Channick, “Will Americans Embrace Single-Player Health Insurance,” 20. 40 Yankelovich, “The Debate That Wasn’t: The Public and The Clinton Plan,”8. 41 Quadagno, “Institutions, Interest Groups, and Ideology,” 130. 42 Michael R. Reich, “The Politics of Reforming Health Policies,” IUHPE 19, no. 4 (2002): 138-142, https://cdn1.sph.harvard.edu/wp content/uploads/sites/480/2012/10/Politics_of_ reform.pdf, 141. 43 Channick, “Will Americans Embrace Single-Player Health Insurance,” 21. 44 Reich, “The Politics of Reforming Health Policies,” 141. 45 Béland et al., “Obamacare and the Politics of Universal Health Insurance Coverage in the United States,” 432. 46 Béland et al., “Obamacare and the Politics of Universal Health Insurance Coverage in the United States,” 430. 47 Béland et al., “Obamacare and the Politics of Universal Health Insurance Coverage in the United States,” 431. 48 Béland et al., “Obamacare and the Politics of Universal Health Insurance Coverage in the United States,” 441. 49 Record, Litigating the ACA, 542. 50 Jonathan Oberlander, “Implementing the Affordable Care Act: The Promise and Limits of Health Care Reform,” Journal of Health Politics, Policy and Law 41, no. 4 (2016): 803-826, https://read.dukeupress.edu/jhppl/article/41/4/803/13901/Implementing-the-Afford- able-Care-Act-The-Promise, 807. 51 Béland et. al, “Obamacare and the Politics of Universal Health Insurance Coverage in the United States,” 441. 52 Young and Schwartz, “Healthy, Wealthy, and Wise,” 34. 53 Quadagno, “Institutions, Interest Groups, and Ideology,” 133.
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