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For more than 100 years, reformers in the United States argued for the passage of a national health insurance program, a government guarantee that every person is covered for basic health care. Finally in 2010, the United States took a major, though incomplete, step forward toward universal health insurance with the passage of the Affordable Care Act (ACA). In 2019, the ACA had survived numerous attempts to repeal it, but the law’s future is uncertain.

The subject of national health insurance has seen six periods of intense activity, alternating with times of political inattention. From 1912 to 1916, 1946 to 1949, 1963 to 1965, 1970 to 1974, 1991 to 1994, and 2009 to 2019, it was the topic of major national debate. In 1916, 1949, 1974, and 1994, national health insurance was defeated and temporarily consigned to the nation’s back burner. Guaranteed health coverage for two groups—the elderly and some of the poor—was enacted in 1965 through Medicare and Medicaid. In 2010, with the passage of the ACA or “Obamacare,” the stage was set for the expansion of coverage to millions of uninsured people. National health insurance means the guarantee of health insurance for all the nation’s residents—what is commonly referred to as “universal coverage.” Much of the focus, as well as the political contentiousness, of national health insurance proposals concern how to pay for universal coverage. National health insurance proposals may also address provider payment and cost containment.

The controversies that erupt over universal health care coverage become simpler to understand if one returns to the four basic modes of health care financing outlined in Chapter 2: out-of-pocket payment, individual private insurance, employment-based private insurance, and government financing. There is general agreement that out-of-pocket payment does not work as a sole financing method for costly contemporary health care. National health insurance involves the replacement of out-of-pocket payments by one, or a mixture, of the other three financing modes.

Under government-financed national health insurance plans, funds are collected by a government or quasigovernmental fund, which in turn pays hospitals, physicians, and other health care providers. Under private individual or employment-based national health insurance, funds are collected by private insurance companies, which then pay providers of care.

Historically, health care financing in the United States began with out-of-pocket payment and progressed through individual private insurance, then employment-based insurance, and finally government financing for Medicare and Medicaid (see Chapter 2). In the history of US national health insurance, the chronologic sequence is reversed. Early attempts at national health insurance legislation proposed government programs; private employment-based national health insurance was not seriously entertained until 1971, and individually purchased universal coverage was not suggested until the 1980s (Table 15–1). Following this historical progression, we shall first discuss government-financed national health insurance, followed by private employment-based and then individually purchased coverage. The ACA represents a pluralistic approach that draws on ...

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