The debate now raging over how much money the federal government should spend to provide basic health insurance for poor children is just an opening skirmish in what is likely to be an all-out war in coming months and years over how to pay for health care in America.
Almost every presidential candidate in both parties has come up with some proposal that promises to control the costs, broaden the availability and upgrade the quality of health care. At the same time, a growing number of states and localities -- including Howard County and the state of Maryland -- are seeking local answers to the problem.
Health care is in the spotlight for an array of reasons -- a growing proportion of Americans have no health insurance, costs of providing care are rising far faster than the overall rate of inflation, costs to workers of employer-provided insurance are growing while benefits are limited and the costs of coping with catastrophic illness are placing a growing burden on families and communities.
The challenge is finding ways to provide every American with quality affordable health care without dictating how the care will be offered.
Our failure to make progress toward that goal is causing a slow-motion health care crisis that is already threatening the well-being of millions.
In most other developed countries the government offers universal care with more private care choices available to those who can afford them. But many Americans fear the bureaucratic implications of a publicly funded universal care system that might provide mediocre or inadequate care. They say they want the right to choose their own doctors and methods of care.
But, truth be told, a growing proportion of Americans are losing their access to health care choice and seek care only in emergencies. The costs of providing that emergency care are extraordinarily high and the benefits are limited.
Employer-provided insurance, the bedrock of health insurance, is eroding.
About one in six people in the United States -- 46.6 million people -- lacked health insurance for all of 2005 and the ranks of the uninsured are growing with every passing year.
Many companies, particularly smaller firms, faced with fast-rising health insurance expenses are asking workers to cover some of the cost, are limiting benefits or dropping insurance plans altogether. Thirty-nine percent of firms in the United States didn't offer health insurance at all in 2006 and 41.9 percent of "wage and salary" workers aged 18 to 64 were not offered health coverage through their own employers.
Americans worry about health coverage and health care costs. For instance, 54 percent of those polled by the Pew Research Center in 2006 said that paying for the cost of a major illness is a major problem. Some 44 percent said paying for prescription drugs is a major problem.
At the same time, many are not convinced that being uninsured is a problem. A majority in a national poll taken in 2004 mistakenly believed that the uninsured can receive the care they need through clinics and hospital emergency departments.
In fact, lacking health insurance can be seriously dangerous to your health, studies by the National Academy of Sciences' Institute of Medicine (IOM) show.
According to the IOM, an estimated 18,000 adults die each year because they are uninsured and can't get appropriate health care. Hospitalized patients without health insurance receive fewer needed services and lower-quality care, and have a greater risk of dying in the hospital or shortly after discharge than patients with insurance. Uninsured victims with trauma due to an auto crash are 37 percent more likely to die of their injuries.
Uninsured children are five times more likely to have an unmet dental need and about half as likely to get needed mental health care or counseling.
And there's a good chance that at some point an uninsured person or family will face serious, economically destabilizing medical expense. Six out of 10 uninsured working-age adults report problems paying medical bills, compared with 35 percent of insured adults. Among those reporting medical bill problems, 27 percent said they struggled to pay for expenses such as food, rent and heat.
Still, a significant number of workers are balking at the rising costs of employer-sponsored insurance. Premiums for a family of four paid for by workers increased almost 12 percent between 2004 and 2005 -- from $222 a month to $248. Almost two out of three workers who chose not to participate in their employer's health plan in 2002 said the plan was too costly.
Employer-paid health care for retired workers has declined significantly in recent decades, a development that has prompted a growing number of older workers to stay on the job years beyond their original plan. Overall, 35 percent of companies with 200 or more workers offered retiree health benefits in 2006, down substantially from 66 percent in 1988.
A vital health insurance contributor in recent years has been the Medicaid program, funded by both state and federal dollars. Medicaid offers a relatively generous package of benefits to low-income mothers and children, people with disabilities and some low income seniors.
Some 56.3 million people were covered by Medicaid during the 2006 fiscal year and a number of current state and federal proposals to broaden publicly funded health insurance coverage to include more low-income people would use Medicaid as a funnel for the aid.
Children, the healthiest of Medicaid beneficiaries, accounted for 49 percent of the enrollees but just 18 percent of the spending in 2004. People over 65 with disabilities in contrast comprised only 25 percent of beneficiaries but accounted for 70 percent of spending.
Medicaid also pays for nearly half of all long-term care services. Nearly 60 percent of all nursing home residents receive support from Medicaid.
Eligibility rules for Medicaid are complicated and vary widely from state to state.
Critics of proposals to expand some Medicaid coverage -- like the recently debated bipartisan plan to increase spending on the SCHIP program for low-income children -- argue that the added aid would prompt the movement of children from job-based insurance to government-paid coverage.
In fact, the portion of children covered through job-based insurance decreased from 65.6 percent to 60.5 percent between 2000 and 2005 as Medicaid and SCHIP coverage grew.
The quality of Medicaid coverage varies widely, depending on the ability and willingness of state governments to make contributions. Nationally, Medicaid has grown to be the second largest item for state government general fund spending after allocations for elementary and secondary education.
The sheer size of the Medicaid program has forced all states to try to hold down its spending growth. Despite such efforts state and local Medicaid expenses are projected to rise 7.8 percent in 2007.
Beyond the existing Medicaid programs, members of Congress and presidential candidates are debating other mechanisms to broaden access to health insurance and improve care.
Democrats have generally been proposing publicly funded alternatives.
Sen. Hillary Rodham Clinton of New York has suggested that people could keep their existing coverage, choose a private plan offered by the Federal Employees Health Benefits Program or sign up for a new "public plan option similar to Medicare."
Former Sen. John Edwards of North Carolina would give everyone "a choice between private insurers and a public insurance plan modeled after Medicare."
Sen. Barack Obama of Illinois says he would "establish a new public insurance program" for people who do not have access to group coverage.
By contrast, Republicans have generally proposed reforms based on more entrepreneurial concepts.
Former New York Mayor Rudolph W. Giuliani proposes shifting to a system where individuals could buy their own insurance, with the help of tax incentives. Critics say people with relatively few health problems might get a good deal from that plan, while people with more health problems could end up paying more.
Mitt Romney, who was widely praised when he was governor of Massachusetts for his plan to bring provide universal coverage to state residents, said he would like to offer flexible federal aid to empower states to come up with their own solutions to control rising health costs and expand coverage.
Sen. John McCain of Arizona has said that his goal would be to control health care costs by demanding accountability from every player in the industry -- from drug companies to insurance companies to doctors, hospitals, the government and patients.
He argues that significant progress could be made with better treatment of chronic diseases like diabetes and heart disease, which account for 75 percent of all health care costs.
The idea that health care costs could be substantially constrained with better, more pro-active management of care, is one that most health care professionals endorse.
A recent study by the Milken Institute, based in Santa Monica, Calif., said a reorientation of health care toward more prevention counseling could save more than $1 trillion in 2023. Reducing obesity alone could trim the incidence of disease by 14.8 million cases in 2023, saving $60 billion in treatment costs that year.
The idea of coaching patients to better health habits is a key element of an innovative health care plan that will be offered by Howard County to low income residents in the coming year. County officials emphasize the program is not health insurance, but a fee-for-services plan. Coaches will help participants overcome obstacles to fitness and patients can be dropped from the plan if they fail to make good-faith efforts to improve their health.