Health policy in the U.S. has long been defined by competing principles and ideas that have led to the highly fragmented current system. On November 7, 2009, a new healthcare bill was passed by the House of Representatives, and, two weeks later, the Senate opened the healthcare debate with a vote of 60 to 39. On Christmas Eve, Senate Democrats passed the healthcare bill with the same tight majority. After the loss of their super-majority in the Senate as a consequence of the Massachusetts election Democrats are now beginning fact-to-face negotiations to merge the two bills. With lawmakers’ debating of alternative proposals, it is important to recognise the underlying causes of institutional complexity in the healthcare system and how the system’s foundational principles can be reformed to make it more comprehensible.
A key instigator of the fragmentation in the healthcare system is that access depends on age, income, occupation, employer, geographical location, or, as in the Oregon health insurance lottery, good fortune. While healthcare systems in other developed economies rely on one main principle of coverage, the U.S. system consists of Medicare, Medicaid, various forms of private insurance, veteran healthcare and emergency services for the uninsured. This combination of different and often opposing principles of coverage has resulted in the world’s most expensive healthcare system without providing healthcare for all. As long as healthcare arrangements ‘fail all reasonable tests of ethical institutional design’, healthcare reform will remain a top priority in U.S. politics.
