The power of ideas - can Obama's healthcare reforms change the U.S. health system?

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 (Oregonians who do not qualify for Medicaid, but are too poor to buy their own insurance, can apply for state-subsidised health insurance. The winners are randomly selected). 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 (1). While private insurance has the option to make profits through the coverage of younger and healthier age groups, persons over 65 with a greater likelihood of chronic health conditions are covered under public Medicare. Publicly funded schemes are therefore a lender of last resort for a private insurance market. As long as healthcare arrangements ‘fail all reasonable tests of ethical institutional design’ (1: 103), healthcare reform will remain a top priority in U.S. politics. Ethics, health, and healthcare