The Underwriting of American Healthcare: One Hundred Years of Reform and the Need for a New Paradigm

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In 2009, healthcare costs in the United States totaled $2.5 trillion dollars and constituted more than 17% of GDP. 1 , 2 Healthcare inflation has trended higher than general CPI for more than twenty years and this pattern is expected to escalate. The U.S. currently has the most expensive healthcare system in the world both in terms of absolute dollars and per capita spending. The underwriting for these costs however, is highly fragmented and currently leaves 47 million Americans to either cover the full costs themselves or forego treatment. 3 Recent enactment of healthcare reform via the Patient Protection and Affordability Act and the Health Care and Education Reconciliation Act promises to expand insurance coverage as well as redress systemic shortcomings in the delivery and financing of healthcare. However, there is considerable debate as to what will really be accomplished by this latest reform attempt as well as considerable opposition its promulgation. The current debate over healthcare reform is a continuation of a conflict that arose more than one hundred years ago when powerful business, political and medical interest groups allied themselves against changes to the status quo. In 2010, it is simply “déjà vu all over again”.* This paper will present the salient features of the current healthcare model in the U.S. It details the elements making up the three segments of the model and the factors that led to their entrenchment. The paper will also trace the evolutionary reformation of healthcare and the forces that have shaped the model we have today. It will highlight the process surrounding the passage of the latest reform measure as well as specific requirements and protections being introduced by it. *Quote attributed to Yogi Berra As other countries have faced the same issues with respect to the role of government in ensuring the health and welfare of its citizens, a comparative review of the healthcare financing and delivery models in Great Britain, Germany, France and Canada will be presented. The paper will further examine the governance structures in these countries versus those in the U.S. to gain insight as to why the U.S. has lagged behind its democratic peers in implementing healthcare reform. Lastly, this paper will seek to reframe the current U.S. debate over healthcare reform from one centered on underwriting principles to one centered on national values.

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Submitted to the Program of Organizational Dynamics in the Graduate Division of the School of Arts and Sciences in Partial Fulfillment of the Requirements for the Degree of Master of Philosophy at the University of Pennsylvania Advisor: Alan Barstow
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