Abstract

Since birth in 1965 under the Social Security Act, Medicare has struggled to define itself not as a Brit, a Swede, or a Swiss but rather as American. The defining feature of being American, therefore, is a ‘public’ sector that draws solely from general revenues. Ironically, it is one of the most accessible in the western world. Even foreigners and pregnant women from all over the world could go there, have babies to be citizens at birth, be slapped only with bills that they were not obligated to pay. It has always been this way only that this time around – in post 9-11 environment – rising cost has put another layer over the access problem. Then there is a ‘private’ one, a segment whose providers are tightly regulated as public goods providers even as it behaves as if it is supplying purely private goods: catering to those with generous workplace plans who are able to afford expensive procedures pitched to them. Any chance to bring the two together? President Obama seeks to by (a) following Massachusetts no-fault formula popularized in the 1970s to mandate enrolment, and (b) bring in insurance exchange to do a dual job of i. desegregating the ‘private’ sector and at the same time ii. force policymakers to bring the inefficient ‘public’ one into one program the way Switzerland, Canada, and Sweden does. But President Obama will not have it easy no matter how modest the proposals he backs because interest groups from both ‘public’ and the ‘private’ sides – from the ‘private’ segment providers, those with generous workplace plans, and from the ‘public’ Veterans, the very poor, and to a lesser extent children (from the ‘private’ segment under the Children’s Health Insurance Programs, CHIP) does just fine under the present rationing models. They fear genuine reform proposal will cut into their perks so they are not going to stand for that, at least not with the present proposals on the table.