January 2003 - Division of Medical Sciences Bulletin - Harvard ...

The Harvard University BBS website: January Bulletin
to pass such a plan in 1945 to its most recent incarnation under the
Clinton administration in 1999. The most significant advance was
made in the 1960s, with the passage of Medicare, which guarantees
coverage to those over 65, and Medicaid, which does the same for
many of the poor.
The main questions Dukakis addressed were how to solve the
problem of rising costs and rising numbers of the uninsured.
Dukakis feels that letting the free market economy dictate health
costs has been a failure, and health care is one area where cost
regulations need to be instituted. In addition, a universal health care
plan should save money, since insurance premiums would no
longer need to be inflated to pay for emergency care for the
uninsured, and administrative costs would be lower.
While Dukakis thinks that a government-administered universal
health care system such as those in Europe and Canada would be
best, it would be too complicated to introduce such a plan in the U.
S. Instead, he suggested two steps to ensure coverage for all. The
first is to expand Medicare, to be paid for by increasing the payroll
tax. The second is to expand employer responsibility by requiring all
employers with more than 25 employees to provide health
insurance, including part-time employees. People who are
unemployed or not covered by this plan would be covered by a
federal program, which would be paid for by a small surcharge
added to the unemployment tax. In addition, Dukakis suggests
limiting the number of insurers, requiring all insurers to accept
anyone despite any pre-existing conditions, putting reasonable
limits on charges for medical procedures, and developing a defined
benefits package. Obviously, achieving these goals will be a long
and arduous process, and more detailed questions surrounding how
to pay for and administer such a plan still remain. Dukakis
emphasized that for any bill to pass, the plan will need to be simple
and straightforward, and will need broad support to build a strong
coalition to take on the powerful insurance companies and other
agencies opposed to this.
However, as an example of a successful policy, Dukakis cited the
state system in Hawaii. In 1974, Hawaii enacted a plan in which all
employers are required to pay for health care for their employees.
As a result, health outcomes in Hawaii are among the best in the
country. However, as one audience member pointed out, this plan
has raised other problems, as in Hawaii it is very difficult to find a
full-time or even part-time position, since employers are loathe to
take on health insurance costs. In addition, as discussed in another
audience question, many other countries with universal health care
plans see the development of a two-tier system, where those with
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