A day hasn't gone by this year where the national discussion doesn't involve some aspect of health care. Most of the discussions involve health care reform, which means many different things. In one case, it means developing a national health care system that manages to pay for universal health care. This idea, while sounding quite radical, is one pathway to solve our health care problems and more people are discussing this option.

Our current system of employee-funded health care works for many millions of people who obtain their health care through work-related insurance. Balance sheets for a business must consider profitability of their products to include the cost of providing the service or product along with the cost of providing health care for their workers. In the middle are health insurance companies who must generate a profit while keeping their insurance costs down and attractive to the industries that must purchase the health care.

In a market with multiple health care insurers, competition among health care insurance systems tends to drive insurance cost down, but could ultimately reduce the benefits received by the worker. No matter how we look at health care funding, money flows from some source of funds to the consumer of health care, usually through payments to physicians and others who provide the care. The problem with government-funded systems is that there needs to be a source of funds to pay for the care, and this problem has not been solved, so we continue to accumulate debt as we provide services that are underfunded.

When one looks at the balance sheet for funding health care, one realizes that we have developed excellent systems for providing the care, but we haven’t solved the problem of how to pay.

When one looks at the balance sheet for funding health care, one realizes that we have developed excellent systems for providing the care, but we haven’t solved the problem of how to pay. Consequently, our national debt continues to increase, and we create ever-increasing deficits. In the world of employed workers, income earned by an individual or company is the source of health care funding. In the Medicare and Medicaid world, the income side of the health care funding comes from government funds usually through taxation, but our system of taxation is not adequate to fund all of the government-funded health care. And here is where the polarization begins.

On the one hand, advocates of a government-funded system say that we should increase taxes enough on every citizen to cover the cost of health care. Such systems function in Europe and usually generate the needed health care funds from tax revenue. Such a system, however, means that all citizens must pay something for health care either through government taxation or through assessment of individuals for the cost of their health insurance. Whatever method is used, individuals are obligated to pay into the health care cost pool to pay for their insurance. Whatever we choose to call it, the payments are a tax paid to the government to pay for health care.

In the U.S., we are debating the concept that government-funded health care should be minimized and health care purchased as needed. This system assumes that the labor force will support employment-related income and will provide the funds to pay for health care when needed.

And herein lies one of the great debates of our time: Is health care a right to be funded for all citizens through government-supported systems or is it a privilege granted to those who manage to create the needed funds to purchase health care?

Many people would advocate a “Medicare-for-all” solution, but this requires a tax on every citizen to pay for it and a subsidy to those who can’t. The alternative would likely result in many more uninsured citizens who would seek health care in free clinics or forego health care due to a lack of funds. And so, the debate goes on.

Proposals for reform are made almost weekly, up and down votes have been cast, large public protests have been mounted, but no solution is yet forthcoming. It’s clear that we cannot continue to pay for health care without additional funding to avoid an ever-expanding national debt.

The next several months should provide some clarity on where we go from here. So far, government-funded health care in the form of Medicare and Medicaid prevails, but there are efforts to reduce the scope of the existing government programs. Changes in health care funding will have a direct impact on our practices, so keeping up with the changes will be essential to maintaining a successful clinical practice.

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Alfred A. Bove, MD, PhD, MACC, is professor emeritus of medicine at Temple University School of Medicine in Philadelphia, and a former president of the ACC.

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Keywords: ACC Publications, Cardiology Magazine, Medicaid, Health Care Reform, Insurance Carriers, Health Care Costs, Medically Uninsured, Insurance, Health, Medicare, Delivery of Health Care, Government, Government Programs

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