By M. Gregg Bloche, M.D., J.D.


If the United States is to come close to universal coverage, personal responsibility will need to play a larger role than it did in the mid-20th-century welfare state. Is there room for a new compact between citizen and state along these lines? Resurgent interest in universal coverage — among state legislators, business leaders, and presidential candidates — suggests that there is.

The new compact is likely to start with an enhanced sense of individual obligation — to eat sensibly, exercise regularly, avoid smoking, and otherwise care for ourselves. It may include an obligation to buy insurance. Government, in exchange, can offer some protection against the threat of economic and social change that will disrupt people’s coverage by destabilizing employment and family relationships. Not only can the state provide subsidies to enable poorer citizens to buy insurance; it can, at low cost, combine people’s purchasing power and clear away obstacles to competition, empowering markets to extend coverage to tens of millions who now go without it. Government can also fashion incentives to foster evidence-based practice, health promotion, the elimination of racial disparities in care, and the reduction of medical errors.

The ideas on health care reform that are being taken seriously in state capitals and in the 2008 presidential campaign are variations on this theme. No plausible presidential candidate is urging a European-style program of generous public insurance for all. Like the Massachusetts plan, the proposals from John Edwards and Senator Barack Obama (D-IL) patch together existing public programs, employment-based coverage, insurance market reforms, and new public subsidies. Their proposals have the potential to achieve near-universal coverage and to improve the quality of care.

In the wake of September 11, 2001, and again after Hurricane Katrina, many Americans hoped to restore a spirit of shared sacrifice and mutual support. More able leaders might have brought us closer. But barring a catastrophe much more severe than that of 9/11, a return to a World War II ethos isn’t likely. What is possible is a new reciprocity of personal and public commitment, tailored to American self-reliance and the uncertainties of a global economy. This arrangement stands a decent chance of delivering near-universal coverage. Success could cement a new understanding of government’s role — not as a guarantor of easy living irrespective of striving but as an insurer of basic decency when self-reliance fails.

Excerpt from an article in the NEJM: NEJM — Health Care for All?

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