James Madison University JMU Scholarly Commons Senior Honors Projects, 2020-current Honors College 5-8-2020 Understanding the failure of universal healthcare proposals in the U.S. and paths forward Nicholas Telesco Follow this and additional works at: https://commons.lib.jmu.edu/honors202029 Part of the Health Policy Commons, Policy History, Theory, and Methods Commons, Public Policy Commons, and the Social Policy Commons Recommended Citation Telesco, Nicholas, "Understanding the failure of universal healthcare proposals in the U.S. and paths forward" (2020). Senior Honors Projects, 2020-current. 52. https://commons.lib.jmu.edu/honors202029/52 This Thesis is brought to you for free and open access by the Honors College at JMU Scholarly Commons. It has been accepted for inclusion in Senior Honors Projects, 2020-current by an authorized administrator of JMU Scholarly Commons. For more information, please contact [email protected]. Understanding the Failure of Universal Healthcare Proposals in the U.S. and Paths Forward _______________________ An Honors College Project Presented to the Faculty of the Undergraduate College of Arts and Letters James Madison University _______________________ by Nicholas James Telesco May 2020 Accepted by the faculty of the Department of Political Science, James Madison University, in partial fulfillment of the requirements for the Honors College. FACULTY COMMITTEE: HONORS COLLEGE APPROVAL: _____________________________________ __________________________________ Project Advisor: Kathleen M. Ferraiolo, Ph.D. Bradley R. Newcomer, Ph.D., Professor, Political Science Dean, Honors College _____________________________________ Reader: Liliokanaio X. Peaslee, Ph.D. Professor, Political Science _____________________________________ Reader: Maria G. DeValpine, Ph.D. Professor, Nursing Table of Contents List of Figures ........................................................................................................................ 4 Acknowledgements ............................................................................................................... 5 Abstract ................................................................................................................................ 6 Introduction .......................................................................................................................... 7 Chapter 1: Overview of U.S. Healthcare System and Literature Review ................................. 12 Issues with Cost, Access, and Quality.......................................................................................... 12 Universal Health Insurance Around the World .......................................................................... 19 Socialized Health Insurance (SHI) in Germany ................................................................................................... 20 National Health Insurance (NHI) in Canada........................................................................................................ 22 National Health System (NHS) in the U.K. .......................................................................................................... 22 Health Policy Literature Review ................................................................................................. 24 A History of Healthcare Reform in the U.S. ........................................................................................................ 24 Explanations for the Failure of Universal Healthcare......................................................................................... 27 Chapter 2: Multiple Streams Approach, Health Security Act, and Affordable Care Act ........... 33 The Problem Stream ................................................................................................................... 33 The Policy Stream ....................................................................................................................... 35 The Political Stream ................................................................................................................... 39 The Policy Window ..................................................................................................................... 42 Applying the Multiple Streams Approach to the Health Security Act and the Affordable Care Act .............................................................................................................................................. 44 2 The Problem Stream, the Health Security Act, and the Affordable Care Act .................................................... 44 The Policy Stream, the Health Security Act, and the Affordable Care Act ......................................................... 48 The Political Stream, the Health Security Act, and the Affordable Care Act ..................................................... 53 The Convergence of the Three Streams and the Policy Window ....................................................................... 60 Paths Forward ..................................................................................................................................................... 62 Chapter 3: Applying the Multiple Streams Approach to Medicare for All ............................... 64 The Problem Stream ................................................................................................................... 64 The Policy Stream ....................................................................................................................... 70 The Politics Stream ..................................................................................................................... 81 Policy Alternatives ...................................................................................................................... 87 Conclusion ........................................................................................................................... 89 References ........................................................................................................................... 94 3 List of Figures Figure 1 This figure details the growth of national health. .......................................................... 12 Figure 2 U.S. per capita spending in 2016 was more .................................................................. 14 Figure 3 The uninsured population decreased after the ACA ...................................................... 14 Figure 4 The U.S. has the second lowest insurance rate .............................................................. 15 Figure 5 This is a visual representation of the multiple. .............................................................. 43 Figure 6 Public support for the Health Security Act was ............................................................ 56 Figure 7 Estimates for Medicare for All have ranged from ......................................................... 76 Figure 8 Over the past two years, a majority of Americans ........................................................ 82 Figure 9 Support for Medicare for All decreases depending ....................................................... 83 4 Acknowledgements I would like to thank my committee and Dr. Lee for their considerable feedback and time spent assisting me with this project. I appreciate all of the excellent advice Dr. Ferraiolo, Dr. Peaslee, and Dr. DeValpine have given me throughout this project and a special thanks to Dr. Ferraiolo for serving as my thesis chair and helping me through every step. I also want to thank my family and friends for their support throughout this project. 5 Abstract Unlike most developed countries, the U.S. does not have a form of universal healthcare, where the government provides insurance for all citizens, despite attempts dating back to 1915. The Patient Protection and Affordable Care Act (ACA), passed in 2010 by President Obama, was a significant expansion of government power in healthcare policy, yet did not guarantee universal insurance. In recent years, universal healthcare proposals have gained traction as the U.S. healthcare system faces issues of low access, high cost, and mediocre quality. In this thesis, I intended to discover the factors that influenced the passage of past U.S. healthcare reforms and potential paths forward. I applied Kingdon’s multiple streams approach, which addresses the factors in the policymaking process that influences a bill’s passage, to the ACA and the Health Security Act, which was a universal healthcare proposal by President Clinton. The ACA was able to achieve passage because of its incremental approach and Obama’s presidential strategy, which included delegating the creation of the legislation to Congress, negotiating with organized forces, and maximizing his political capital. Kingdon’s multiple streams approach highlights the difficulty Medicare for All advocates will have in gaining passage, especially due to insufficient support among the policy community and political actors. In the short-term, advocates should pursue other policies, such as a public option or Continuous Autoenrollment with Retroactive Enforcement (CARE), that can contain costs and expand coverage. 6 Introduction Debates regarding universal healthcare in the U.S., a policy that would guarantee health insurance for all individuals, have occurred since the early twentieth century. The American Association of Labor Legislation (AALL) sponsored a bill in 1915 that would not establish