aMerICan health PolItICs over reCent deCades
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problems of both U.S. medicine generally and Medicare’s fiscal problems in particular.15 One response is the broad proposal for health savings accounts (HSAs). Instead of participating in group insurance at the place of employment or paying the health insurance portion of Federal Insurance Contributions Act taxes, Americans are urged to contribute, tax free, to health savings accounts to cover their medical care needs. A version of such accounts was included in the 2003 Medicare Prescription Drug, Improvement, and Modernization Act (MMA). The buildup in these accounts, along with an inexpensive “high-deductible” or “catastrophic” insurance policy, would, it is claimed, provide sufficient reserves for medical care both while employed and during old age. There are major transitional problems with this scheme, but those need not distract from the main line of argument. For the young, the healthy, and the affluent, a health savings account approach is a great deal, particularly so if, as is virtually certain, these tax-free savings could be tapped for other purposes once a sufficient cushion was achieved. What happens to the rest of the population is only slightly less clear but broadly predictable. With “good risks” now not in the insurance pool, bad risks must be “insured” by general taxation. In short, instead of medical care as a part of a national pool of social insurance financing (or its Canadian equivalent), the system would move rapidly toward segmentation: private insurance for the young, healthy, and relatively well-off; welfare medicine for everyone else. An alternative “privatization” approach retains Medicare’s social insurance coverage for the elderly but attempts to save public funds by having privately managed care plans compete for Medicare patients. This alternative poses no direct threat to social insurance. Rather, the worrisome issue is whether managed care can both save money and deliver decent medical care at the same time to the elderly, or to anyone else. These are crucial questions for the whole of U.S. medicine, not just Medicare.