Solving the long-run financing challenges facing Medicare and Medicaidrequires addressing the similar growth in health spending taking place inthe private sector. Americas patchwork, incomplete system of healthinsurance impedes the flexibility the economy needs to thrive and grow. Many workers are effectively locked into their jobs because they fear losinghealth insurance. According to one study, labor mobility is 25 percent lessfor those with employer-sponsored health insurance than for those withoutit Madrian Moreover, the market-based economics and trade liber-alization that are key to strong growth are more politically sustainablewhen workers have a greater sense of security and feel that they have moreto gain and less to lose from the global economy.
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The next four chapters contain fouralternative proposals to achieve universal health care coverage, and thefollowing three chapters contain three proposals intended to promotegreater affordability and more effectiveness in the health care system. In some casesthe approaches are complementary; in other cases they represent alterna-tives to achieve the Projects broad goals of promoting growth, broad-basedparticipation in growth, and economic security. In every case they areintended to be innovative ideas that will promote discussion and debate onone of the central economic challenges facing the United States.
Although they all agree on the same goal ofexpanding access to health care, the proposals represent a wide range ofphilosophical approaches. Therefore, their pro-posal would allow individuals to keep their current employer-sponsoredcoverage while also offering insurance to all Americans through Medicare. Their proposal achieves universal coverage by requiring individuals toacquire health insurance with federal subsidies for low-income house-holds and requiring firms to provide it. By building on the history andexperience of Medicare, Anderson and Waters aim for a feasible planthat provides affordable, continuous, and efficient health care coverageto everyone.
Butlers proposed reformcalls for the creation of the Health Exchange Plan. Operating in parallelwithrather than replacingthe employer-sponsored system, the plan isdesigned to fill in the present systems gaps. Butlers plan contains threekey steps that he argues are needed to achieve a gradual transformation inthe health insurance system without disrupting the successful parts of thesystem. First, states should establish insurance exchanges.
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Exchangeswould offer an array of coverage options, and families could retain theirchosen plan from workplace to workplace with the same tax benefits asthose available for traditional employer-sponsored plans. Second, mostemployers should become facilitators, rather than sponsors, of coverage.
While many large employers would continue to sponsor coverage, mostemployers would hand over sponsorship to an insurance exchange andfocus on providing administrative support for their employees insurancechoices. Third, the federal government should reform the tax treatment ofhealth insurance to focus the benefits on lower-income families. By partlydelinking the availability and the subsidy of health coverage from theworkplace, Butlers plan aims at evolutionary reform of the current systemthat would enhance economic and health security for all working families.
Under their proposed Guaranteed Health Care Access Plan,all Americans would receive a universal healthcare voucher to purchase acomprehensive benefit package through private insurance. Private insurance firms would administer the program,and Americans would be able to choose their own physicians, hospitals,and health plans. The authors argue that their proposal would give privateinsurers more incentives to cut costs and compete on the basis of quality,and fewer incentives to discriminate against individuals based on theirhealth since the government would pay insurers a risk-adjusted amount foreach individual.
The authors propose an independent National HealthBoard to define and adjust standard benefits, calculate premiums pai Cure Desintoxication Documents. She no doubt sincerely believed herself to have been injured by the decision; and States, like individuals, acquiesce with great reluctance in determinations to their disadvantage.
Those who had an opportunity of seeing the inside of the transactions which attended the progress of the controversy between this State and the district of Vermont, can vouch the opposition we experienced, as well from States not interested as from those which were interested in the claim; and can attest the danger to which the peace of the Confederacy might have been exposed, had this State attempted to assert its rights by force.
Two motives preponderated in that opposition: one, a jealousy entertained of our future power; and the other, the interest of certain individuals of influence in the neighboring States, who had obtained grants of lands under the actual government of that district. Even the States which brought forward claims, in contradiction to ours, seemed more solicitous to dismember this State, than to establish their own pretensions. These were New Hampshire, Massachusetts, and Connecticut. New Jersey and Rhode Island, upon all occasions, discovered a warm zeal for the independence of Vermont; and Maryland, till alarmed by the appearance of a connection between Canada and that State, entered deeply into the same views.
These being small States, saw with an unfriendly eye the perspective of our growing greatness. In a review of these transactions we may trace some of the causes which would be likely to embroil the States with each other, if it should be their unpropitious destiny to become disunited. The competitions of commerce would be another fruitful source of contention. The States less favorably circumstanced would be desirous of escaping from the disadvantages of local situation, and of sharing in the advantages of their more fortunate neighbors.
Each State, or separate confederacy, would pursue a system of commercial policy peculiar to itself. This would occasion distinctions, preferences, and exclusions, which would beget discontent. The habits of intercourse, on the basis of equal privileges, to which we have been accustomed since the earliest settlement of the country, would give a keener edge to those causes of discontent than they would naturally have independent of this circumstance.
The spirit of enterprise, which characterizes the commercial part of America, has left no occasion of displaying itself unimproved. It is not at all probable that this unbridled spirit would pay much respect to those regulations of trade by which particular States might endeavor to secure exclusive benefits to their own citizens. The infractions of these regulations, on one side, the efforts to prevent and repel them, on the other, would naturally lead to outrages, and these to reprisals and wars.
The opportunities which some States would have of rendering others tributary to them by commercial regulations would be impatiently submitted to by the tributary States.
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The relative situation of New York, Connecticut, and New Jersey would afford an example of this kind. New York, from the necessities of revenue, must lay duties on her importations.
A great part of these duties must be paid by the inhabitants of the two other States in the capacity of consumers of what we import. New York would neither be willing nor able to forego this advantage. Her citizens would not consent that a duty paid by them should be remitted in favor of the citizens of her neighbors; nor would it be practicable, if there were not this impediment in the way, to distinguish the customers in our own markets.
Should we be long permitted to remain in the quiet and undisturbed enjoyment of a metropolis, from the possession of which we derived an advantage so odious to our neighbors, and, in their opinion, so oppressive?
Should we be able to preserve it against the incumbent weight of Connecticut on the one side, and the co-operating pressure of New Jersey on the other? These are questions that temerity alone will answer in the affirmative. The public debt of the Union would be a further cause of collision between the separate States or confederacies. The apportionment, in the first instance, and the progressive extinguishment afterward, would be alike productive of ill-humor and animosity. How would it be possible to agree upon a rule of apportionment satisfactory to all?
There is scarcely any that can be proposed which is entirely free from real objections. These, as usual, would be exaggerated by the adverse interest of the parties.
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There are even dissimilar views among the States as to the general principle of discharging the public debt. Some of them, either less impressed with the importance of national credit, or because their citizens have little, if any, immediate interest in the question, feel an indifference, if not a repugnance, to the payment of the domestic debt at any rate. These would be inclined to magnify the difficulties of a distribution. Others of them, a numerous body of whose citizens are creditors to the public beyond proportion of the State in the total amount of the national debt, would be strenuous for some equitable and effective provision.
The procrastinations of the former would excite the resentments of the latter. The settlement of a rule would, in the meantime, be postponed by real differences of opinion and affected delays. The citizens of the States interested would clamour; foreign powers would urge for the satisfaction of their just demands, and the peace of the States would be hazarded to the double contingency of external invasion and internal contention.
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Suppose the difficulties of agreeing upon a rule surmounted, and the apportionment made. Still there is great room to suppose that the rule agreed upon would, upon experiment, be found to bear harder upon some States than upon others. Those which were sufferers by it would naturally seek for a mitigation of the burden.
The others would as naturally be disinclined to a revision, which was likely to end in an increase of their own incumbrances. Their refusal would be too plausible a pretext to the complaining States to withhold their contributions, not to be embraced with avidity; and the non-compliance of these States with their engagements would be a ground of bitter discussion and altercation.
If even the rule adopted should in practice justify the equality of its principle, still delinquencies in payments on the part of some of the States would result from a diversity of other causes--the real deficiency of resources; the mismanagement of their finances; accidental disorders in the management of the government; and, in addition to the rest, the reluctance with which men commonly part with money for purposes that have outlived the exigencies which produced them, and interfere with the supply of immediate wants.
Delinquencies, from whatever causes, would be productive of complaints, recriminations, and quarrels.
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There is, perhaps, nothing more likely to disturb the tranquillity of nations than their being bound to mutual contributions for any common object that does not yield an equal and coincident benefit. For it is an observation, as true as it is trite, that there is nothing men differ so readily about as the payment of money. Laws in violation of private contracts, as they amount to aggressions on the rights of those States whose citizens are injured by them, may be considered as another probable source of hostility. We are not authorized to expect that a more liberal or more equitable spirit would preside over the legislations of the individual States hereafter, if unrestrained by any additional checks, than we have heretofore seen in too many instances disgracing their several codes.
We have observed the disposition to retaliation excited in Connecticut in consequence of the enormities perpetrated by the Legislature of Rhode Island; and we reasonably infer that, in similar cases, under other circumstances, a war, not of PARCHMENT, but of the sword, would chastise such atrocious breaches of moral obligation and social justice. The probability of incompatible alliances between the different States or confederacies and different foreign nations, and the effects of this situation upon the peace of the whole, have been sufficiently unfolded in some preceding papers.
From the view they have exhibited of this part of the subject, this conclusion is to be drawn, that America, if not connected at all, or only by the feeble tie of a simple league, offensive and defensive, would, by the operation of such jarring alliances, be gradually entangled in all the pernicious labyrinths of European politics and wars; and by the destructive contentions of the parts into which she was divided, would be likely to become a prey to the artifices and machinations of powers equally the enemies of them all.
Divide et impera [ 1 ] must be the motto of every nation that either hates or fears us. In order that the whole subject of these papers may as soon as possible be laid before the public, it is proposed to publish them four times a week--on Tuesday in the New York Packet and on Thursday in the Daily Advertiser. Tuesday, November 20, ASSUMING it therefore as an established truth that the several States, in case of disunion, or such combinations of them as might happen to be formed out of the wreck of the general Confederacy, would be subject to those vicissitudes of peace and war, of friendship and enmity, with each other, which have fallen to the lot of all neighboring nations not united under one government, let us enter into a concise detail of some of the consequences that would attend such a situation.
War between the States, in the first period of their separate existence, would be accompanied with much greater distresses than it commonly is in those countries where regular military establishments have long obtained. The disciplined armies always kept on foot on the continent of Europe, though they bear a malignant aspect to liberty and economy, have, notwithstanding, been productive of the signal advantage of rendering sudden conquests impracticable, and of preventing that rapid desolation which used to mark the progress of war prior to their introduction.