1 See, e.g., Steffie, Woolhandler & David U., Himmelstein, A National Health Program: Northern Light at the End of the Tunnel, 262 JAMA 2136 (1989);Google Scholar see also Kevin, Grumbach et al., Liberal Benefits, Conservative Spending, 265 JAMA 2549 (1991);Google Scholar Paul D., Wellstone & Ellen R., Shaffer, The American Health Security Act — A Single-Payer Proposal, 328 New Eng. J. Med. 1489 (1993).Google Scholar

2 See, e.g., John D., Rockefeller IV, A Call For Action: The Pepper Commission's Blueprint For Health Care Reform, 265 JAMA 2507 (1991);Google Scholar see also General Accounting Office, Access to Health Care: States Respond to Growing Crisis 32-35 (June 1992) (describing the Massachusetts “pay or play” plan enacted in 1988).

3 See generally Bill, Clinton, The Clinton Health Care Plan, 327 New Eng. J. Med. 804 (1992)Google Scholar (for an overview of the Clinton Health Care plan, as proposed during the 1992 Presidential campaign).

4 See generally Alain C., Enthoven, Consumer-Choice Health Plan: A National Health Insurance Proposal Based on Regulated Competition in the Private Sector, 298 New Eng. J. Med. 709 (1978)Google Scholar (detailing the Jackson Hole group's proposal).

5 See American Medical Peer Review Association, Managed Competition and the Role of Quality Oversight (Mar. 1993).

6 Alain C., Enthoven, The History and Principles of Managed Competition, Health Aff., Supp. 1993, at 24,Google Scholar 29 [hereinafter History and Principles],

7 See, e.g., Norman Daniels, Just Health Care (1985).

8 See, e.g., H. Denman, Scott & Howard B., Shapiro, Universal Insurance for American Health Care, 117 Annals Internal Med. 511 (1992).Google Scholar

9 See, e.g., Robert J., Blendon et al., The Health Insurance Industry in the Year 2001: One Scenario, Health Aff., Winter 1991, at 170.Google Scholar

10 BNA, Number of Uninsured Persons Increases to 36.6 Million in 1991, Daily Labor Rep., Jan. 12, 1993, available in Lexis, Nexis Library, Omni File (reporting results of the Employee Benefit Research Institute Study).

11 See Paul H., Wise et al., Racial and Socioeconomic Disparities in Childhood Mortality in Boston, 313 New Eng. J. Med. 360, 364 (1985).Google Scholar

12 See Council on Ethical and Jud. Aff., Black-White Disparities in Health Care, 263 JAMA 2344 (1990).

13 See John Z., Ayanian & Arnold M., Epstein, Differences in the Use of Procedures Between Women and Men Hospitalized for Coronary Heart Disease, 325 New Eng. J. Med. 221, 223-25 (1991).Google Scholar

14 Louis W., Sullivan, The Bush Administration's Health Care Plan, 327 New Eng. J. Med. 801, 801 (y).Google Scholar

15 See Sally T., Sonnenfeld et al., Projection of National Health Expenditures Through the Year 2,000, Health Care Fin. Rev., Fall 1991, at 1, 4, 22;Google Scholar see also Congressional Budget Off., Projections of National Health Expenditures 14 (Table 1) (Oct. 1992).

16 See George J., Scheiber et al., Health Care Systems in Twenty-Four Nations, Health Aff., Fall 1991, at 22, 24.Google Scholar These cost projections are examined with great clarity in Timothy S., Jost & Sandra J., Tanenbaum, Selling Cost Containment, 19 Am. J. L. & Med. 95, 96–97 (1993).Google Scholar

17 See Steffi, Woolhandler & David U., Himmelstein, The Deteriorating Administrative Efficiency of the U.S. Health Care System, 324 New Eng. J. Med. 1253, 1255-56 (1991)Google Scholar (19 to 24 percent of health care expenditures goes toward administrative expenses, including those of the nation's insurance companies).

18 See History and Principles, supra note 6, at 25-27; see also Charles, Weller, “Free Choice” as a Restraint of Trade in American Health Care Delivery and Insurance, 69 Iowa L. Rev. 1351 (1984)Google Scholar (exploring how patients are isolated from the competitive aspects of the health care market).

19 See Paul, Starr & Walter A., Zelman, Bridge to Compromise: Competition Under A Budget, Health Aff., Supp. 1993, at 7, 9.Google Scholar

20 For a related discussion about single-payer systems, see supra note 1.

21 See generally Walter A., Zelman, Who Should Govern the Purchasing Cooperative?, Health Aff., Supp. 1993, at 49.Google Scholar

22 Starr & Zelman, supra note 19, at 17.

23 Clearly, the government could be less generous, offering a full subsidy for those at or below 50% of the poverty line, with diminishing payments for those up to the poverty line.

24 See Robert, Pear, Health Care Costs May Be Increased $100 Billion A Year, N.Y. Times, May 3, 1993,Google Scholar at Al [hereinafter Health Care Costs].

25 See John F., Sheils et al., Potential Public Expenditures Under Managed Competition, Health Aff., Supp. 1993, at 229, 231, 239;Google Scholar Starr & Zelman, supra note 19, at 17; see also John K., Iglehart, The American Health Care System - Medicaid, 328 New Eng. J. Med. 896 (1993).Google Scholar

26 Sheils et al., supra note 25, at 239.

27 See Robert, Pear, Health Care Plan to Cover Injuries on Job and Roads, N.Y. Times, May 8, 1993, at Al.Google Scholar

28 29 U.S.C.A. §§ 1001-1461 (West 1985 & Supp. 1993).

29 See Wendy K., Mariner, Problems with Employer-Provided Health Insurance — The Employee Retirement Income Security Act and Health Care Reform, 327 New Eng. J. Med. 1682, 1685 (1992);Google Scholar see also Lawrence O., Gostin & Alan I., Widiss, What's Wrong with the ERISA I'acuum?: Employers’ Freedom to Limit Health Care Coverage Provided by Risk Retention Plans, 269 JAMA 2527, 2529-31 (1993).Google Scholar

30 If a person who is not enrolled needs health services, some attempt to collect current premiums and recoup past premiums would probably be built into the system.

31 The ideas for Section II were generated collectively by Cluster 17 (“Ethical Foundations“) of the health policy working group, chaired by Nancy Dubler and Marion Secundy. My gratitude goes to all members of this Cluster.

32 See Reinhard, Priester, A Values Framework for Health System Reform, Health Aff., Spring 1992, at 84, 105Google Scholar (proposing fair access as the “preeminent value” of U.S. health care). For general analyses of ethical frameworks, see Daniels, supra note 7.

33 See Health Care Costs, supra note 24.

34 See, e.g., Stephen H., Long & John L., Palmer, Financing Health Care, in Income-Tested Transfer Procrams: the Case for and Against 367, 398Google Scholar (Irwin Garfinkel ed., 1982) (acknowledging that Medicaid recipients may feel stigma because of income testing). See generally, e.g., Lee, Rainwater, Stigma in Income-Tested Programs, in Income Tested Transfer Programs, supra, at 19.Google Scholar

35 Under a negative income tax, eligibility depends on income, not inclusion in a limited category of people. See Irwin, Garfinkel, Introduction, in Income-Tested Transfer Programs, supra note 34, at 1,4.Google Scholar

36 For a discussion of this phenomenon, see Troyen A., Brennan, An Ethical Perspective on Health Care Insurance Reform, 19 Am. J. L. & Med. 37, 42–43 (1993).Google Scholar

37 See Helen R., Burstin et al., Socioeconomic Status and Risk for Substandard Medical Care, 268 JAMA 2383 (1992).Google Scholar

38 See Wise et al., supra note 11.

39 See Mark B., Wenneker et al., The Association of Payer With Utilization of Cardiac Procedure in Massachusetts, 264 JAMA 1255 (1990).Google Scholar

40 See Council on Ethical and Jud. Aff., supra note 12.

41 For example, it is unlikely that any new system in America would prohibit people from buying a supplemental health benefits package with their own money. While many may argue that people can spend their money on any service they choose, there are inherent risks for the new health system. First, if persons can purchase services, they may be taking scarce resources from others in the new system. The most obvious examples involve truly limited resources, such as sophisticated equipment or vital organs. Could a private buyer jump the queue for a kidney transplant over a person who has been waiting in the system? Would society consider that just? Second, one must consider whether government should continue to subsidize health care purchases through tax deductions. Arguably, if persons choose to buy supplemental insurance, they should pay the full and real cost of these services.

42 Professor Laurence Tribe discusses the notion of intrinsic value in the due process right to be heard in Laurence H. Tribe, American Constitutional Law 666-67 (2d ed. 1988).

43 Id. at 666.

44 See id.

45 Some employers in the present system impose managed care on employees, thereby depriving them of a choice of health plan.

46 See, e.g., Weaver v. Reagan, 886 F.2d 194 (8th Cir. 1989).

47 See, e.g., Cruzan v. Director, Missouri Dept. of Health, 497 U.S. 261 (1990).