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March 15, 2010: speech on health care reform, about this speech.

Barack Obama

March 15, 2010

Remarks by the president on healthcare reform in Strongville, Ohio.

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THE PRESIDENT:  Hello, Ohio!  (Applause.)  It is good to be here in the Buckeye State.  Congratulations on winning the Big Ten Championship.  (Laughter.)  I'm filling out my brackets now.  (Laughter.)  And it’s even better to be out of Washington for a little while.

AUDIENCE:  O-H-I-O.

THE PRESIDENT:  Yes, that kid Turner looks pretty good.  You guys are doing all right.

It is wonderful to be here --

AUDIENCE MEMBER:  I love you!

THE PRESIDENT:  I love you back.  I do.  (Applause.)

Couple of people I just want to make sure I give special mention to.  First of all, you already saw him, Governor Ted Strickland in the house.  (Applause.)  Ted is fighting every day to bring jobs and economic development to Ohio.

So is your terrific United States Senator Sherrod Brown.  Love Sherrod Brown.  (Applause.)  Your own congressman, who is tireless on behalf of working people, Dennis Kucinich.  (Applause.)

AUDIENCE MEMBER:  Vote yes!

THE PRESIDENT:  Did you hear that, Dennis?  Go ahead, say that again.

THE PRESIDENT:  A couple members of Congress are here:  U.S. Representative Betty Sutton.  (Applause.)  U.S. Representative Marcia Fudge.  (Applause.)  U.S. Representative Tim Ryan.  (Applause.)  U.S. Representative Charlie Wilson.  (Applause.)

I want to thank Mayor Tom Perciak here in Strongsville.  Please, Mr. Mayor, you’re on.  (Applause.)  That's a good bunch of folks we got here in Ohio, working hard.  Which is why I'm glad to be back -- and let’s face it, it’s nice to be out of Washington once in a while.  (Laughter.)

I want to thank Connie -- I want to thank Connie, who introduced me.  I want to thank her and her family for being here on behalf of her sister, Natoma.  I don't know if everybody understood that Natoma is in the hospital right now, so Connie was filling in.  It’s not easy to share such a personal story, when your sister who you love so much is sick.  And so I appreciate Connie being willing to do so here today, and -- (applause) -- and I want everybody to understand that Connie and her sister are the reason that I’m here today.  (Applause.)

See, Connie felt it was important that her sister’s story be told.  But I want to just repeat what happened here.  Last month, I got a letter from Connie’s sister, Natoma.  She’s self-employed, she’s trying to make ends meet, and for years she’s done the responsible thing, just like most of you have.  She bought insurance -- she didn’t have a big employer who provided her insurance, so she bought her health insurance through the individual market.

And it was important for her to have insurance because 16 years ago, she was diagnosed with a treatable form of cancer.  And even though she had been cancer-free for more than a decade, the insurance companies kept on jacking up her rates, year after year.  So she increased her out-of-pocket expenses.  She raised her deductible.  She did everything she could to maintain her health insurance that would be there just in case she got sick, because she figured, I didn’t want to be -- she didn’t want to be in a position where, if she did get sick, somebody else would have to pick up the tab; that she’d have to go to the emergency room; that the cost would be shifted onto folks through their higher insurance premiums or hospitals charging higher rates.  So she tried to do the right thing.

And she upped her deductible last year to the minimum [sic], the highest possible deductible.  But despite that, Natoma’s insurance company raised her premiums by more than 25 percent.  And over the past year, she paid more than $6,000 in monthly premiums.

AUDIENCE:  Boo!

THE PRESIDENT:  She paid more than $4,000 in out-of-pocket medical costs, for co-pays and medical care and prescriptions.  So all together, this woman paid $10,000 -- one year.  But because she never hit her deductible, her insurance company only spent $900 on her care.  So the insurance company is making -- getting $10,000; paying out $900.  Now, what comes in the mail at the end of last year?

AUDIENCE MEMBER:  A bill!

AUDIENCE MEMBER:  A rate hike!

THE PRESIDENT:  It’s a letter telling Natoma that her premiums would go up again by more than 40 percent.

THE PRESIDENT:  So here’s what happens.  She just couldn’t afford it.  She didn’t have the money.  She realized that if she paid those health insurance premiums that had been jacked up by 40 percent, she couldn’t make her mortgage.  And despite her desire to keep her coverage, despite her fears that she would get sick and lose the home that her parents built -- she finally surrendered, she finally gave up her health insurance.  She stopped paying it -- she couldn’t make ends meet.

So January was her last month of being insured.  Like so many responsible Americans -- folks who work hard every day, who try to do the right thing -- she was forced to hang her fortunes on chance.  To take a chance, that’s all she could do.  She hoped against hope that she would stay healthy.  She feared terribly that she might not stay healthy.

That was the letter that I read to the insurance companies, including the person responsible for raising her rates.  Now, I understand Natoma was pretty surprised when she found out that I had read it to these CEOs.  But I thought it was important for them to understand the human dimensions of this problem.  Her rates have been hiked more than 40 percent.

And this was less than two weeks ago.  Unfortunately, Natoma’s worst fears were realized.  And just last week, she was working on a nearby farm, walking outside -- apparently, chasing after a cow -- (laughter) -- when she collapsed.  And she was rushed to the hospital.  She was very sick.  She needed two blood transfusions.  Doctors performed a battery of tests.  And on Saturday, Natoma was diagnosed with leukemia.

Now, the reason Natoma is not here today is that she’s lying on a hospital bed, suddenly faced with this emergency -- suddenly faced with the fight of her life.  She expects to face more than a month of aggressive chemotherapy.  She is racked with worry not only about her illness but about the costs of the tests and the treatment that she’s surely going to need to beat it.

So you want to know why I’m here, Ohio?  I’m here because of Natoma.  (Applause.)   I’m here because of the countless others who have been forced to face the most terrifying challenges in their lives with the added burden of medical bills they can’t pay.  I don't think that’s right.  (Applause.)   Neither do you.  That’s why we need health insurance right now.  Health insurance reform right now.  (Applause.)

AUDIENCE:  Obama!  Obama!  Obama!  Obama!

THE PRESIDENT:  I’m here because of my own mother’s story.  She died of cancer, and in the last six months of her life, she was on the phone in her hospital room arguing with insurance companies instead of focusing on getting well and spending time with her family.

I’m here because of the millions who are denied coverage because of preexisting conditions or dropped from coverage when they get sick.  (Applause.)

I’m here because of the small businesses who are forced to choose between health care and hiring.  (Applause.)

I’m here because of the seniors unable to afford the prescriptions that they need.  (Applause.)

I’m here because of the folks seeing their premiums go up 20 and 30 and 40 and 50 and 60 percent in a year.  (Applause.)

Ohio, I am here because that is not the America I believe in and that’s not the America that you believe in.

AUDIENCE MEMBER:  What’s your plan?

THE PRESIDENT:  So when you hear people say “start over” --

AUDIENCE:  No!!

THE PRESIDENT:  -- I want you to think about Natoma.  When you hear people saying that this isn’t the “right time,” you think about what she’s going through.  When you hear people talk about, well, what does this mean for the Democrats?  What does this mean for the Republicans?  I don’t know how the polls are doing.  When you hear people more worried about the politics of it than what’s right and what’s wrong, I want you to think about Natoma and the millions of people all across this country who are looking for some help, and looking for some relief.  That’s why we need health insurance reform right now.  (Applause.)

Part of what makes this issue difficult is most of us do have health insurance, we still do.  And so -- and so we kind of feel like, well, I don’t know, it’s kind of working for me; I’m not worrying too much.  But what we have to understand is that what’s happened to Natoma, there but for the grace of God go any one of us.  (Applause.)  Anybody here, if you lost your job right now and after the COBRA ran out --

(Audience member faints.)

THE PRESIDENT:  It looks like we’ve got somebody who might’ve fainted down there, so if we’ve got a medic.  No, no, no.  Hold on.  I’m talking about there’s somebody who might’ve fainted right down here, so if we can get a medic just back here.  They’re probably okay.  Just give her or him some space.

AUDIENCE MEMBER:  Hope you have insurance.  (Laughter.)

THE PRESIDENT:  So let’s just think about -- think about if you lost your job right now.  How many people here might have had a preexisting condition that would mean it’d be very hard to get health insurance on the individual market?  Think about if you wanted to change jobs.  Think about if you wanted to start your own business but you suddenly had to give up your health insurance on your job.  Think about what happens if a child of yours, heaven forbid, got diagnosed with something that made it hard for them to insure. For so many people, it may not be a problem right now but it’s going to be a problem later, at any point.  And even if you’ve got good health insurance, what’s happening to your premiums?  What’s happening to your co-payments?  What’s happening to your deductible?  They’re all going up.  That’s money straight out of your pocket. So the bottom line is this:  The status quo on health care is simply unsustainable.  (Applause.)  We can’t have -- we can’t have a system that works better for the insurance companies than it does for the American people.  (Applause.) And we know what will happen if we fail to act.  We know that our government will be plunged deeper into debt.  We know that millions more people will lose their coverage.  We know that rising costs will saddle millions more families with unaffordable expenses.  And a lot of small businesses are just going to drop their coverage altogether.  That’s already what’s been happening. A study came out just yesterday -- this is a nonpartisan study -- it’s found that without reform, premiums could more than double for individuals and families over the next decade.  Family policies could go to an average of $25,000 or more.  Can you afford that? AUDIENCE:  No! THE PRESIDENT:  You think your employer can afford that? AUDIENCE:  No! THE PRESIDENT:  Your employer can’t sustain that.  So what’s going to happen is, they’re basically -- more and more of them are just going to say, you know what?  You’re on your own on this. We have debated this issue now for more than a year.  Every proposal has been put on the table.  Every argument has been made.  I know a lot of people view this as a partisan issue, but, look, the fact is both parties have a lot of areas where we agree -- it’s just politics are getting in the way of actually getting it done.  (Applause.)

Somebody asked what’s our plan.  Let me describe exactly what we’re doing, because we’ve ended up with a proposal that incorporates the best ideas from Democrats and Republicans, even though Republicans don’t give us any credit.  (Laughter.)  That’s all right.

You know, if you think about the debate around health care reform, there were some who wanted to scrap the system of private insurance and replace it with government-run care.  And, look, that works in a number of places, but I did not see that being practical to help right away for people who really need it.

And on the other end of the spectrum, and this is what a lot of the Republicans are saying right now, there are those who simply believe that the answer is to unleash the insurance industry, to deregulate them further, provide them less oversight and fewer rules.

THE PRESIDENT:  This is called the fox-guarding-the-henhouse approach to health insurance reform.  (Laughter.)  So what it would do is it would give insurance companies more leeway to raise premiums, more leeway to deny care.  It would segment the market further.  It would be good if you were rich and healthy.  You’d save money.  But if you’re an ordinary person, if you get older, if you get a little sicker, you’d be paying more.

Now, I don’t believe we should give the government or insurance companies more control over health care in America.  I believe it’s time to give you, the American people, more control over your own health insurance.  (Applause.)

And that’s what our proposal does.  Our proposal builds on the current system where most Americans get their health insurance from their employer.  So if you like your plan, you can keep your plan.  If you like your doctor, you can keep your doctor.  I don't want to interfere with people’s relationships between them and their doctors.

Essentially, here’s what my proposal would change:  three things about the current health care system, but three important things.

Number one, it would end the worst practices of the insurance companies.  (Applause.)  All right?  This is like a patient’s bill of rights on steroids.  (Laughter.)  Within the first year of signing health care reform, thousands of uninsured Americans with preexisting conditions will be able to purchase health insurance for the first time in their lives or the first time since they got sick.  (Applause.)  This year, insurance companies will be banned forever from denying coverage to children with preexisting conditions.  So parents can have a little bit of security.  (Applause.)  This year, under this legislation, insurance companies will be banned from dropping your coverage when you get sick.  Those practices would end.  (Applause.)

With this reform package, all new insurance plans would be required to offer free preventive care to their customers starting this year -- so free check-ups to catch preventable diseases on the front end.  That’s a smart thing to do.  (Applause.)  Starting this year, if you buy a new plan, there won’t be lifetime or restrictive annual limits on the amount of care you receive from your insurance companies, so you won’t be surprised by the fine print that says suddenly they’ve stopped paying and you now suddenly are $50,000 or $100,000 or $200,000 out of pocket.  That won’t -- that will not happen if this becomes law this year.  (Applause.) I see -- I see some young people in the audience.  (Applause.)  If you’re an uninsured young adult, you will be able to stay on your parents’ policy until you’re 26 years old under this law.  (Applause.)  So number one -- number one is insurance reform.  The second thing that this plan would change about the current system is this:  For the first time, uninsured individuals, small businesses, they’d have the same kind of choice of private health insurance that members of Congress get for themselves.  (Applause.)  Understand if this reform becomes law, members of Congress, they’ll be getting their insurance from the same place that the uninsured get theirs, because if it’s good enough for the American people, it’s good enough for the people who send us to Washington.  (Applause.) So basically what would happen is, we’d set up a pool of people; millions of people across the country would all buy into these pools that give them more negotiating power.  If you work for a big company, you’ve got a better insurance deal because you’ve got more bargaining power as a whole.  We want you to have all the bargaining power that the federal employees have, that big companies have, so you’ll be able to buy in or a small business will be able to buy into this pool.  And that will lower rates, it’s estimated, by up to 14 to 20 percent over what you’re currently getting.  That’s money out of pocket. And what my proposal says is if you still can’t afford the insurance in this new marketplace, then we’re going to offer you tax credits to do so.  And that will add up to the largest middle-class tax cut for health care in history.  That’s what we’re going to do.  (Applause.) Now, when I was talking about this at that health care summit, some of you saw it -- I sat there for about seven hours; I know you guys watched the whole thing.  (Laughter.)  But some of these folks said, well, we just -- that’s a nice idea but we just can’t afford to do that.  Look, I want everybody to understand -- the wealthiest among us can already buy the best insurance there is.  The least well among us, the poorest among us, they get their health care through Medicaid.  So it’s the middle class, it’s working people that are getting squeezed, and that’s who we have to help, and we can afford to do it.  (Applause.)

Now, it is true that providing these tax credits to middle class families and small businesses, that’s going to cost some money.  It’s going to cost about $100 billion per year.  But most of this comes from the nearly $2.5 trillion a year that Americans already spend on health care.  It’s just right now, a lot of that money is being spent badly.

So with this plan, we’re going to make sure the dollars we make -- the dollars that we spend on health care are going to make insurance more affordable and more secure.  And we’re going to eliminate wasteful taxpayer subsidies that currently go to insurance company.  Insurance companies are making billions of dollars on subsidies from you, the taxpayer.  And if we take those subsidies away, we can use them to help folks like Natoma get health insurance so she doesn’t lose her house.  (Applause.)

And, yes, we will set a new fee on insurance companies because they stand to gain millions more customers who are buying insurance.  There’s nothing wrong with them giving something back.  But here’s the bottom line:  Our proposal is paid for -- which, by the way, is more than can be said for our colleagues on the other side of the aisle when they passed that big prescription drug plan that cost about as much as my health care plan and they didn’t pay for any of it and it went straight to the deficit.  And now they’re up there on their high horse talking about, well, we don’t want to expand the deficit.  This plan doesn’t expand the deficit.  Their plan expanded the deficit.  That’s why we pay for what we do.  That’s the responsible thing to do.  (Applause.) Now, so let me talk about the third thing, which is my proposal would bring down the cost of health care for families, for businesses, and for the federal government.  So Americans buying comparable coverage to what they have today -- I already said this -- would see premiums fall by 14 to 20 percent -- that’s not my numbers, that’s what the nonpartisan Congressional Budget Office says -- for Americans who get their insurance through the workplace.  How many people are getting insurance through their jobs right now?  Raise your hands.  All right.  Well, a lot of those folks, your employer it’s estimated would see premiums fall by as much as 3,000 percent [sic], which means they could give you a raise.  (Applause.) We have incorporated most of the serious ideas from across the political spectrum about how to contain the rising costs of health care.  We go after waste and abuse in the system, especially in Medicare.  Our cost-cutting measures would reduce most people’s premiums and bring down our deficit by up to a  trillion dollars over the next two decades.  Those aren’t my numbers.  Those are the numbers determined by the Congressional Budget Office.  They’re the referee.  That’s what they say, not what I say.

Now, the opponents of reform, they’ve tried to make a lot of different arguments to stop these changes.  You remember.  First, they said, well, there’s a government takeover of health care.  Well, that wasn’t true.  Well, that wasn’t true.  Then they said, well, what about death panels?  Well, that turned out -- that didn’t turn out to be true.

You know, the most insidious argument they’re making is the idea that somehow this would hurt Medicare.  I know we’ve got some seniors here with us today -- I couldn’t tell; you guys look great.  (Laughter.)  I wouldn’t have guessed.  But want to tell you directly:  This proposal adds almost a decade of solvency to Medicare.  (Applause.)  This proposal would close the gap in prescription drug coverage, called the doughnut hole -- you know something about that -- that sticks seniors with thousands of dollars in drug costs.  This proposal will over time help to reduce the costs of Medicare that you pay every month.  This proposal would make preventive care free so you don’t have to pay out-of-pocket for tests to keep you healthy.  (Applause.)

So yes, we’re going after the waste, the fraud, the abuse in Medicare.  We are eliminating some of the insurance subsidies that should be going to your care.  That’s because these dollars should be spent on care for seniors, not on the care and feeding of the insurance companies through sweetheart deals.  And every senior should know there is no cutting of your guaranteed Medicare benefits.  Period.  No “ifs,” “ands,” or “buts.”  (Applause.)  This proposal makes Medicare stronger, it makes the coverage better, and it makes the finances more secure.  And anybody who says otherwise is either misinformed -- or they’re trying to misinform you.  Don’t let them hoodwink you.  They’re trying to hoodwink you.  (Laughter.)

So, look, Ohio, that’s the proposal.  And I believe Congress owes the American people a final up or down vote.  (Applause.)  We need an up or down vote.  It’s time to vote.  And now as we get closer to the vote, there is a lot of hand-wringing going on.  We hear a lot of people in Washington talking about politics, talking about what this means in November, talking about the poll numbers for Democrats and Republicans. AUDIENCE MEMBER:  We need courage! THE PRESIDENT:  We need courage.  (Applause.)  Did you hear what somebody just said?  (Applause.)  That’s what we need.  That’s why I came here today.  We need courage.  (Applause.) We need courage.  You know, in the end, this debate is about far more than politics.  It comes down to what kind of country do we want to be.  It’s about the millions of lives that would be touched and, in some cases, saved, by making health insurance more secure and more affordable.  (Applause.)  It’s about a woman who’s lying in a hospital bed who just wants to be able to pay for the care she needs.  And the truth is, what’s at stake in this debate, it’s not just our ability to solve this problem; it’s about our ability to solve any problem.

I was talking to Dennis Kucinich on the way over here about this.  I said, you know what?  It’s been such a long time since we made government on the side of ordinary working folks -- (applause) -- where we did something for them that relieved some of their struggles; that made folks who work hard every day and are doing the right thing and who are looking out for the families and contributing to their communities, that just gave them a little bit of a better chance to live out their American Dream. The American people want to know if it’s still possible for Washington to look out for these interests, for their future.  So what they’re looking for is some courage.  They’re waiting for us to act.  They’re waiting for us to lead.  They don’t want us putting our finger out to the wind.  They don’t want us reading polls.  They want us to look and see what is the best thing for America, and then do what’s right.  (Applause.)  And as long as I hold this office, I intend to provide that leadership.  And I know these members of Congress are going to provide that leadership.  I don’t know about the politics, but I know what’s the right thing to do.  And so I’m calling on Congress to pass these reforms -- and I’m going to sign them into law.  I want some courage.  I want us to do the right thing, Ohio.  And with your help, we’re going to make it happen.

God bless you, and God bless the United States of America.  (Applause.)

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Obama’s Health Care Speech to Congress

Following is the prepared text of President Obama’s speech to Congress on the need to overhaul health care in the United States, as released by the White House.

Madame Speaker, Vice President Biden, Members of Congress, and the American people:

When I spoke here last winter, this nation was facing the worst economic crisis since the Great Depression. We were losing an average of 700,000 jobs per month. Credit was frozen. And our financial system was on the verge of collapse.

As any American who is still looking for work or a way to pay their bills will tell you, we are by no means out of the woods. A full and vibrant recovery is many months away. And I will not let up until those Americans who seek jobs can find them; until those businesses that seek capital and credit can thrive; until all responsible homeowners can stay in their homes. That is our ultimate goal. But thanks to the bold and decisive action we have taken since January, I can stand here with confidence and say that we have pulled this economy back from the brink.

I want to thank the members of this body for your efforts and your support in these last several months, and especially those who have taken the difficult votes that have put us on a path to recovery. I also want to thank the American people for their patience and resolve during this trying time for our nation.

But we did not come here just to clean up crises. We came to build a future. So tonight, I return to speak to all of you about an issue that is central to that future – and that is the issue of health care.

I am not the first President to take up this cause, but I am determined to be the last. It has now been nearly a century since Theodore Roosevelt first called for health care reform. And ever since, nearly every President and Congress, whether Democrat or Republican, has attempted to meet this challenge in some way. A bill for comprehensive health reform was first introduced by John Dingell Sr. in 1943. Sixty-five years later, his son continues to introduce that same bill at the beginning of each session.

Our collective failure to meet this challenge – year after year, decade after decade – has led us to a breaking point. Everyone understands the extraordinary hardships that are placed on the uninsured, who live every day just one accident or illness away from bankruptcy. These are not primarily people on welfare. These are middle-class Americans. Some can't get insurance on the job. Others are self-employed, and can't afford it, since buying insurance on your own costs you three times as much as the coverage you get from your employer. Many other Americans who are willing and able to pay are still denied insurance due to previous illnesses or conditions that insurance companies decide are too risky or expensive to cover.

We are the only advanced democracy on Earth – the only wealthy nation – that allows such hardships for millions of its people. There are now more than thirty million American citizens who cannot get coverage. In just a two year period, one in every three Americans goes without health care coverage at some point. And every day, 14,000 Americans lose their coverage. In other words, it can happen to anyone.

But the problem that plagues the health care system is not just a problem of the uninsured. Those who do have insurance have never had less security and stability than they do today. More and more Americans worry that if you move, lose your job, or change your job, you'll lose your health insurance too. More and more Americans pay their premiums, only to discover that their insurance company has dropped their coverage when they get sick, or won't pay the full cost of care. It happens every day.

One man from Illinois lost his coverage in the middle of chemotherapy because his insurer found that he hadn't reported gallstones that he didn't even know about. They delayed his treatment, and he died because of it. Another woman from Texas was about to get a double mastectomy when her insurance company canceled her policy because she forgot to declare a case of acne. By the time she had her insurance reinstated, her breast cancer more than doubled in size. That is heart-breaking, it is wrong, and no one should be treated that way in the United States of America.

Then there's the problem of rising costs. We spend one-and-a-half times more per person on health care than any other country, but we aren't any healthier for it. This is one of the reasons that insurance premiums have gone up three times faster than wages. It's why so many employers – especially small businesses – are forcing their employees to pay more for insurance, or are dropping their coverage entirely. It's why so many aspiring entrepreneurs cannot afford to open a business in the first place, and why American businesses that compete internationally – like our automakers – are at a huge disadvantage. And it's why those of us with health insurance are also paying a hidden and growing tax for those without it – about $1000 per year that pays for somebody else's emergency room and charitable care.

Finally, our health care system is placing an unsustainable burden on taxpayers. When health care costs grow at the rate they have, it puts greater pressure on programs like Medicare and Medicaid. If we do nothing to slow these skyrocketing costs, we will eventually be spending more on Medicare and Medicaid than every other government program combined. Put simply, our health care problem is our deficit problem. Nothing else even comes close.

These are the facts. Nobody disputes them. We know we must reform this system. The question is how.

There are those on the left who believe that the only way to fix the system is through a single-payer system like Canada's, where we would severely restrict the private insurance market and have the government provide coverage for everyone. On the right, there are those who argue that we should end the employer-based system and leave individuals to buy health insurance on their own.

I have to say that there are arguments to be made for both approaches. But either one would represent a radical shift that would disrupt the health care most people currently have. Since health care represents one-sixth of our economy, I believe it makes more sense to build on what works and fix what doesn't, rather than try to build an entirely new system from scratch. And that is precisely what those of you in Congress have tried to do over the past several months.

During that time, we have seen Washington at its best and its worst.

We have seen many in this chamber work tirelessly for the better part of this year to offer thoughtful ideas about how to achieve reform. Of the five committees asked to develop bills, four have completed their work, and the Senate Finance Committee announced today that it will move forward next week. That has never happened before. Our overall efforts have been supported by an unprecedented coalition of doctors and nurses; hospitals, seniors' groups and even drug companies – many of whom opposed reform in the past. And there is agreement in this chamber on about eighty percent of what needs to be done, putting us closer to the goal of reform than we have ever been.

But what we have also seen in these last months is the same partisan spectacle that only hardens the disdain many Americans have toward their own government. Instead of honest debate, we have seen scare tactics. Some have dug into unyielding ideological camps that offer no hope of compromise. Too many have used this as an opportunity to score short-term political points, even if it robs the country of our opportunity to solve a long-term challenge. And out of this blizzard of charges and counter-charges, confusion has reigned.

Well the time for bickering is over. The time for games has passed. Now is the season for action. Now is when we must bring the best ideas of both parties together, and show the American people that we can still do what we were sent here to do. Now is the time to deliver on health care.

The plan I'm announcing tonight would meet three basic goals:

It will provide more security and stability to those who have health insurance. It will provide insurance to those who don't. And it will slow the growth of health care costs for our families, our businesses, and our government. It's a plan that asks everyone to take responsibility for meeting this challenge – not just government and insurance companies, but employers and individuals. And it's a plan that incorporates ideas from Senators and Congressmen; from Democrats and Republicans – and yes, from some of my opponents in both the primary and general election.

Here are the details that every American needs to know about this plan:

First, if you are among the hundreds of millions of Americans who already have health insurance through your job, Medicare, Medicaid, or the VA, nothing in this plan will require you or your employer to change the coverage or the doctor you have. Let me repeat this: nothing in our plan requires you to change what you have.

What this plan will do is to make the insurance you have work better for you. Under this plan, it will be against the law for insurance companies to deny you coverage because of a pre-existing condition. As soon as I sign this bill, it will be against the law for insurance companies to drop your coverage when you get sick or water it down when you need it most. They will no longer be able to place some arbitrary cap on the amount of coverage you can receive in a given year or a lifetime. We will place a limit on how much you can be charged for out-of-pocket expenses, because in the United States of America, no one should go broke because they get sick. And insurance companies will be required to cover, with no extra charge, routine checkups and preventive care, like mammograms and colonoscopies – because there's no reason we shouldn't be catching diseases like breast cancer and colon cancer before they get worse. That makes sense, it saves money, and it saves lives.

That's what Americans who have health insurance can expect from this plan – more security and stability.

Now, if you're one of the tens of millions of Americans who don't currently have health insurance, the second part of this plan will finally offer you quality, affordable choices. If you lose your job or change your job, you will be able to get coverage. If you strike out on your own and start a small business, you will be able to get coverage. We will do this by creating a new insurance exchange – a marketplace where individuals and small businesses will be able to shop for health insurance at competitive prices. Insurance companies will have an incentive to participate in this exchange because it lets them compete for millions of new customers. As one big group, these customers will have greater leverage to bargain with the insurance companies for better prices and quality coverage. This is how large companies and government employees get affordable insurance. It's how everyone in this Congress gets affordable insurance. And it's time to give every American the same opportunity that we've given ourselves.

For those individuals and small businesses who still cannot afford the lower-priced insurance available in the exchange, we will provide tax credits, the size of which will be based on your need. And all insurance companies that want access to this new marketplace will have to abide by the consumer protections I already mentioned. This exchange will take effect in four years, which will give us time to do it right. In the meantime, for those Americans who can't get insurance today because they have pre-existing medical conditions, we will immediately offer low-cost coverage that will protect you against financial ruin if you become seriously ill. This was a good idea when Senator John McCain proposed it in the campaign, it's a good idea now, and we should embrace it.

Now, even if we provide these affordable options, there may be those – particularly the young and healthy – who still want to take the risk and go without coverage. There may still be companies that refuse to do right by their workers. The problem is, such irresponsible behavior costs all the rest of us money. If there are affordable options and people still don't sign up for health insurance, it means we pay for those people's expensive emergency room visits. If some businesses don't provide workers health care, it forces the rest of us to pick up the tab when their workers get sick, and gives those businesses an unfair advantage over their competitors. And unless everybody does their part, many of the insurance reforms we seek – especially requiring insurance companies to cover pre-existing conditions – just can't be achieved.

That's why under my plan, individuals will be required to carry basic health insurance – just as most states require you to carry auto insurance. Likewise, businesses will be required to either offer their workers health care, or chip in to help cover the cost of their workers. There will be a hardship waiver for those individuals who still cannot afford coverage, and 95% of all small businesses, because of their size and narrow profit margin, would be exempt from these requirements. But we cannot have large businesses and individuals who can afford coverage game the system by avoiding responsibility to themselves or their employees. Improving our health care system only works if everybody does their part.

While there remain some significant details to be ironed out, I believe a broad consensus exists for the aspects of the plan I just outlined: consumer protections for those with insurance, an exchange that allows individuals and small businesses to purchase affordable coverage, and a requirement that people who can afford insurance get insurance.

And I have no doubt that these reforms would greatly benefit Americans from all walks of life, as well as the economy as a whole. Still, given all the misinformation that's been spread over the past few months, I realize that many Americans have grown nervous about reform. So tonight I'd like to address some of the key controversies that are still out there.

Some of people's concerns have grown out of bogus claims spread by those whose only agenda is to kill reform at any cost. The best example is the claim, made not just by radio and cable talk show hosts, but prominent politicians, that we plan to set up panels of bureaucrats with the power to kill off senior citizens. Such a charge would be laughable if it weren't so cynical and irresponsible. It is a lie, plain and simple.

There are also those who claim that our reform effort will insure illegal immigrants. This, too, is false – the reforms I'm proposing would not apply to those who are here illegally. And one more misunderstanding I want to clear up – under our plan, no federal dollars will be used to fund abortions, and federal conscience laws will remain in place.

My health care proposal has also been attacked by some who oppose reform as a "government takeover" of the entire health care system. As proof, critics point to a provision in our plan that allows the uninsured and small businesses to choose a publicly-sponsored insurance option, administered by the government just like Medicaid or Medicare.

So let me set the record straight. My guiding principle is, and always has been, that consumers do better when there is choice and competition. Unfortunately, in 34 states, 75% of the insurance market is controlled by five or fewer companies. In Alabama, almost 90% is controlled by just one company. Without competition, the price of insurance goes up and the quality goes down. And it makes it easier for insurance companies to treat their customers badly – by cherry-picking the healthiest individuals and trying to drop the sickest; by overcharging small businesses who have no leverage; and by jacking up rates.

Insurance executives don't do this because they are bad people. They do it because it's profitable. As one former insurance executive testified before Congress, insurance companies are not only encouraged to find reasons to drop the seriously ill; they are rewarded for it. All of this is in service of meeting what this former executive called "Wall Street's relentless profit expectations."

Now, I have no interest in putting insurance companies out of business. They provide a legitimate service, and employ a lot of our friends and neighbors. I just want to hold them accountable. The insurance reforms that I've already mentioned would do just that. But an additional step we can take to keep insurance companies honest is by making a not-for-profit public option available in the insurance exchange. Let me be clear – it would only be an option for those who don't have insurance. No one would be forced to choose it, and it would not impact those of you who already have insurance. In fact, based on Congressional Budget Office estimates, we believe that less than 5% of Americans would sign up.

Despite all this, the insurance companies and their allies don't like this idea. They argue that these private companies can't fairly compete with the government. And they'd be right if taxpayers were subsidizing this public insurance option. But they won't be. I have insisted that like any private insurance company, the public insurance option would have to be self-sufficient and rely on the premiums it collects. But by avoiding some of the overhead that gets eaten up at private companies by profits, excessive administrative costs and executive salaries, it could provide a good deal for consumers. It would also keep pressure on private insurers to keep their policies affordable and treat their customers better, the same way public colleges and universities provide additional choice and competition to students without in any way inhibiting a vibrant system of private colleges and universities.

It's worth noting that a strong majority of Americans still favor a public insurance option of the sort I've proposed tonight. But its impact shouldn't be exaggerated – by the left, the right, or the media. It is only one part of my plan, and should not be used as a handy excuse for the usual Washington ideological battles. To my progressive friends, I would remind you that for decades, the driving idea behind reform has been to end insurance company abuses and make coverage affordable for those without it. The public option is only a means to that end – and we should remain open to other ideas that accomplish our ultimate goal. And to my Republican friends, I say that rather than making wild claims about a government takeover of health care, we should work together to address any legitimate concerns you may have.

For example, some have suggested that that the public option go into effect only in those markets where insurance companies are not providing affordable policies. Others propose a co-op or another non-profit entity to administer the plan. These are all constructive ideas worth exploring. But I will not back down on the basic principle that if Americans can't find affordable coverage, we will provide you with a choice. And I will make sure that no government bureaucrat or insurance company bureaucrat gets between you and the care that you need.

Finally, let me discuss an issue that is a great concern to me, to members of this chamber, and to the public – and that is how we pay for this plan.

Here's what you need to know. First, I will not sign a plan that adds one dime to our deficits – either now or in the future. Period. And to prove that I'm serious, there will be a provision in this plan that requires us to come forward with more spending cuts if the savings we promised don't materialize. Part of the reason I faced a trillion dollar deficit when I walked in the door of the White House is because too many initiatives over the last decade were not paid for – from the Iraq War to tax breaks for the wealthy. I will not make that same mistake with health care.

Second, we've estimated that most of this plan can be paid for by finding savings within the existing health care system – a system that is currently full of waste and abuse. Right now, too much of the hard-earned savings and tax dollars we spend on health care doesn't make us healthier. That's not my judgment – it's the judgment of medical professionals across this country. And this is also true when it comes to Medicare and Medicaid.

In fact, I want to speak directly to America's seniors for a moment, because Medicare is another issue that's been subjected to demagoguery and distortion during the course of this debate.

More than four decades ago, this nation stood up for the principle that after a lifetime of hard work, our seniors should not be left to struggle with a pile of medical bills in their later years. That is how Medicare was born. And it remains a sacred trust that must be passed down from one generation to the next. That is why not a dollar of the Medicare trust fund will be used to pay for this plan.

The only thing this plan would eliminate is the hundreds of billions of dollars in waste and fraud, as well as unwarranted subsidies in Medicare that go to insurance companies – subsidies that do everything to pad their profits and nothing to improve your care. And we will also create an independent commission of doctors and medical experts charged with identifying more waste in the years ahead.

These steps will ensure that you – America's seniors – get the benefits you've been promised. They will ensure that Medicare is there for future generations. And we can use some of the savings to fill the gap in coverage that forces too many seniors to pay thousands of dollars a year out of their own pocket for prescription drugs. That's what this plan will do for you. So don't pay attention to those scary stories about how your benefits will be cut – especially since some of the same folks who are spreading these tall tales have fought against Medicare in the past, and just this year supported a budget that would have essentially turned Medicare into a privatized voucher program. That will never happen on my watch. I will protect Medicare.

Now, because Medicare is such a big part of the health care system, making the program more efficient can help usher in changes in the way we deliver health care that can reduce costs for everybody. We have long known that some places, like the Intermountain Healthcare in Utah or the Geisinger Health System in rural Pennsylvania, offer high-quality care at costs below average. The commission can help encourage the adoption of these common-sense best practices by doctors and medical professionals throughout the system – everything from reducing hospital infection rates to encouraging better coordination between teams of doctors.

Reducing the waste and inefficiency in Medicare and Medicaid will pay for most of this plan. Much of the rest would be paid for with revenues from the very same drug and insurance companies that stand to benefit from tens of millions of new customers. This reform will charge insurance companies a fee for their most expensive policies, which will encourage them to provide greater value for the money – an idea which has the support of Democratic and Republican experts. And according to these same experts, this modest change could help hold down the cost of health care for all of us in the long-run.

Finally, many in this chamber – particularly on the Republican side of the aisle – have long insisted that reforming our medical malpractice laws can help bring down the cost of health care. I don't believe malpractice reform is a silver bullet, but I have talked to enough doctors to know that defensive medicine may be contributing to unnecessary costs. So I am proposing that we move forward on a range of ideas about how to put patient safety first and let doctors focus on practicing medicine. I know that the Bush Administration considered authorizing demonstration projects in individual states to test these issues. It's a good idea, and I am directing my Secretary of Health and Human Services to move forward on this initiative today.

Add it all up, and the plan I'm proposing will cost around $900 billion over ten years – less than we have spent on the Iraq and Afghanistan wars, and less than the tax cuts for the wealthiest few Americans that Congress passed at the beginning of the previous administration. Most of these costs will be paid for with money already being spent – but spent badly – in the existing health care system. The plan will not add to our deficit. The middle-class will realize greater security, not higher taxes. And if we are able to slow the growth of health care costs by just one-tenth of one percent each year, it will actually reduce the deficit by $4 trillion over the long term.

This is the plan I'm proposing. It's a plan that incorporates ideas from many of the people in this room tonight – Democrats and Republicans. And I will continue to seek common ground in the weeks ahead. If you come to me with a serious set of proposals, I will be there to listen. My door is always open.

But know this: I will not waste time with those who have made the calculation that it's better politics to kill this plan than improve it. I will not stand by while the special interests use the same old tactics to keep things exactly the way they are. If you misrepresent what's in the plan, we will call you out. And I will not accept the status quo as a solution. Not this time. Not now.

Everyone in this room knows what will happen if we do nothing. Our deficit will grow. More families will go bankrupt. More businesses will close. More Americans will lose their coverage when they are sick and need it most. And more will die as a result. We know these things to be true.

That is why we cannot fail. Because there are too many Americans counting on us to succeed – the ones who suffer silently, and the ones who shared their stories with us at town hall meetings, in emails, and in letters.

I received one of those letters a few days ago. It was from our beloved friend and colleague, Ted Kennedy. He had written it back in May, shortly after he was told that his illness was terminal. He asked that it be delivered upon his death.

In it, he spoke about what a happy time his last months were, thanks to the love and support of family and friends, his wife, Vicki, and his children, who are here tonight . And he expressed confidence that this would be the year that health care reform – "that great unfinished business of our society," he called it – would finally pass. He repeated the truth that health care is decisive for our future prosperity, but he also reminded me that "it concerns more than material things." "What we face," he wrote, "is above all a moral issue; at stake are not just the details of policy, but fundamental principles of social justice and the character of our country."

I've thought about that phrase quite a bit in recent days – the character of our country. One of the unique and wonderful things about America has always been our self-reliance, our rugged individualism, our fierce defense of freedom and our healthy skepticism of government. And figuring out the appropriate size and role of government has always been a source of rigorous and sometimes angry debate.

For some of Ted Kennedy's critics, his brand of liberalism represented an affront to American liberty. In their mind, his passion for universal health care was nothing more than a passion for big government.

But those of us who knew Teddy and worked with him here – people of both parties – know that what drove him was something more. His friend, Orrin Hatch, knows that. They worked together to provide children with health insurance. His friend John McCain knows that. They worked together on a Patient's Bill of Rights. His friend Chuck Grassley knows that. They worked together to provide health care to children with disabilities.

On issues like these, Ted Kennedy's passion was born not of some rigid ideology, but of his own experience. It was the experience of having two children stricken with cancer. He never forgot the sheer terror and helplessness that any parent feels when a child is badly sick; and he was able to imagine what it must be like for those without insurance; what it would be like to have to say to a wife or a child or an aging parent – there is something that could make you better, but I just can't afford it.

That large-heartedness – that concern and regard for the plight of others – is not a partisan feeling. It is not a Republican or a Democratic feeling. It, too, is part of the American character. Our ability to stand in other people's shoes. A recognition that we are all in this together; that when fortune turns against one of us, others are there to lend a helping hand. A belief that in this country, hard work and responsibility should be rewarded by some measure of security and fair play; and an acknowledgement that sometimes government has to step in to help deliver on that promise.

This has always been the history of our progress. In 1933, when over half of our seniors could not support themselves and millions had seen their savings wiped away, there were those who argued that Social Security would lead to socialism. But the men and women of Congress stood fast, and we are all the better for it. In 1965, when some argued that Medicare represented a government takeover of health care, members of Congress, Democrats and Republicans, did not back down. They joined together so that all of us could enter our golden years with some basic peace of mind.

You see, our predecessors understood that government could not, and should not, solve every problem. They understood that there are instances when the gains in security from government action are not worth the added constraints on our freedom. But they also understood that the danger of too much government is matched by the perils of too little; that without the leavening hand of wise policy, markets can crash, monopolies can stifle competition, and the vulnerable can be exploited. And they knew that when any government measure, no matter how carefully crafted or beneficial, is subject to scorn; when any efforts to help people in need are attacked as un-American; when facts and reason are thrown overboard and only timidity passes for wisdom, and we can no longer even engage in a civil conversation with each other over the things that truly matter – that at that point we don't merely lose our capacity to solve big challenges. We lose something essential about ourselves.

What was true then remains true today. I understand how difficult this health care debate has been. I know that many in this country are deeply skeptical that government is looking out for them. I understand that the politically safe move would be to kick the can further down the road – to defer reform one more year, or one more election, or one more term.

But that's not what the moment calls for. That's not what we came here to do. We did not come to fear the future. We came here to shape it. I still believe we can act even when it's hard. I still believe we can replace acrimony with civility, and gridlock with progress. I still believe we can do great things, and that here and now we will meet history's test.

Because that is who we are. That is our calling. That is our character. Thank you, God Bless You, and may God Bless the United States of America.

Presidential Remarks on Health Care Reform

President Obama spoke to an audience of uniformed medical professionals and called on Congress to enact health care reform. He also outlined… read more

President Obama spoke to an audience of uniformed medical professionals and called on Congress to enact health care reform. He also outlined his reform proposal to lower costs and end abuses by insurance companies, including discrimination against people with preexisting conditions. In his remarks he indicated that he would support passage through reconciliation rules by referencing several past votes on legislation. close

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Obama’s Speech: Reviving Health Reform

Subscribe to the economic studies bulletin, henry j. aaron henry j. aaron the bruce and virginia maclaury chair, senior fellow emeritus - economic studies.

September 10, 2009

After the August congressional recess, health care reform was on life support. In a speech of remarkable force and eloquence on Wednesday night to a congressional joint session, President Obama made clear that he would use every resource available to him to assure that health reform survives to become law.

The August recess had left hopes for successful reform hanging by a thread.  The public had become confused and frightened by the prospect of fundamental reform.  Members of Congress were badgered by worried constituents, fearful that reform might jeopardize the relatively good insurance that most enjoy and fear to lose.  The president’s earlier message had been that fundamental change was necessary to preserve that coverage.  Without reform, he said, rising costs would make health insurance unaffordable.  The number of uninsured, which has increased for years, would continue to grow.

But the president had not offered a detailed plan.  Instead, he left the job of writing a bill to Congress.  Various committees came up with not one, but several.  None was complete.  None was fully paid for.  Critics subjected those plans to withering attacks.  Some criticism was substantive.  Much, however, consisted of distortion and misrepresentation—attacks on provisions not actually present in any bill and actively opposed by the president.  Although the bills explicitly excluded illegal aliens from public subsidy, critics falsely said they would be covered.  Where the bills proposed to provide information to the terminally ill, critics conjured up the bogeyman of death panels.  Critics alleged that the president planned a government takeover of health insurance, although he had made clear that his goal was to assure that people could choose among several competing plans and that no more than one would be a government-organized plan.  And at least one Republican opponent said the primary goal was to defeat reform of any sort because beating the president on this issue would cripple his presidency.

Twin Goals: Laying Down Specifics And Appealing To Moderates President Obama had been curiously restrained in the face of these attacks.  That restraint ended Wednesday night.  His speech had two broad goals.  The first was to lay out specific elements of a reform plan.  The second was to secure a majority by reaching out to the moderates in both parties who had not yet decided whether to support or oppose broad reform.

The specifics in the president’s proposal were clear and easy to understand.  If people have insurance, they can keep it.  If they don’t have it, they will have to buy basic coverage.  Subsidies will be provided to make insurance affordable.  Insurers will not be able to turn people away or drop them if they become ill.  Insurance companies will be prohibited from setting limits on annual or lifetime benefits.  Exchanges will regulate the sale of health insurance to enforce these rules.  Drug benefits for seniors would be increased.

As important as clarifying his legislative goals was the need for the president to reach out to Republicans and Democrats who have not yet made up their minds about health reform.  Toward that end, he assured those concerned about burgeoning deficits that he would not sign a bill unless it was fully paid for.  Most of the added cost for subsidies to make insurance affordable would be offset by reductions in the cost of current programs, and if those savings were not realized, he endorsed automatic spending cuts.  To those concerned about costly malpractice litigation, mostly Republicans, he backed reform of medical liability law.  For those moderates of both parties who deplore how the tax system subsidizes the purchase of exorbitant insurance plans, he endorsed a tax on insurance companies that sell high-cost plans.  He reminded Republicans with whom Ted Kennedy had worked on other health care reforms that bi-partisanship should not be a dirty word.

The president explicitly couched health reform in moral terms, harkening back to the small-town values of an America in which neighbors help each other when in need.  But he also raised even higher the already huge political stakes of the health reform debate.  During the presidential campaign and even after, some doubted whether President Obama was serious about health care reform and willing to fight for it.  After his Wednesday night speech, no doubt can remain.  He pushed every political chip to the center of the table and called his opponents to show their hands.

Economic Studies

Elaine Kamarck

April 17, 2024

Frank J. Thompson

October 9, 2020

William A. Galston

February 1, 2019

Presidential Healthcare Reform Rhetoric pp 217–253 Cite as

Barack Obama’s September 9, 2009 Healthcare Speech to Congress

• Noam Schimmel 5  
• First Online: 23 September 2016

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Part of the book series: Rhetoric, Politics and Society ((RPS))

This chapter analyzes Barack Obama’s major healthcare speech to Congress. It situates it in the political context of an increasingly powerful conservative ideology of limited government which was successfully introduced by Ronald Reagan, which remained influential during the presidency of Bill Clinton, and became well entrenched during the presidency of George W. Bush. It pays particular attention to the place of the “middle class” in Obama’s rhetoric and to the significance of the phrase “middle class” as an idealized American signifier. It illustrates what rhetorical strategies are used to demonstrate his concern for the middle class, including strategies of moralization, moral muting, and historical temporality. It notes the importance of conciliation, compromise, and bipartisanship in his rhetoric, and the way in which he is deliberately cautious about expressing an overtly liberal ethos, favoring instead an implicit ethos that does not advocate social and economic rights in a broad manner. He couples moral arguments for expanded health insurance with pragmatic ones based on economics and principles of efficiency. Like Clinton, he uses the rhetorical strategy of personalization to advance the ethos of his proposed healthcare reforms. It notes that low-income and working-class Americans are largely excluded from his rhetoric and, consequently, from the social imaginary and moral order to which he refers and which his rhetoric constructs.

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Schimmel, N. (2016). Barack Obama’s September 9, 2009 Healthcare Speech to Congress. In: Presidential Healthcare Reform Rhetoric. Rhetoric, Politics and Society. Palgrave Macmillan, Cham. https://doi.org/10.1007/978-3-319-32960-4_7

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Watch CBS News

Obama Health Care Speech Highlights

By Kevin Hechtkopf

September 9, 2009 / 8:58 PM EDT / CBS News

In his long-awaited speech to a joint-session of Congress, President Obama tonight laid out many of his key principles and plans for health care reform. Here are some of the highlights from the speech:

• "I am not the first president to take up this cause, but I am determined to be the last. It has now been nearly a century since Theodore Roosevelt first called for health care reform. And ever since, nearly every President and Congress, whether Democrat or Republican, has attempted to meet this challenge in some way. A bill for comprehensive health reform was first introduced by John Dingell Sr. in 1943. Sixty-five years later, his son continues to introduce that same bill at the beginning of each session. Our collective failure to meet this challenge – year after year, decade after decade – has led us to a breaking point."

• "Under my plan, individuals will be required to carry basic health insurance – just as most states require you to carry auto insurance. Likewise, businesses will be required to either offer their workers health care, or chip in to help cover the cost of their workers. There will be a hardship waiver for those individuals who still cannot afford coverage, and 95% of all small businesses, because of their size and narrow profit margin, would be exempt from these requirements. But we cannot have large businesses and individuals who can afford coverage game the system by avoiding responsibility to themselves or their employees. "

• "My health care proposal has also been attacked by some who oppose reform as a "government takeover" of the entire health care system. As proof, critics point to a provision in our plan that allows the uninsured and small businesses to choose a publicly-sponsored insurance option, administered by the government just like Medicaid or Medicare. So let me set the record straight. My guiding principle is, and always has been, that consumers do better when there is choice and competition."

• "I have no interest in putting insurance companies out of business. They provide a legitimate service, and employ a lot of our friends and neighbors. I just want to hold them accountable. The insurance reforms that I've already mentioned would do just that. But an additional step we can take to keep insurance companies honest is by making a not-for-profit public option available in the insurance exchange. Let me be clear – it would only be an option for those who don't have insurance. No one would be forced to choose it, and it would not impact those of you who already have insurance."

• "Despite all this, the insurance companies and their allies don't like this idea. They argue that these private companies can't fairly compete with the government. And they'd be right if taxpayers were subsidizing this public insurance option. But they won't be. I have insisted that like any private insurance company, the public insurance option would have to be self-sufficient and rely on the premiums it collects."

• "Some have suggested that that the public option go into effect only in those markets where insurance companies are not providing affordable policies. Others propose a co-op or another non-profit entity to administer the plan. These are all constructive ideas worth exploring. But I will not back down on the basic principle that if Americans can't find affordable coverage, we will provide you with a choice. And I will make sure that no government bureaucrat or insurance company bureaucrat gets between you and the care that you need."

• "This is the plan I'm proposing. It's a plan that incorporates ideas from many of the people in this room tonight – Democrats and Republicans. And I will continue to seek common ground in the weeks ahead. If you come to me with a serious set of proposals, I will be there to listen. My door is always open. But know this: I will not waste time with those who have made the calculation that it's better politics to kill this plan than improve it. I will not stand by while the special interests use the same old tactics to keep things exactly the way they are. If you misrepresent what's in the plan, we will call you out. And I will not accept the status quo as a solution. Not this time. Not now. "

Full CBSNews.com coverage of the president's speech on health care:

Kevin Hechtkopf is CBSNews.com's politics editor.

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• Editorial Health Care Is a Right, Not a Privilege Howard Bauchner, MD; Phil B. Fontanarosa, MD, MBA; Karen Joynt Maddox, MD, MPH JAMA
• Viewpoint Executive Action to Expand Health Services in the Biden Administration Timothy M. Westmoreland, JD; M. Gregg Bloche, MD, JD; Lawrence O. Gostin, JD JAMA
• Comment & Response The Expansion of Health Care Services in the US—Reply Larry Levitt, MPP JAMA
• Comment & Response Expansion of Health Care Services in the US Christopher R. Morris, MD JAMA

When a new president takes office, it often heralds a major health care reform debate. In fact, health reform in various forms has been debated in the US since the early 1900s.

In 2009, following the election of President Barack Obama, a contentious debate led to the passage of the Affordable Care Act (ACA), possibly the most important domestic policy initiative since the creation of Medicare and Medicaid in 1965. In 2017, following the election of President Donald Trump, a divisive debate over repealing and replacing the ACA ultimately failed, although some significant steps, such as repealing the ACA’s individual mandate penalty, did succeed.

• Editorial Health Care Is a Right, Not a Privilege JAMA

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Levitt L. The Language of Health Care Reform. JAMA. 2021;325(3):215–216. doi:10.1001/jama.2020.25717

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Communication Currents

Communicating About Health Care Reform

The health care debate has been discussed in  many ways : public vs. private, big government vs. small government, freedom vs. tyranny, socialism vs. liberty, and change vs. choice. Effectively communicating about health care reform is essential as it is a predominant issue on both the presidential and congressional agendas. Unfortunately, 48% of the American public still reports being  confused  about health care reform. Too much time has been spent manipulating words to convince the public that specific policies are superior. Instead, policymakers should focus on clearly communicating main tenets of the plans and allowing citizens to decide for themselves.

Information about “rhetoric on health insurance reform” leads the  White House webpage . President Barack Obama has acknowledged the importance of communicating about health care reform and has presented addresses on the issue to both  Congress  and  the public . The Department of Health & Human Services has devoted a  website  to health care reform that provides links to specific pages on communicating about the issue . Additionally, 2009 saw both the White House and congresspersons  (e.g., Arlen Specter) hold open public debate forums across the country regarding national policy on health care. These political sources all attempt to influence policy and public opinion, but many are so burdened with partisan rhetoric that it is nearly impossible to extricate embellishment and rhetorical manipulation from fact. Never has communication been so central to a major political issue, and never has it been so complicated.

With Congressional votes being largely party motivated (Olympia Snowe stands as one  notable exception ), health care reform has been the most divisive political issue in Obama's tenure. Politicians have spent months hammering out the policy details in Congress while interest groups, media outlets, bureaucrats, and pundits struggle to frame the issue on both sides of the aisle. Framing, or making a specific dimension of an issue salient to a given population, has become a priority for politicians in recent years. George Lakoff has written extensively about how controlling the messaging surrounding an issue can change the policy landscape. In  Don't Think of an Elephant , Lakoff explains how Republicans have successfully framed such issues as estate taxes (i.e., “the death tax”) and global warming (i.e., “climate change”) to push policy in their favor. This swirling rhetoric exists on both sides of the aisle; both liberals and conservatives are squarely focused on exploiting the power of words in their pursuit of health care reform.

Howard Dean's book ( Howard Dean's Prescription for Real Health-Care Reform ) gives special treatment to the way the health-care reform is communicated. Dean stresses the idea of choice in health care. That is, American citizens must feel like they have options regarding their care. Lakoff has also outlined  communication strategies  for progressives involved in health care reform. He argues that evoking concepts like empathy and democracy will help liberals advance their reform goals.

Frank Luntz similarly wrote a document targeted toward Republicans in Congress instructing them how to talk about health care reform. Based on a national survey, Luntz's data suggest specific tactics Republicans can use to defeat Democratic proposals and win the battle of public opinion. For example, Luntz recomends that Republicans talk about American citizens as human beings and avoid directly referring to President Obama. He also writes that shifting the blame away from individuals and onto Washington bureaucrats may be a fruitful avenue to gain public support.

Of course this all sounds well and good, as great minds from both parties are consulting communication research and framing theory to guide communication regarding one of the most important political issues of our time. But a problem remains. These groups are trying so hard to exploit the power of well articulated frames that it is impossible to tell what is truth and what is just spin. Spin has been and will likely remain a pervasive force in politics, but the health care debate has escalated it to a new level. It appears that what matters is not the policy content, as few citizens, or members of Congress are well acquainted with the legislation. What seems to matter most is what the public  thinks  the policy says. This lack of public understanding has sparked  minor hysteria  regarding a  public option , so called  death panels , and  opt out policies . Spin from both sides does nothing but hide the facts and complicate the health care policy landscape.

Despite the lack of clarity provided by most politicians and interest groups, some organizations are attempting to communicate directly to the public about health care reform without attempting to extol the superiority of one plan over another. For example, the  Kaiser Family Foundation  has developed  a tool  that allows individuals to compare plans approved by the House and Senate as well as committee plans and individual plans advanced by President Obama and several other members of Congress. The website also provides a health reform subsidy calculator that allows individuals to enter personal information, such as age and annual income, to compute projected costs associated with different plans. These online tools can be complicated and highlight health literacy issues, as even informed citizens may have difficulty understanding the content. Still they are less convoluted than the policy text. They also provide an opportunity for citizens to gain unbiased, concise, and accurate information about the different plans.

With public support of the current health care reform plan hovering around 40%, it is evident that, despite explicit attempts by both sides to successfully frame the issue, neither side is really winning; meanwhile, the public is losing. Even Lakoff  and  Luntz , experts poised on opposite sides of the debate, insist that framing cannot be used to manipulate the facts and must only be used to communicate truth to the people. Message framing is not a weapon to be hastily wielded like hatchet; the only way framing can benefit policy makers and the public is when it is used precisely, properly and with good intentions. If politicians can focus on clearly outlining proposed plans to their constituents instead of hatching crafty catchphrases that sell words, not policy, then we may be much closer to narrowing the gap between health care reform plans than many think.

About the author (s)

Lindsay neuberger.

Doctoral Candidate

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Health Care Reform: Understanding Individuals' Attitudes and Information Sources

Carolyn k. shue.

1 Department of Communication Studies, Ball State University, Muncie, IN 47306, USA

Kerry Anne McGeary

2 Department of Economics, Ball State University, Muncie, IN 47306, USA

3 Global Health Institute, Ball State University, Muncie, IN 47306, USA

Jagdish Khubchandani

4 Department of Physiology and Health Science, Ball State University, Muncie, IN 47306, USA

Maoyong Fan

Since passage of the Affordable Care Act (ACA) was signed into law by President Barrack Obama, little is known about state-level perceptions of residents on the ACA. Perceptions about the act could potentially affect implementation of the law to the fullest extent. This 3-year survey study explored attitudes about the ACA, the types of information sources that individuals rely on when creating those attitudes, and the predictors of these attitudes among state of Indiana residents. The respondents were split between favorable and unfavorable views of the ACA, yet the majority of respondents strongly supported individual components of the act. National TV news, websites, family members, and individuals' own reading of the ACA legislation were identified as the most influential information sources. After controlling for potential confounders, the respondent's political affiliation, age, sex, and obtaining ACA information from watching national television news were the most important predictors of attitudes about the ACA and its components. These results mirror national-level findings. Implications for implementing health care reform at the state-level are discussed.

1. Introduction

In March of 2010, President Barack Obama signed into law health care reform legislation focused on expanding access to affordable health care coverage, controlling rising health care costs, and improving health care delivery [ 1 ]. While few would argue against these goals, how best to achieve the goals and the merit of the current health care legislation has been intensely debated. A variety of opinion polls and statistics have fueled discussion over health care reform.

In June 2010, an Associated Press-GfK opinion poll found an overall increase in support for the Affordable Care Act (ACA). In particular, in one month's time, support increased 10% among men, 14% among adults between the ages 30 and 49, and 9% among Republicans, although the majority of Republicans (83%) still disapprove of the law [ 2 ]. Yet by October 2010, a Kaiser Family Foundation (KFF) report, summarizing eight national polls, found that people generally favored partial or full repeal of the law [ 3 ]. Public opinion in January of 2011 suggested the overall views regarding health care reform remained split with an even number of Americans supporting and opposing the law [ 4 ]. By November 2011, more Americans held an unfavorable view of the law than a favorable view [ 5 ]. Even after the June 2012 Supreme Court ruling in favor of the majority of the ACA provisions, US citizens polled in early July 2012 were evenly split between support for (41%) and against (41%) the ACA [ 6 ]. Throughout the 2012 presidential campaign, this trend remained consistent with 43% in favor and 39% opposed to reform. While health care reform was a factor in the race, it was not a driving factor and opinions did not vacillate much from the trends that began in April of 2010 [ 7 ]. The KFF Poll conducted in the wake of the governmental shutdown, October 2013, demonstrated a slight dip in the favorable views with 38% in favor of the legislation and 44% opposed [ 8 ]. The latest poll conducted in January 2014 indicated more unfavorable views (50%) than favorable views (34%), but in total, the trend numbers illustrate that attitudes toward the ACA have remained relatively stable even during substantial political events [ 9 ].

Despite the split in opinion regarding the ACA, in general, public opinion surveys suggest that Americans do favor many elements of the law. For example, in a January 2011 poll, 59% of individuals supported the provision that penalizes medium- and large-sized companies that do not offer health insurance to employees [ 4 ]. A November 2011 poll identified other elements of health care reform supported by the general public including understandable benefit summaries, small business tax credits and subsidies to aid in the purchase of insurance, and coverage even when individuals have preexisting conditions [ 5 ]. Even though Americans support health care reform elements, there is a general lack of support for tax increases to cover the cost of the reforms and questions remain about the impact of reform on current employer-sponsored insurance programs [ 10 , 11 ].

While health care reform has been mandated at the national level, the execution of that reform will be realized at the state level. In addition, legal action requiring Supreme Court review of the legislation was advanced by state-level opposition. An April 2010 report by The Commonwealth Fund explored health care opinion leaders' views on health care reform, implementation, and postreform priorities. According to opinion leaders, the states' capacity to implement reform and the enforcement of the individual mandate requiring Americans to have health insurance are among the top barriers to implementation [ 12 ]. Lending support for this claim is the KFF's finding that the least favorable element of the health care reform law is the individual mandate [ 5 ].

While the preponderance of attitude research on health care reform has focused on national polls, this study examines attitudes held by Indiana residents over a three-year period. Our goal was to understand the views of Americans at the state level and how those views may be reflective of, or in opposition to, the ACA and national-level public opinion polls regarding health care reform. In addition, it is important to understand the information sources residents rely on as they learn about and form opinions about health care reform. This is a valuable analysis because reform at the state level requires an understanding of the attitudes of a state's citizenry, possible changes in attitudes over time, and the factors that may predict or contribute to specific attitudes for, or against, health care reform and/or its elements. To this end, we explored the following research questions.

• RQ1a: How do residents in states view health care reform?
• RQ1b: How have residents' views about health care reform changed?
• RQ1c: Are the attitudes held by residents in a state different from national views regarding health care reform?
• RQ2a: What information sources do residents use to learn about health care reform?
• RQ2b: How influential are the information sources?
• RQ3: Do factors, such as sex, race, age, political affiliation, insurance coverage, health care usage, and specific information sources predict support for, or against, elements of health care reform?

2. Materials and Methods

2.1. selection and description of participants.

The IRB approved survey was conducted in conjunction with Princeton Research Associates International of Princeton, NJ. A random sample of adults in the state of Indiana over the age of 18 was recruited during the last two weeks in November 2010, 2011, and 2012 to participate in the telephone, both cell phone and landline, survey. The recruitment procedure was consistent across the three years. To recruit respondents, a combination of landline and cellular random digit dial samples was used to identify the telephone numbers of and to contact adult Indiana residents. This systematic respondent selection technique enabled us to obtain a sample that closely represented the population in terms of age and gender when combined with the cell phone sample. For all the samples, the interviewers confirmed the respondent was a current resident of Indiana before administering the survey.

In 2010, the survey included questions on Indiana residents' views of the ACA in general, specific elements of the ACA, and demographic information. In 2011, the survey included the same polling questions regarding the residents' views of the ACA from 2010 so relevant comparisons could be made. In addition, we expanded the 2011 survey to include questions regarding the use of health care services. In 2012, we repeated the previous years' survey questions and added a question about the mandate to require individuals to purchase health care insurance and two questions regarding the variety of sources individuals used to obtain information about health care reform along with how influential the source was in the formation of the individuals' opinion. The response formats used for the survey items were multipoint Likert-type responses (e.g., favorable to unfavorable), closed-format responses (e.g., check one or check all that apply), and open-ended items to obtain frequency data (e.g., in the past 12 months, how many times have you, yourself, gone to an emergency room for medical treatment?). The survey was pilot tested prior to data collection.

Power analysis was conducted a priori and based on an eligible population of approximately 5 million adults in Indiana, a sampling error of ±5% at the 99% confidence level, it was determined that a sample of 498 adults would be needed to make inferences to the total population of adults in the state of Indiana. Our final sample size for all three years of the study far exceeded the required number ( n = 601 in 2010, n = 607 in 2011, and n = 602 in 2012).

2.2. Data Analysis

Data were analyzed using STATA 12. Using weighted data, we computed descriptive statistics to investigate the responses to the survey items as well as the demographic and background characteristics of the respondents. We computed chi-square tests and conducted binary logistic regression analyses using the weighted data to assess the association between the dependent variables (attitudes about health care reform, health services usage, and information sources) and independent predictor variables (race, gender, age, insurance status, education, and political affiliation of the respondents). A two-stage weighting procedure was used. The first stage of weighting corrected for different probabilities of selection associated with the number of adults in each household and each respondent's telephone usage patterns. The second stage of weighting balanced sample demographics to population parameters. The sample was balanced to match parameters for sex, age, education, race, Hispanic origin, region, population density, number of adults in the household, and telephone usage.

3.1. Demographic and Background Characteristics of Study Participants

Table 1 presents the descriptive frequencies for the respondent characteristics across all three years of the study. In general, the samples were similar from year to year; the respondents represented in the samples were predominately white, non-Hispanic, covered by some form of health insurance, and evenly split between men and women. The weighted average age of the respondents was approximately 47 years (2010: x - = 47.56 years, std error = ±0.84; 2011: x - = 47.12 years, std error = ±0.80; and 2012: x - = 47.77 years, std error = ±0.84). The most frequently reported household income range was $30,000 to $50,000. Most of the respondents held a high school degree and approximately a quarter of the respondents had completed some college. Political affiliation was generally consistent across the three years of the study.

Respondent characteristics by year: weighted frequencies.

Note: categorical percentages may not sum to 100%, given that some respondents selected not to answer some of the demographic questions.

In this study, we asked respondents whether they supported the ACA or not. The resulting data demonstrated a change in Indiana residents' views of the ACA (see Figure 1 ). In 2010, 48% of Indiana residents expressed an unfavorable view of the ACA compared with 51% in 2011, and 42% in 2012. The initial increase in negative sentiment may have been the result of a decrease in the number of Indiana residents who reported having a mixed view of the ACA in 2010, while the subsequent increase in positive sentiment in 2012 was a shift from unfavorable to favorable views. The percentage of those reporting a “mixed view” of the ACA fell from 3% to 1% from 2010 to 2011 and increased to 2% in 2012. There was not a statistically significant difference in the “mixed view” category among the years. The Kruskal-Wallis equality of populations rank test indicated a statistically significant difference at the 1% level among the years regarding overall changes in views of the ACA ( χ 2 = 13.694, P = 0.001). Follow-up chi-square analyses indicated that the increase in the proportion of individuals reporting favorable views over the three years was the greatest contributing factor to the overall significant chi-square result (favorable proportional changes χ 2 = 9.315, P = 0.001; unfavorable proportional changes χ 2 = 4.797, P = 0.091).

Indiana residents' views of the Affordable Care Act 2010–2012.

In regard to health care use and perceptions of the ACA during 2011 and 2012, there was a difference in overall support. Generally, respondents who had used some form of health care service at least once during each year of the survey reported more support for the ACA (2011: 35%; 2012: 45%) than those respondents who did not seek or require health services (2011: 29%; 2012: 38%), χ 2 = 4.309, P = 0.038.

In our study, in addition to indicating their overall view of the ACA, respondents were asked about key elements of the ACA, specifically if making coverage affordable, ensuring coverage for everyone, mandating that preexisting conditions be accepted by insurance companies, providing coverage for children until age 26, and the individual mandate requiring people to purchase health insurance were important. In 2010, despite 48% reporting an unfavorable view of the ACA, 96% of Indiana residents revealed that making coverage affordable was important. Similarly, 80% and 91% of Indiana residents in 2010 felt that ensuring coverage for everyone and the coverage for preexisting condition mandates were important. When asked about the importance of providing coverage for children until age 26, 69% of Indiana residents felt that was important. In 2011 and 2012, despite 51% and 42% reporting an unfavorable view of the ACA, respectively, 95% and 93% of Indiana residents felt affordable health care coverage was important, 83% and 81% supported ensuring coverage for everyone, 90% of residents in both 2011 and 2012 felt insurance companies should cover preexisting conditions, 70% and 77% felt children should be covered until age 26, and in 2012, 63% of Indiana residents supported the individual mandate requiring people to purchase health insurance. While the majority of changes in the percentage of Indiana residents reporting that these elements were important from 2010 to 2012 are small and not statistically significant, there is a significant difference among the years in the percentage reporting they felt that children should be covered until the age of 26 at the 1% level ( χ 2 = 13.896, P = 0.001). Overall, from 2010 to 2012, despite a general negative attitude toward the ACA, the majority of Indiana residents consistently support key elements of the legislation.

While making insurance coverage affordable was viewed as important by more than 9 out of 10 Indiana residents from 2010 to 2012, the importance of affordable coverage, or any of the ACA elements, may be viewed differently based on the respondent's health insurance status. Therefore, we stratified the respondents by insurance status to determine if there were attitude differences. In 2010, 36% of insured respondents had a favorable view of the ACA compared to 32% of uninsured respondents. In 2011, the respective comparisons were 34% of insured respondents versus 36% of uninsured respondents and in 2012, 44% versus 42%.

In general, providing insurance coverage for everyone was important to approximately 8 in 10 Indiana residents. Between 2010 and 2012 support for this element of the ACA initially increased from 80% to 83% and then decreased to 81%. In 2010, support for this provision was higher among uninsured Indiana residents (87%) compared to insured Indiana residents (78%), and this difference was statistically significant, χ 2 = 4.557, P = 0.031. In 2011, while the percentage of uninsured respondents who felt ensuring coverage for everyone remained constant (87%), the number of insured respondents reporting that providing coverage for everyone was important increased to 82%. By 2012, nearly equal percentages of insured and uninsured respondents felt providing coverage for everyone was important (81% and 80%, resp.).

The ACA elements receiving the least amount of support from Indiana residents were allowing children up to age 26 to be covered by their parents' health insurance whether or not they were in college and the individual mandate. In 2010 and 2011, approximately 69% of respondents supported insuring children up to age 26. In 2012, the percentage of respondents indicating support for this element of the ACA rose to 77%. This increase in 2012 was statistically significant, χ 2 = 13.896, P = 0.001. Across the three years, support for covering children up to age 26 was relatively consistent with approximately 71% of insured respondents and 75% of uninsured respondents in favor of this element. In 2012, 63% of respondents felt the individual mandate was important. Analysis of attitude difference by insurance status revealed 64% of insured respondents felt the individual mandate was important compared to 59% of uninsured respondents.

In an effort to clarify our understanding of the public's opinion of the ACA, the 2011 and 2012 surveys were expanded to include questions that would elicit information regarding additional confounders. Therefore, these surveys included questions regarding health care utilization. Health care utilization questions asked respondents how many times during the past 12 months they had visited a doctor, stayed overnight in the hospital, visited the hospital for outpatient care, or went to the emergency room. The most interesting results revolved around emergency room use and physician visits.

In 2011 and 2012, equivalent percentages of insured and uninsured respondents reported utilizing the ER at least once during the past 12 months (2011: 29% versus 30%; 2012: 27% versus 29%). Since ER use is not necessarily planned and, in general, is a more expensive point-of-access into the health care system, we polled Indiana residents on their use of physician visits, a less expensive health care service ( Figure 2 ). Insured Indiana residents were more likely to use physician services compared to uninsured Indiana residents. Of the Indiana residents polled in 2011 and 2012, 85% and 89% of insured Indiana residents reported visiting a physician in the last 12 months compared to 54% and 59% of Indiana residents who were not insured. These differences were significant, χ 2 = 45.82, P < 0.001 and χ 2 = 44.21, P < 0.001.

Physician visits by insurance coverage 2011-2012. Note: the data reported in Figure 2 is based on only those respondents who answered both survey questions—physician use and insurance status.

3.2. Logistic Analysis of Predictors

For the data from 2010 to 2012, we explored how the respondent characteristics predicted attitudes about the ACA using logistic regression modeling to control for confounders that could influence the views of individuals ( Table 2 ). Each categorical independent variable was recoded to create a dichotomous variable (e.g., race was recoded into white versus nonwhite). The models presented in Table 2 report the adjusted odds ratios which controlled for potential confounders. All models were significant at P < 0.01 and F -values ranged from 2.73 to 15.00. We found that females (AOR = 1.48, P < 0.01), nonwhites (AOR = 1.72, P = 0.02), Democrats (AOR = 2.75, P < 0.01), and insured individuals (AOR = 1.60, P = 0.04) were more likely to have a general favorable attitude towards health care reform. Older Indiana residents (AOR = 0.99, P = 0.04) and Republicans (AOR = 0.41, P < 0.01) were less likely to have a favorable attitude towards health care reform.

Predictors of attitudes towards health care reform and five provisions.

+ The specific questions asked to elicit attitude data are as follows: What is your overall impression of the health care law passed by Congress? Is it…?, How important is making health care more affordable?, How important is ensuring health coverage for everyone?, How important is prohibiting insurance companies from cancelling health plans due to preexisting conditions?, How important is allowing children up to age 26 to be covered by their parents' health insurance whether or not they are in college?

∗AOR: adjusted odds ratio implies controlling for age, gender, race, education, insurance status, and political affiliation. These are for association of favorable attitudes with independent predictors. The binary dependent variable was “attitude”-favorable (1) or unfavorable (0) or important (1) or unimportant (0). P values for odds (2 df, Wald's χ 2 test).

† Data regarding respondents' attitudes toward the individual mandate to purchase health insurance was only collected in 2012.

When asked about the importance of health care affordability, females (AOR = 1.90, P = 0.04) and Democrats (AOR = 31.33, P < 0.01) were more likely to affirm that attitude, while the opposite was true as income (AOR = 0.99, P < 0.01) increased. When asked about the importance of preexisting condition coverage, females (AOR = 1.99, P = 0.01) were more likely to support that view. Females (AOR = 2.25, P < 0.01), nonwhites (AOR = 4.31, P = 0.02), and Democrats (AOR = 6.38, P < 0.01) were more likely to view providing health care coverage for everyone as important, while Republicans (AOR = 0.47, P < 0.01) were less likely to view this as important and support for this element decreased as age (AOR = 0.98, P < 0.01) and income (AOR = 0.99, P = 0.02) increased. Females (AOR = 2.01, P < 0.01) and Democrats (AOR = 2.29, P < 0.01) were more likely to support coverage of children up to age 26 and, in general, support for this element increased from 2010 to 2012 (AOR = 1.28, P < 0.01). Consistent with previous findings, support for insuring children up to age 26 decreased as age (AOR = 0.97, P < 0.01) increased. For the individual mandate requiring people to purchase health insurance introduced in 2012, females (AOR = 1.97, P < 0.01), nonwhites (AOR = 7.83, P < 0.01), and Democrats (AOR = 2.77, P < 0.01) were more likely to support this element.

For the 2011 and 2012 surveys, we explored whether the independent respondent characteristic variables predicted health services usage ( Table 3 ). As in Table 2 , we present the adjusted analysis controlling for potential confounders. All models were significant with F -values ranging from 2.21 to 9.77 and P values ranging from .019 to <.001. The results indicate visiting a physician in the past 12 months was strongly associated with females (AOR = 1.84, P < 0.01), older age (AOR = 1.01, P = 0.01), Democrats (AOR = 1.67, P = 0.05), and having health insurance coverage (AOR = 5.32, P < 0.01). Those with health insurance were more likely to have stayed overnight in the hospital (AOR = 3.46, P < 0.01) or to have been treated as an outpatient in the hospital (AOR = 2.62, P < 0.01). The likelihood of an overnight stay increased as age increased (AOR = 1.01, P = 0.03), yet the likelihood of an ER visit decreased as age increased (AOR = 0.99, P = 0.03). Finally, the likelihood of overnight hospital stays and ER visits decreased as income increased (AOR = 0.99, P < 0.001).

Predictors of health care usage.

+ The specific questions asked to elicit health services usage data are as follows: In the past 12 months, how many times have you, yourself, made a doctor visit?, In the past 12 months, how many times have you, yourself, had an overnight stay in a hospital?, In the past 12 months, how many times have you, yourself, gone to the hospital for outpatient care, not including ER visits?, In the past 12 months, how many times have you, yourself, gone to an emergency room for medical treatment? Our usage variables take two values with 0 indicating zero usage and 1 indicating at least one usage.

∗AOR: adjusted odds ratio implies controlling for age, gender, race, education, insurance status, and political affiliation. These are for association of favorable attitudes with independent predictors. The binary dependent variable was “usage of health services” with 0 indicating no health care use.

These data provide intriguing insights into individuals' views about the ACA and what participant characteristics are associated with these views. The 2010 and 2011 data, however, does not provide insight into what information sources may be contributing to the creation of these views. Thus, in 2012, we added survey questions to ascertain what communication sources individuals used to obtain information about the ACA and whether the information they obtained from those sources contributed to their opinions regarding the ACA and its elements. Table 4 lists the information sources, the percentage (weighted data) of individuals who obtained information from those sources and the percentage (weighted data) of individuals who identified this source as important to their opinion formation.

Information sources and importance 2012.

Note: respondents were able to identify multiple information sources.

As demonstrated in Table 4 , individuals in Indiana, and we would argue across the nation, received messages regarding the ACA from a variety of sources; the top four sources that respondents reported contributing most to their opinion formation were national news programs, websites, family members, and their own reading of the legislation. To determine if these four sources were predictive of overall ACA views and support for the individual elements, we employed logistic regression modeling ( Table 5 ) using only the 2012 data. Each model was significant with F -values ranging from 2.11 to 5.38 and P values ranging from 0.017 to <0.001.

Information source as predictors of attitudes towards health care reform.

+ Blank cells indicate that in the model calculation the variable did not predict the attitude and was ultimately omitted.

Review of the logistic regression results indicated that individuals who relied on national television news as an ACA information source generally held more favorable attitudes toward health care reform and its provisions (AOR ranging from 1.70 to 4.11 and P values ranging from <0.001 to 0.040) and individuals who obtained information from the Internet held more favorable views toward affordable coverage for all (AOR = 2.77, P = 0.050). Surprisingly family members, while identified as a significant information source, only influenced individuals' views regarding the preexisting condition provision. Generally, those individuals who relied on family members' opinions held less favorable views regarding coverage for preexisting conditions (AOR = 0.38, P = 0.044). While over a third of the respondents reported having read the legislation and that the information they gained was very or somewhat important to their opinion formation, this information source was not significant in the model.

4. Discussion

Health care reform is a significant policy issue facing the United States. The issue remains politically charged as evidenced by our findings and national level studies. State-level distinctions are essential for state government officials to understand as they make ACA implementation decisions and choices [ 13 ]. State-level support is necessary for success since many of the individual regulations found in the ACA will be implemented by the states. Our study shows that, in Indiana, there is overwhelming support for three of the five individual provisions of the ACA addressed in this research and strong support for the remaining two provisions. Individuals in our sample have formed their perceptions of the overall ACA based primarily on political affiliation and relied heavily on information gained from the national news media. The partisan nature of this issue and lack of support from the states are further evidenced by the arguments brought before the Supreme Court of the United States by some states including Indiana.

Amidst the political debate, residents of Indiana strongly support the main provisions of the ACA. This could serve as a foundation to grow further bipartisan and grass roots support for health care reform. Yet, as demonstrated in the results, people's attitudes toward reform ideals and the ACA are inconsistent. The cause of this inconsistency is beyond the scope of the current findings and is an area in need of future research; however, our 2012 investigation into the influence of varying information sources offers a necessary first step when determining factors contributing to these inconsistencies.

Based on our 2010 and 2011 results, we believed that those individuals who reported actually reading the legislation were more likely to form an opinion, good or bad, based on the merits of the legislation. In contrast, reliance on secondary sources such as the media, politicians, or members of social networks for information regarding any legislative action could lead to the lack of support for legislation that in fact is consistent with an individual's views. The results of the 2012 analysis indicate that one's own reading of the legislation is not associated with opinion formation and information individuals obtain from the national news media is associated with positive attitude formation. This finding may be a reflection of the complexity inherent in the formal articulation of the health care reform legislation and could be argued of legislative documents in general. Individuals must be able to comprehend and process information to make informed decisions and opinions regarding the issue at hand. The national news media is able to provide a necessary first-interpretation of the legislation that then enables individuals to process the ideas and formulate opinions. While more research is needed into the cause of these inconsistencies, it is clear that the national news media continues to be a powerful influence in public opinion formation [ 14 – 16 ].

The results of our study should be viewed in light of several potential limitations that are generic for our study design and specific for our study content. First, the information sought in this study had to be obtained through self-reported perceptions and behaviors. Some individuals may not have remembered events correctly or may have provided socially desirable responses to some items, both being potential threats to the internal validity of the findings. Second, the monothematic nature of the questionnaire may have caused some individuals to think about the topic in a unique manner; if so, this would be a threat to the internal validity of the findings. Third, this study used a cross-sectional design. Thus, no cause and effect conclusions can be drawn from these results. Fourth, even though we had a reasonable sample size and included the questions of key relevance, it is still possible that a larger sample size and other unmeasured variables could better explain support for and perceptions of the ACA.

5. Conclusions and Policy Implications

Nationwide, and in Indiana specifically, this inconsistency in attitudes toward the ACA and attitudes about health care ideals must be addressed if health care reform and subsequent policies are to be successful. In the wake of the Supreme Court decision upholding much of the ACA, states will have to move forward with an implementation plan. One element of the plan must include clearly communicating to the citizenry how specific elements of the ACA align with their current views. Reform acceptance will likely require additional education about health care reform benefits and limitations. Previous research conducted by Nixon and Aruguete established a link between knowledge of the health care delivery system and negative attitudes toward the health care delivery system. In the Nixon and Aruguete study, these attitudes predicted support for health care reform [ 17 ]. Perhaps for reform to succeed there needs to be education about the reform elements along with education about current health care delivery system failures.

Clearly, the acts of passing the legislation by Congress and the upholding of the legislation by the Supreme Court cannot guarantee the acceptance of the ACA. There are many challenges associated with implementation of the ACA. A goal of the ACA is to increase Americans' access to health care services. The results of our study demonstrate that residents with health insurance are more likely to visit the doctor, stay overnight in the hospital, and seek outpatient hospital care. Questions remain regarding whether the current health care system can meet the increase in demand for care and services that will occur when the ACA is fully implemented. While more physicians are projected to enter the workforce in the upcoming years, the rate of growth is not expected to meet the 22% increase in demand projected for 2020 [ 18 ] and experts have identified the inadequate supply of primary care physicians as a main barrier to ACA implementation [ 12 ].

Along with addressing health care delivery barriers, policy makers will have to attend to the negative overall view held by the citizenry. It is important to understand, predict, and address the negative attitudes to promote effective implementation of any new legislation. Failure to do so will result in energies focused on fighting these policies versus determining which policy processes effectively and efficiently meet the health care needs of the public.

Conflict of Interests

The authors declare that there is no conflict of interests regarding the publication of this paper.

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Persuasive speech outline (1)

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Full text of Barack Obama's speech to Congress on healthcare reform

Madame Speaker, Vice President Biden, members of Congress, and the American people:

When I spoke here last winter, this nation was facing the worst economic crisis since the Great Depression. We were losing an average of 700,000 jobs per month. Credit was frozen. And our financial system was on the verge of collapse.

As any American who is still looking for work or a way to pay their bills will tell you, we are by no means out of the woods. A full and vibrant recovery is many months away. And I will not let up until those Americans who seek jobs can find them; until those businesses that seek capital and credit can thrive; until all responsible homeowners can stay in their homes. That is our ultimate goal. But thanks to the bold and decisive action we have taken since January, I can stand here with confidence and say that we have pulled this economy back from the brink.

I want to thank the members of this body for your efforts and your support in these last several months, and especially those who have taken the difficult votes that have put us on a path to recovery. I also want to thank the American people for their patience and resolve during this trying time for our nation.

But we did not come here just to clean up crises. We came to build a future. So tonight, I return to speak to all of you about an issue that is central to that future and that is the issue of health care.

I am not the first president to take up this cause, but I am determined to be the last. It has now been nearly a century since Theodore Roosevelt first called for healthcare reform. And ever since, nearly every president and Congress, whether Democrat or Republican, has attempted to meet this challenge in some way. A bill for comprehensive health reform was first introduced by John Dingell Sr in 1943. Sixty-five years later, his son continues to introduce that same bill at the beginning of each session.

Our collective failure to meet this challenge year after year, decade after decade has led us to a breaking point. Everyone understands the extraordinary hardships that are placed on the uninsured, who live every day just one accident or illness away from bankruptcy. These are not primarily people on welfare. These are middle-class Americans. Some can't get insurance on the job. Others are self-employed, and can't afford it, since buying insurance on your own costs you three times as much as the coverage you get from your employer. Many other Americans who are willing and able to pay are still denied insurance due to previous illnesses or conditions that insurance companies decide are too risky or expensive to cover.

We are the only advanced democracy on Earth, the only wealthy nation that allows such hardships for millions of its people. There are now more than 30 million American citizens who cannot get coverage. In just a two-year period, one in every three Americans goes without healthcare coverage at some point. And every day, 14,000 Americans lose their coverage. In other words, it can happen to anyone.

But the problem that plagues the health care system is not just a problem of the uninsured. Those who do have insurance have never had less security and stability than they do today. More and more Americans worry that if you move, lose your job, or change your job, you'll lose your health insurance too. More and more Americans pay their premiums, only to discover that their insurance company has dropped their coverage when they get sick, or won't pay the full cost of care. It happens every day.

One man from Illinois lost his coverage in the middle of chemotherapy because his insurer found that he hadn't reported gallstones that he didn't even know about. They delayed his treatment, and he died because of it. Another woman from Texas was about to get a double mastectomy when her insurance company cancelled her policy because she forgot to declare a case of acne. By the time she had her insurance reinstated, her breast cancer more than doubled in size. That is heartbreaking, it is wrong, and no one should be treated that way in the United States of America.

Then there's the problem of rising costs. We spend one-and-a-half times more per person on healthcare than any other country, but we aren't any healthier for it. This is one of the reasons that insurance premiums have gone up three times faster than wages. It's why so many employers especially small businesses are forcing their employees to pay more for insurance, or are dropping their coverage entirely. It's why so many aspiring entrepreneurs cannot afford to open a business in the first place, and why American businesses that compete internationally like our automakers are at a huge disadvantage. And it's why those of us with health insurance are also paying a hidden and growing tax for those without it – about $1000 per year that pays for somebody else's emergency room and charitable care.

Finally, our health care system is placing an unsustainable burden on taxpayers. When healthcare costs grow at the rate they have, it puts greater pressure on programs like Medicare and Medicaid. If we do nothing to slow these skyrocketing costs, we will eventually be spending more on Medicare and Medicaid than every other government program combined. Put simply, our healthcare problem is our deficit problem. Nothing else even comes close.

These are the facts. Nobody disputes them. We know we must reform this system. The question is how.

There are those on the left who believe that the only way to fix the system is through a single-payer system like Canada's, where we would severely restrict the private insurance market and have the government provide coverage for everyone. On the right, there are those who argue that we should end the employer-based system and leave individuals to buy health insurance on their own.

I have to say that there are arguments to be made for both approaches. But either one would represent a radical shift that would disrupt the healthcare most people currently have. Since healthcare represents one-sixth of our economy, I believe it makes more sense to build on what works and fix what doesn't, rather than try to build an entirely new system from scratch. And that is precisely what those of you in Congress have tried to do over the past several months.

During that time, we have seen Washington at its best and its worst.

We have seen many in this chamber work tirelessly for the better part of this year to offer thoughtful ideas about how to achieve reform. Of the five committees asked to develop bills, four have completed their work, and the Senate Finance Committee announced today that it will move forward next week. That has never happened before.

Our overall efforts have been supported by an unprecedented coalition of doctors and nurses; hospitals, seniors' groups and even drug companies many of whom opposed reform in the past. And there is agreement in this chamber on about 80% of what needs to be done, putting us closer to the goal of reform than we have ever been.

But what we have also seen in these last months is the same partisan spectacle that only hardens the disdain many Americans have toward their own government. Instead of honest debate, we have seen scare tactics. Some have dug into unyielding ideological camps that offer no hope of compromise. Too many have used this as an opportunity to score short-term political points, even if it robs the country of our opportunity to solve a long-term challenge. And out of this blizzard of charges and countercharges, confusion has reigned.

Well the time for bickering is over. The time for games has passed. Now is the season for action. Now is when we must bring the best ideas of both parties together, and show the American people that we can still do what we were sent here to do. Now is the time to deliver on health care.

The plan I'm announcing tonight would meet three basic goals:

It will provide more security and stability to those who have health insurance. It will provide insurance to those who don't. And it will slow the growth of healthcare costs for our families, our businesses, and our government. It's a plan that asks everyone to take responsibility for meeting this challenge not just government and insurance companies, but employers and individuals. And it's a plan that incorporates ideas from Senators and Congressmen; from Democrats and Republicans and yes, from some of my opponents in both the primary and general election.

Here are the details that every American needs to know about this plan:

First, if you are among the hundreds of millions of Americans who already have health insurance through your job, Medicare, Medicaid, or the VA, nothing in this plan will require you or your employer to change the coverage or the doctor you have. Let me repeat this: nothing in our plan requires you to change what you have.

What this plan will do is to make the insurance you have work better for you. Under this plan, it will be against the law for insurance companies to deny you coverage because of a preexisting condition. As soon as I sign this bill, it will be against the law for insurance companies to drop your coverage when you get sick or water it down when you need it most. They will no longer be able to place some arbitrary cap on the amount of coverage you can receive in a given year or a lifetime. We will place a limit on how much you can be charged for out-of-pocket expenses, because in the United States of America, no one should go broke because they get sick. And insurance companies will be required to cover, with no extra charge, routine checkups and preventive care, like mammograms and colonoscopies because there's no reason we shouldn't be catching diseases like breast cancer and colon cancer before they get worse. That makes sense, it saves money, and it saves lives.

That's what Americans who have health insurance can expect from this plan – more security and stability.

Now, if you're one of the tens of millions of Americans who don't currently have health insurance, the second part of this plan will finally offer you quality, affordable choices. If you lose your job or change your job, you will be able to get coverage. If you strike out on your own and start a small business, you will be able to get coverage. We will do this by creating a new insurance exchange a marketplace where individuals and small businesses will be able to shop for health insurance at competitive prices. Insurance companies will have an incentive to participate in this exchange because it lets them compete for millions of new customers. As one big group, these customers will have greater leverage to bargain with the insurance companies for better prices and quality coverage. This is how large companies and government employees get affordable insurance. It's how everyone in this Congress gets affordable insurance. And it's time to give every American the same opportunity that we've given ourselves.

For those individuals and small businesses who still cannot afford the lower-priced insurance available in the exchange, we will provide tax credits, the size of which will be based on your need. And all insurance companies that want access to this new marketplace will have to abide by the consumer protections I already mentioned. This exchange will take effect in four years, which will give us time to do it right. In the meantime, for those Americans who can't get insurance today because they have preexisting medical conditions, we will immediately offer low-cost coverage that will protect you against financial ruin if you become seriously ill. This was a good idea when Senator John McCain proposed it in the campaign, it's a good idea now, and we should embrace it.

Now, even if we provide these affordable options, there may be those particularly the young and healthy who still want to take the risk and go without coverage. There may still be companies that refuse to do right by their workers. The problem is, such irresponsible behaviour costs all the rest of us money. If there are affordable options and people still don't sign up for health insurance, it means we pay for those people's expensive emergency room visits. If some businesses don't provide workers health care, it forces the rest of us to pick up the tab when their workers get sick, and gives those businesses an unfair advantage over their competitors. And unless everybody does their part, many of the insurance reforms we seek especially requiring insurance companies to cover preexisting conditions just can't be achieved.

That's why under my plan, individuals will be required to carry basic health insurance just as most states require you to carry auto insurance. Likewise, businesses will be required to either offer their workers health care, or chip in to help cover the cost of their workers. There will be a hardship waiver for those individuals who still cannot afford coverage, and 95% of all small businesses, because of their size and narrow profit margin, would be exempt from these requirements. But we cannot have large businesses and individuals who can afford coverage game the system by avoiding responsibility to themselves or their employees. Improving our health care system only works if everybody does their part.

While there remain some significant details to be ironed out, I believe a broad consensus exists for the aspects of the plan I just outlined: consumer protections for those with insurance, an exchange that allows individuals and small businesses to purchase affordable coverage, and a requirement that people who can afford insurance get insurance.

And I have no doubt that these reforms would greatly benefit Americans from all walks of life, as well as the economy as a whole. Still, given all the misinformation that's been spread over the past few months, I realize that many Americans have grown nervous about reform. So tonight I'd like to address some of the key controversies that are still out there.

Some of people's concerns have grown out of bogus claims spread by those whose only agenda is to kill reform at any cost. The best example is the claim, made not just by radio and cable talk show hosts, but prominent politicians, that we plan to set up panels of bureaucrats with the power to kill off senior citizens. Such a charge would be laughable if it weren't so cynical and irresponsible. It is a lie, plain and simple.

There are also those who claim that our reform effort will insure illegal immigrants. This, too, is false the reforms I'm proposing would not apply to those who are here illegally.

And one more misunderstanding I want to clear up under our plan, no federal dollars will be used to fund abortions, and federal conscience laws will remain in place.

My healthcare proposal has also been attacked by some who oppose reform as a "government takeover" of the entire health care system. As proof, critics point to a provision in our plan that allows the uninsured and small businesses to choose a publicly sponsored insurance option, administered by the government just like Medicaid or Medicare.

So let me set the record straight. My guiding principle is, and always has been, that consumers do better when there is choice and competition. Unfortunately, in 34 states, 75% of the insurance market is controlled by five or fewer companies. In Alabama, almost 90% is controlled by just one company. Without competition, the price of insurance goes up and the quality goes down. And it makes it easier for insurance companies to treat their customers badly by cherry-picking the healthiest individuals and trying to drop the sickest; by overcharging small businesses who have no leverage; and by jacking up rates.

Insurance executives don't do this because they are bad people. They do it because it's profitable. As one former insurance executive testified before Congress, insurance companies are not only encouraged to find reasons to drop the seriously ill; they are rewarded for it. All of this is in service of meeting what this former executive called "Wall Street's relentless profit expectations".

Now, I have no interest in putting insurance companies out of business. They provide a legitimate service, and employ a lot of our friends and neighbours. I just want to hold them accountable. The insurance reforms that I've already mentioned would do just that. But an additional step we can take to keep insurance companies honest is by making a not-for-profit public option available in the insurance exchange. Let me be clear it would only be an option for those who don't have insurance. No one would be forced to choose it, and it would not impact those of you who already have insurance. In fact, based on Congressional Budget Office estimates, we believe that less than 5% of Americans would sign up.

Despite all this, the insurance companies and their allies don't like this idea. They argue that these private companies can't fairly compete with the government. And they'd be right if taxpayers were subsidizing this public insurance option. But they won't be. I have insisted that like any private insurance company, the public insurance option would have to be self-sufficient and rely on the premiums it collects. But by avoiding some of the overhead that gets eaten up at private companies by profits, excessive administrative costs and executive salaries, it could provide a good deal for consumers. It would also keep pressure on private insurers to keep their policies affordable and treat their customers better, the same way public colleges and universities provide additional choice and competition to students without in any way inhibiting a vibrant system of private colleges and universities.

It's worth noting that a strong majority of Americans still favour a public insurance option of the sort I've proposed tonight. But its impact shouldn't be exaggerated by the left, the right, or the media. It is only one part of my plan, and should not be used as a handy excuse for the usual Washington ideological battles. To my progressive friends, I would remind you that for decades, the driving idea behind reform has been to end insurance company abuses and make coverage affordable for those without it. The public option is only a means to that end and we should remain open to other ideas that accomplish our ultimate goal. And to my Republican friends, I say that rather than making wild claims about a government takeover of healthcare, we should work together to address any legitimate concerns you may have.

For example, some have suggested that the public option go into effect only in those markets where insurance companies are not providing affordable policies. Others propose a co-op or another nonprofit entity to administer the plan. These are all constructive ideas worth exploring. But I will not back down on the basic principle that if Americans can't find affordable coverage, we will provide you with a choice. And I will make sure that no government bureaucrat or insurance company bureaucrat gets between you and the care that you need.

Finally, let me discuss an issue that is a great concern to me, to members of this chamber, and to the public and that is how we pay for this plan.

Here's what you need to know. First, I will not sign a plan that adds one dime to our deficits either now or in the future. Period. And to prove that I'm serious, there will be a provision in this plan that requires us to come forward with more spending cuts if the savings we promised don't materialize. Part of the reason I faced a trillion dollar deficit when I walked in the door of the White House is because too many initiatives over the last decade were not paid for from the Iraq War to tax breaks for the wealthy. I will not make that same mistake with healthcare.

Second, we've estimated that most of this plan can be paid for by finding savings within the existing healthcare system a system that is currently full of waste and abuse. Right now, too much of the hard-earned savings and tax dollars we spend on healthcare doesn't make us healthier. That's not my judgment it's the judgment of medical professionals across this country. And this is also true when it comes to Medicare and Medicaid.

In fact, I want to speak directly to America's seniors for a moment, because Medicare is another issue that's been subjected to demagoguery and distortion during the course of this debate.

More than four decades ago, this nation stood up for the principle that after a lifetime of hard work, our seniors should not be left to struggle with a pile of medical bills in their later years. That is how Medicare was born. And it remains a sacred trust that must be passed down from one generation to the next. That is why not a dollar of the Medicare trust fund will be used to pay for this plan.

The only thing this plan would eliminate is the hundreds of billions of dollars in waste and fraud, as well as unwarranted subsidies in Medicare that go to insurance companies subsidies that do everything to pad their profits and nothing to improve your care. And we will also create an independent commission of doctors and medical experts charged with identifying more waste in the years ahead.

These steps will ensure that you America's seniors get the benefits you've been promised. They will ensure that Medicare is there for future generations. And we can use some of the savings to fill the gap in coverage that forces too many seniors to pay thousands of dollars a year out of their own pocket for prescription drugs. That's what this plan will do for you. So don't pay attention to those scary stories about how your benefits will be cut especially since some of the same folks who are spreading these tall tales have fought against Medicare in the past, and just this year supported a budget that would have essentially turned Medicare into a privatized voucher program. That will never happen on my watch. I will protect Medicare.

Now, because Medicare is such a big part of the healthcare system, making the program more efficient can help usher in changes in the way we deliver healthcare that can reduce costs for everybody. We have long known that some places, like the Intermountain Healthcare in Utah or the Geisinger Health System in rural Pennsylvania, offer high-quality care at costs below average. The commission can help encourage the adoption of these common sense best practices by doctors and medical professionals throughout the system everything from reducing hospital infection rates to encouraging better coordination between teams of doctors.

Reducing the waste and inefficiency in Medicare and Medicaid will pay for most of this plan. Much of the rest would be paid for with revenues from the very same drug and insurance companies that stand to benefit from tens of millions of new customers. This reform will charge insurance companies a fee for their most expensive policies, which will encourage them to provide greater value for the money an idea which has the support of Democratic and Republican experts. And according to these same experts, this modest change could help hold down the cost of health care for all of us in the long-run.

Finally, many in this chamber, particularly on the Republican side of the aisle, have long insisted that reforming our medical malpractice laws can help bring down the cost of healthcare. I don't believe malpractice reform is a silver bullet, but I have talked to enough doctors to know that defensive medicine may be contributing to unnecessary costs. So I am proposing that we move forward on a range of ideas about how to put patient safety first and let doctors focus on practicing medicine. I know that the Bush Administration considered authorizing demonstration projects in individual states to test these issues. It's a good idea, and I am directing my Secretary of Health and Human Services to move forward on this initiative today.

Add it all up, and the plan I'm proposing will cost around $900 billion over ten years, less than we have spent on the Iraq and Afghanistan wars, and less than the tax cuts for the wealthiest few Americans that Congress passed at the beginning of the previous administration. Most of these costs will be paid for with money already being spent but spent badly in the existing health care system. The plan will not add to our deficit. The middle-class will realise greater security, not higher taxes. And if we are able to slow the growth of health care costs by just one-tenth of one percent each year, it will actually reduce the deficit by $4 trillion over the long term.

This is the plan I'm proposing. It's a plan that incorporates ideas from many of the people in this room tonight Democrats and Republicans. And I will continue to seek common ground in the weeks ahead. If you come to me with a serious set of proposals, I will be there to listen. My door is always open.

But know this: I will not waste time with those who have made the calculation that it's better politics to kill this plan than improve it. I will not stand by while the special interests use the same old tactics to keep things exactly the way they are. If you misrepresent what's in the plan, we will call you out. And I will not accept the status quo as a solution. Not this time. Not now.

Everyone in this room knows what will happen if we do nothing. Our deficit will grow. More families will go bankrupt. More businesses will close. More Americans will lose their coverage when they are sick and need it most. And more will die as a result. We know these things to be true.

That is why we cannot fail. Because there are too many Americans counting on us to succeed the ones who suffer silently, and the ones who shared their stories with us at town hall meetings, in e-mails, and in letters.

I received one of those letters a few days ago. It was from our beloved friend and colleague, Ted Kennedy. He had written it back in May, shortly after he was told that his illness was terminal. He asked that it be delivered upon his death.

In it, he spoke about what a happy time his last months were, thanks to the love and support of family and friends, his wife, Vicki, and his children, who are here tonight. And he expressed confidence that this would be the year that health care reform "that great unfinished business of our society," he called it would finally pass. He repeated the truth that healthcare is decisive for our future prosperity, but he also reminded me that "it concerns more than material things." "What we face," he wrote, "is above all a moral issue; at stake are not just the details of policy, but fundamental principles of social justice and the character of our country."

I've thought about that phrase quite a bit in recent days the character of our country. One of the unique and wonderful things about America has always been our self-reliance, our rugged individualism, our fierce defence of freedom and our healthy scepticism of government. And figuring out the appropriate size and role of government has always been a source of rigorous and sometimes angry debate.

For some of Ted Kennedy's critics, his brand of liberalism represented an affront to American liberty. In their mind, his passion for universal health care was nothing more than a passion for big government.

But those of us who knew Teddy and worked with him here people of both parties know that what drove him was something more. His friend, Orrin Hatch, knows that. They worked together to provide children with health insurance. His friend John McCain knows that. They worked together on a Patient's Bill of Rights. His friend Chuck Grassley knows that. They worked together to provide healthcare to children with disabilities.

On issues like these, Ted Kennedy's passion was born not of some rigid ideology, but of his own experience. It was the experience of having two children stricken with cancer. He never forgot the sheer terror and helplessness that any parent feels when a child is badly sick; and he was able to imagine what it must be like for those without insurance; what it would be like to have to say to a wife or a child or an aging parent there is something that could make you better, but I just can't afford it.

That large heartedness, that concern and regard for the plight of others is not a partisan feeling. It is not a Republican or a Democratic feeling. It, too, is part of the American character. Our ability to stand in other people's shoes. A recognition that we are all in this together; that when fortune turns against one of us, others are there to lend a helping hand. A belief that in this country, hard work and responsibility should be rewarded by some measure of security and fair play; and an acknowledgement that sometimes government has to step in to help deliver on that promise.

This has always been the history of our progress. In 1933, when over half of our seniors could not support themselves and millions had seen their savings wiped away, there were those who argued that Social Security would lead to socialism. But the men and women of Congress stood fast, and we are all the better for it. In 1965, when some argued that Medicare represented a government takeover of health care, members of Congress, Democrats and Republicans, did not back down. They joined together so that all of us could enter our golden years with some basic peace of mind.

You see, our predecessors understood that government could not, and should not, solve every problem. They understood that there are instances when the gains in security from government action are not worth the added constraints on our freedom. But they also understood that the danger of too much government is matched by the perils of too little; that without the leavening hand of wise policy, markets can crash, monopolies can stifle competition, and the vulnerable can be exploited. And they knew that when any government measure, no matter how carefully crafted or beneficial, is subject to scorn; when any efforts to help people in need are attacked as un-American; when facts and reason are thrown overboard and only timidity passes for wisdom; and we can no longer even engage in a civil conversation with each other over the things that truly matter that at that point we don't merely lose our capacity to solve big challenges. We lose something essential about ourselves.

What was true then remains true today. I understand how difficult this healthcare debate has been. I know that many in this country are deeply sceptical that government is looking out for them. I understand that the politically safe move would be to kick the can further down the road to defer reform one more year, or one more election, or one more term.

But that's not what the moment calls for. That's not what we came here to do. We did not come to fear the future. We came here to shape it. I still believe we can act even when it's hard. I still believe we can replace acrimony with civility, and gridlock with progress. I still believe we can do great things, and that here and now we will meet history's test.

Because that is who we are. That is our calling. That is our character. Thank you, God bless you, and may God bless the United States of America.

• Barack Obama
• Obama administration
• US healthcare
• US Congress
• US politics

More on this story

Barack obama hits back at critics of health plan, 'you lie': republican joe wilson's outburst at obama health speech, tomasky talk: who is joe wilson, obama launches campaign to build support for healthcare plan, the republicans' legal landmine, a shot in the arm for healthcare reform, ewen macaskill on barack obama's healthcare speech, most viewed.

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Moscow's Top Cancer Hospital Under Pressure Amidst Drive for Health Care Privatization

Translations

Moscow City Oncology Hospital No. 62. Source: http://onco62.ru/history/.

On November 8, Moscow Mayor Sergey Sobyanin signed an order  into law stripping Moscow City Oncological Hospital No. 62, one of Russia's most well-regarded cancer hospitals, of its status as an autonomous institution. In the technocratic parlance of Moscow city officials, the hospital had been “optimized,” coming under the budgetary purview of the city government, and ostensibly improving the institution's efficiency.

But to many, the reclassification of Hospital No. 62 seemed less like an optimization than a step towards closure —part of a broader  movement towards the privatization of the Russian health care system, which is supposed to provide free health services to the country’s 140 million citizens. Indeed, less than three weeks after Sobyanin signed the order, the hospital's chief physician resigned and doctors began wondering about their institution's future. With private hospitals replacing public hospitals around Moscow, and with remaining public hospitals becoming increasingly overburdened and underfunded, many question how long the existing system can hold out. 

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