Dear County Officials:  The debate in Washington, DC, over how to fix America’s broken health system is reaching a critical 

Dear County Officials:  The debate in Washington, DC, over how to fix America’s broken health system is reaching a critical 

Dear County Officials: The debate in Washington, DC, over how to fix America’s broken health system is reaching a critical stage. Congressional committees are rolling out draft legislation as early as next week and leaders are planning to have votes by the end of July. NACo has been preparing for this debate. Under the leadership of President Elect Valerie Brown, NACo’s Health System Reform Working Group held three regional hearings to give county officials from around the country the opportunity to share their concerns. The group has summarized its conclusions in Restoring the Partnership for American Health: Counties in a 21st Century Health System (attached) which was approved by the Health Steering Committee and Board of Directors at the Legislative Conference in March. NACo has shared these principles with officials in the White House and the Department of Health and Human Services as well as with each member of the House and Senate. With all the voices and powerful interests demanding attention, however, we need your county to join us to make sure that reforms consistent with NACo principles are enacted, and enacted this year! Please consider taking the following actions to add your voice to NACo’s urgent call for the right kind of health reform: 1. Pass a resolution supporting passage of health reform this year to restore the partnership between counties and the federal government. Feel free to use the attached model. 2. Publicize your resolution through your local press. 3. Send copies of the resolution to: a. Each member of your Congressional delegation b. The White House: Michael A. Blake Deputy Associate Director Offices of Intergovernmental Affairs & Public Engagement mblake@who.eop.gov c. NACo: Paul V. Beddoe Associate Legislative Director ~ Health pbeddoe@naco.org We thank you for joining us in this effort and for your continued service to your communities through county government. Don Stapley President From NACo – July 7, 2009
Dear State Association Executives,
As you know, health reform at the top of the agenda in DC right now.
NACo is working to make sure that the changes Congress makes to our health system actually
enhance our counties’ capacity to serve their populations.
We face an uphill battle. According to yesterday’s Washington Post, the health-care industry is
spending $1.4 million a day on lobbying. And they’ve hired over 350 former government
staffers and retired Members of Congress to do that lobbying.
We need your members to help us amplify our message by supporting it from home. One way
they can do that is by adopting resolutions endorsing NACo’s health reform principles as set out
in our white paper, “Restoring the Partnership for American Health: Counties in a 21st Century
Health System” (attached). A couple weeks ago President Stapley sent out a memo (attached)
to county board members and county administrators from active NACo counties asking them to
adopt a model resolution (attached). A few have trickled in, but we need to do much better.
Please note that this is not an endorsement of any particular plan – including the President’s –
but rather calling for changes to the system that will work for counties.
Would you consider sending out the request to your state association network and encouraging
counties to adopt the resolutions? They should feel free to edit the model to reflect their own
concerns and priorities. Have them then send copies on to your Congressional delegations, the
White House and to me.
As an incentive for you, President Elect Valerie Brown has asked me to let you know that she
has a case of fine Sonoma County wine for the State Exec with the highest percentage of
counties that adopt resolutions and send them on to us here in DC by the end of July.
If you have any questions, please don’t hesitate to contact me. And stay tuned – I’m going to
have other requests as we move ahead.
See you in Tennessee!
Paul V. Beddoe, Ph.D.
Associate Legislative Director ~ Health Policy
National Association of Counties
(202) 942-4234 - voice
(202) 942-4281 - fax
(202) 550-8946 - mobile
pbeddoe@naco.org
THE BOARD OF COUNTY ________________
OF __________________COUNTY
RESOLUTION NO. ______
A RESOLUTION URGING IMMEDIATE PASSAGE OF COMPREHENSIVE
FEDERAL HEALTH REFORM LEGISLATION
WHEREAS, experts from across the political spectrum agree that America’s
health system is “broken” and unsustainable in its present configuration; and
WHEREAS, families in ______________ County are experiencing this crisis
right now, confronting the high cost of health care that threatens their financial stability,
leaves them exposed to higher premiums and deductibles, and puts them at risk for a
possible loss of health insurance; and
WHEREAS, employer-sponsored health insurance premiums have nearly
doubled in recent years making it increasingly difficult for employers, including county
governments, to provide health insurance coverage for their employees and retirees; and
WHEREAS, millions of Americans do not have health coverage, or have
inadequate coverage and as our economic challenges multiply, the problem of health care
access grows, further straining counties’ capacity to provide care for the uninsured,
underinsured and medically indigent; and
WHEREAS, <add local health and/or economic data>; and
WHEREAS, county officials are elected to protect the health and welfare of their
constituents: and
WHEREAS, <add local county’s costs for meeting health obligations like
indigent care, subsidies for hospitals and clinics, behavioral health, public health, jail
health, non-federal share of Medicaid etc.>; and
WHEREAS, the National Association of Counties (NACo) Health System
Reform Working Group, appointed by President Don Stapley in July 2008 and chaired by
President-Elect Valerie Brown, has held three regional hearings to explore the health
crisis and to hear what county officials believe should be done about it and has
summarized its findings in Restoring the Partnership for American Health: Counties in a
21st Century Health System which was approved and adopted by resolution of the NACo
Health Steering Committee and Board of Directors on March 9, 2009.
NOW THEREFORE BE IT RESOLVED that the Board of County
______________ of __________________________ County endorses NACo’s health
reform principles, as summarized in Restoring the Partnership for American Health:
Counties in a 21st Century Health System; namely, that reform legislation should
1. restore the partnership between county and federal governments;
2. provide access to affordable, quality health care to all;
3. invest in public health, including health promotion and disease and injury
prevention;
4. stabilize and strengthen the local health care safety net system, especially
Medicaid and disproportional share hospital (DSH) payments;
5. invest in the development of the health professional and paraprofessional
workforce;
6. ensure that county health agencies have the resources to meaningfully use health
information technology;
7. enable elderly and disabled persons to receive the services they need in the least
restrictive environment; and
8. reform the delivery and financing of health services in the jail system.
BE IT FURTHER RESOLVED that the Board strongly urges the 111th
Congress of the United States to enact comprehensive health reform legislation without
delay before the end of its first session.
APPROVED, ADOPTED AND PASSED, THIS ______ day of_______, 2009.
THE BOARD OF COUNTY ____________________________
OF _____________________________ COUNTY
By:____________________________________
, Chair
APPROVED AS TO FORM:
ATTEST:
__________________________
, County Attorney
____________________________
, County Clerk
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Restoring the Partnership for American Health
Counties in a 21st Century Health System
Full Partners:
County governments are integral to America’s current health system and will be
crucial partners in achieving successful reform. At the most basic level, county
officials are elected to protect the health and welfare of their constituents. County
governments set the local ordinances and policies which govern the built environment,
establishing the physical context for healthy, sustainable communities. County public
health officials work to promote healthy lifestyles and to prevent injuries and diseases.
Counties provide the local health care safety net infrastructure, financing and operating
hospitals, clinics and health centers. County governments also often serve as the payer
of last resort for the medically indigent. County jails must offer their inmates health care
as required by the U.S. Supreme Court. Counties operate nursing homes and provide
services for seniors. County behavioral health authorities help people with serious
mental health, developmental disability and substance abuse problems who would have
nowhere else to turn. And as employers, county governments provide health benefits to
the nearly three million county workers and their retirees nationwide. Clearly, county tax
payers contribute billions of dollars to the American health care system every year and
their elected representatives must be at the table as full partners in order to achieve the
goal of one hundred percent access and zero disparities.
Local Delivery Systems – Access for All:
NACo believes that reform must focus on access and delivery of quality health
services. Coverage is not enough. County officials, particularly in remote rural or
large urban areas know that even those with insurance may have difficulty gaining
access to the services of a health care provider, which can be exacerbated by the
severity of their illness. Local delivery systems should coordinate services to ensure
efficient and cost-effective access to care, particularly primary and preventive care, for
underserved populations. County governments are uniquely qualified to convene the
appropriate public and private partners to build these local delivery systems in a way
that will respect the unique needs of individuals and their communities. A restored
federal commitment to such partnerships is necessary for equity’s sake.
Public Health and Wellness:
NACo believes that a greater focus on disease and injury prevention and health
promotion is a way to improve the health of our communities and to reduce
health care costs. Disease and injury prevention and health promotion services can
be delivered by a health care professional one patient at a time. Local health
departments, in partnership with community based organizations and traditional health
care providers, deliver community-based prevention services targeted at an entire
population. Population-based prevention services can save money by keeping people
healthy and reducing the costs of treating unchecked chronic disease. These critical
services include assessment of the health status of communities to identify the unique
and most pressing health problems of each community and health education to provide
individuals with the knowledge and skills to maintain and improve their own health. The
public health response to emergencies should be fully integrated into each county’s
emergency management plan. Local public health considerations likewise should be
systematically integrated into land use planning and community design processes to
help prevent injuries and chronic disease. Policies are also needed to address health
inequity, the systemic, avoidable, unfair and unjust differences in health status and
mortality rates, as well as the distribution of disease and illness across population
groups. Investing in wellness and prevention across all communities will result in better
health outcomes, increased productivity and reduce costs associated with chronic
diseases.
Expanding Coverage:
NACo supports universal health insurance coverage. Existing public health
insurance systems should be strengthened and expanded, including Medicare,
Medicaid and the State Children’s Health Insurance Program (SCHIP). As states and
counties attempt to shoulder their legislatively mandated responsibilities to provide care
for the indigent and uninsured, federal regulatory barriers should be removed to allow
flexibility and innovation at the local level. Furthermore, in the effort to expand
coverage, reformers should not forget that the coverage must be meaningful, without
imposing additional mandates on county governments. The benefit package must be
defined so as to provide the full range of services people need, including prevention
services, full parity for behavioral health, substance abuse and developmental disability
services. Barriers to cost-effective treatments, like living organ donation, should be
removed.
Maintaining a Safety Net:
NACo believes that the intergovernmental partnership envisioned in the Medicaid
statute should be restored and strengthened. Local safety nets constructed under
Medicaid should not be dismantled to “pay for” universal coverage. We must not allow
the safety net infrastructure to be undermined. County hospitals and health systems, in
particular, will continue to need extra support to carry out their missions to reduce
disparities and serve underserved populations.
Health Workforce:
NACo believes that the health professional and paraprofessional workforce must
be supported and enhanced. Every effort should be made to recruit, train, license and
retain health professionals, and allied professionals and paraprofessionals, on an
expedited basis. A large body of evidence supports the contribution of direct care staff,
nurses and nursing assistants, to quality outcomes. Funding for existing education and
training programs – in secondary, post-secondary and vocational educational settings –
should be increased and targeted towards initiatives to expand and diversify the health
workforce. Partnerships between local economic developers and workforce
development professionals should be encouraged to meet growing health care sector
demand. Targeted incentives including scholarships, loan forgiveness and low-interest
loan repayment programs should be developed to encourage more providers to enter
and remain in primary care and public health careers. Primary care providers should be
empowered to – and compensated for – case management services.
Health IT:
The federal government should support the integration of health information
technologies into the local health care delivery system. NACo supports the
President’s goal of implementing a nation-wide system of electronic health records in
five years. NACo supports efforts to promote the use of a range of information
technologies to facilitate appropriate access to health records and improve the standard
of care available to patients, while protecting privacy. This includes deployment of
broadband technologies to the widest possible geographic footprint. Other tools
facilitate evidence-based decision making and e-prescribing. Using broadband
technologies, telemedicine applications enable real-time clinical care for geographically
distant patients and providers. Remote monitoring can also facilitate post-operative care
and chronic disease management without hospitalization or institutionalization.
Long Term Care:
Federal policies should encourage the elderly and disabled to receive the
services they need in the least restrictive environment. Since counties provide and
otherwise support long term care and other community based services for the elderly
and disabled, state and federal regulations and funding programs should give them the
flexibility to support the full continuum of home, community-based or institutional care
for persons needing assistance with activities of daily living. Nursing home regulatory
oversight should be reformed in order to foster more person-centered care
environments.
Jail Health:
Reforming America’s health care system must include reforms to its jail system.
Counties are responsible for providing health care for incarcerated individuals as
required by the U.S. Supreme Court in Estelle v. Gamble, 429 U.S. 97 (1976). This
unfunded mandate constitutes a major portion of local jail operating costs and a huge
burden on local property tax payers. The federal government should lift the unfunded
mandate by restoring its obligation for health care coverage for eligible inmates, preconviction. Furthermore, a true national partnership is needed to divert the non-violent
mentally ill from jail and into appropriate evidence-based treatment in community
settings, if possible. Finally, resources should be made available to counties to
implement timely, comprehensive reentry programs so that former inmates have access
to all the health and social services, including behavioral health and substance abuse
treatment, to avoid recidivism and become fully integrated into the community.
C ou n t y of f ic ia l s
FO R H E ALT H R E FO R M
Reducing Costs, Preserving Choice, and Assuring
Quality Affordable Health Care For All Americans
2009 Guide
c o u n t y o f f i c i a l s FO R H E ALT H R E FO R M
2 0 0 9 G UI D E
“I suffer no illusions that this will be an easy process. It will be hard. But I also know that
nearly a century after Teddy Roosevelt first called for reform, the cost of our health care has
weighed down our economy and the conscience of our nation long enough. So let there be no
doubt: health care reform cannot wait, it must not wait, and it will not wait another year.”
– President Barack Obama, Address to Joint Session of Congress, February 24, 2009
I. Goals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
II. Top Line Message . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
III. Ways to Support the President’s Health Reform Agenda . . . . . . . . . . . . . . 2
IV. Background Information and Materials on Health Reform . . . . . . . . . . . 3
V. Suggested Discussion Questions for Health Reform Events . . . . . . . . . . . . 5
VI. Health Reform Talking Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
VII. Overview of the Problem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
COUNTY OFFICIALS FOR HEALTH REFORM
GUIDE TO SUPPORTING THE PRESIDENT’S HEALTH REFORM AGENDA
IN YOUR COMMUNITY
Thank you for supporting President Obama’s commitment to passing health reform this
year that reduces costs to make health care affordable; protects a patient’s choice of doctors,
hospitals, and insurance plans; and assure quality affordable health care for all Americans.
County governments are integral to our current health system and will be crucial partners in
achieving successful reform.
It is clear that health care reform can no longer wait. Rapidly escalating health care costs
are crushing family, business, and government budgets. Employer-sponsored health insurance
premiums have nearly doubled since 2000, a rate three times faster than cumulative wage
increases.1 This forces families to sit around the kitchen table to make impossible choices
between paying rent or paying health premiums. Given all that we spend on health care,
American families should not be presented with that choice. The United States spent
approximately $2.2 trillion on health care in 2007, or $7,421 per person2 – nearly twice the
average of other developed nations.3 Americans spend more on health care than on housing or
food.4 If rapid health cost growth persists, the Congressional Budget Office estimates that by
2025, one out of every four dollars in our national economy will be tied up in the health system.
This growing burden will limit other investments and priorities that are needed to grow our
economy.5 Rising health care costs also affect our economic competitiveness in the global
economy, as American companies compete against companies in other countries that have
dramatically lower health care costs.
The President has vowed that the health reform process will be different in his
Administration – an open, inclusive, and transparent process where all ideas are encouraged and
all parties work together to find a solution to the health care crisis. Working together with
members of Congress, doctors and hospitals, businesses and unions, and other key health care
stakeholders, the President is committed to making sure we enact health care reform this year.
I.
GOALS OF COUNTY OFFICIALS FOR HEALTH REFORM
The goals of County Officials for Health Reform are:

To create local momentum for the President’s health reform agenda and to educate
communities on the need for health reform this year;

To listen to the voices and health care concerns of your communities and to advance the
President’s understanding of the health care problems Americans face and the solutions they
propose; and

To build support amongst peers and constituencies for the President’s health reform agenda.
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II.
TOP LINE MESSAGE
The President is committed to enacting health reform this year that:



III.
Reduces costs to make health care affordable;
Protects a patient’s choice of doctors, hospitals, and insurance plans; and
Assures quality affordable health care for all Americans.
WAYS TO SUPPORT THE PRESIDENT’S HEALTH REFORM AGENDA
There are numerous ways that you can advance the President’s goal of enacting health
reform this year that lowers costs; guarantees choice of doctors, hospitals, and insurance plans;
and assures quality affordable health care for all Americans. Below are some possible ways to
support the President’s health reform agenda, but please think of other initiatives in your
communities that could also be helpful.

Pass Local Resolutions of Support: Encourage local resolutions in support of the President’s
health reform principles of lowering cost; protecting a patient’s choice of doctors, hospitals,
and insurance plans; and assuring quality, affordable health care for all Americans. If
appropriate, you could hold a hearing to allow your community members to speak up and
offer their ideas for health reform this year.

Generate Press Coverage: Using materials in this guide and on www.HealthReform.gov, we
would appreciate your efforts to educate your community on the need for health reform this
year and publicly demonstrate your support for the President’s health reform agenda.
Possibilities include: writing an Op Ed or a letter to the editor for publication in your local
papers; issuing press releases; holding press conferences; or appearing on local radio or
television shows in support of health reform. This guide and www.HealthReform.gov
include materials to support these activities.

Host a Local Event: You could hold a community town hall or a roundtable discussion to
demonstrate the need for health reform this year and hear directly from your citizens about
their health care concerns and suggestions. Events could be held at a university auditorium,
hospital, school, community health center, or even a meeting space at a local coffee shop,
and you could potentially partner with an interested local non-profit organization. Suggested
discussion questions for health reform events are included in this guide. After the event, you
or your staff could submit a summary of your discussion through the “Contact Us—Share
Your Story” feature on www.HealthReform.gov.
If you are willing to demonstrate your public support for health reform this year through local
resolutions, press activity, and local events, we want to hear about it and make sure others know
of your work. Please email us at mblake@who.eop.gov and let us know how your efforts are
going. As always, thanks for your help!
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IV.
BACKGROUND INFORMATION AND MATERIALS ON HEALTH REFORM
The Obama Administration has numerous materials you can use to help demonstrate your
support for the President’s health reform agenda, educate your community on the need for health
reform this year, and engage your community in the health reform process.

Administration’s Health Reform Website, www.HealthReform.gov: The website
HealthReform.gov includes in-depth information and updates about health reform and
provides information how Americans around the country can participate in the discussion. In
addition to the specific features discussed below (Weekly Update, Statement of Support, and
Reports), the website also includes:
o Health reform quiz questions;
o Updates on health reform announcements;
o Videos and live web-streaming of Administration health reform events, such as the
White House Forum on Health Reform, the five Regional White House Forums on
Health Reform, and White House Health Care Stakeholder Discussions;
o Stories from Americans around the country on why we need health reform this year;
and
o Summaries of articles discussing the need for health reform this year.

Weekly Update on Health Reform: Each week, a new “Weekly Update on Health Reform”
video is posted on www.HealthReform.gov featuring either Nancy-Ann DeParle, Counselor
to the President and Director of the White House Office of Health Reform, or Health and
Human Services Secretary Kathleen Sebelius. The Weekly Update on Health Reform is a
short update for the American public on what the Administration worked on last week and
what the Administration is doing this week on health reform. You can watch the video each
week and encourage your local communities to watch the Weekly Updates as well.

Statement of Support on HealthReform.gov: Encourage your communities to visit
www.HealthReform.gov to sign the statement in support of the President’s principles for
health reform this year.

Joining the Discussion: The Administration encourages Americans around the country to
contribute to the health reform discussion. You should encourage community members to
share their stories and ideas about why we need health reform this year by going to the
“Contact Us—Share Your Story” page on www.HealthReform.gov.

Health Reform Updates: Encourage your communities to sign up for health reform e-mail
updates. Individuals can sign up for these updates by clicking “E-mail Updates” at the top
right of www.HealthReform.gov.

Reports on the Need for Health Reform This Year: The Department of Health and Human
Services and the Office of Health Reform have released several reports that provide concise
summaries on the need for health reform this year. These short reports are great handouts for
health reform events and also provide background information for resolutions or Op Eds in
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support of enacting health reform this year. All of the reports below, as well as future
reports, are available on www.HealthReform.gov. The current reports include:
o Americans Speak on Health Reform: Report on Health Care Community Discussions:
This past December, the Health Policy Transition Team encouraged all Americans to host
or attend a Health Care Community Discussion to “share their ideas about what’s broken
and how to fix it.” Over 9,000 people in all 50 states and the District of Columbia signed
up to host a Health Care Community Discussion, and the Health Policy Transition Team
received 3,276 group reports as well as Participant Survey results from over 30,000
participants. This report summarizes what the Administration learned about the health
care problems Americans face and the solutions they propose.
o Report on the White House Forum on Health Reform: On March 5, President Obama
convened a White House Forum on Health Reform to bring together leaders – business
and labor, doctors and insurers, Democrats and Republicans, and Americans from around
the country – to discuss the urgent need to pass health reform this year. This report
summarizes the discussions at this event.
o The Costs of Inaction: The Urgent Need for Health Reform: This report highlights the
flaws in the health care system and demonstrates the cost of maintaining the status quo.
Organized into three sections – Escalating Health Care Costs, Diminishing Access to
Care, and Persistent Gaps in Quality – the report shows how the current system has failed
millions of Americans and why we must enact health reform this year.
o Helping the Bottom Line: Health Reform and Small Business: This report discusses how
the high cost of health care burdens small businesses, weakens our economy, and leaves
millions of Americans without the affordable health care they need and deserve.
o Hard Times in the Heartland: Health Care in Rural America: Throughout rural
America, there are nearly 50 million people who face challenges in accessing health care.
This report provides insight into the current state of health care in rural areas and the
critical need for health care reform.
o Roadblocks to Health Care: Why the Current Health Care System Does Not Work For
Women: Today there are 21 million uninsured women and girls, and this report discusses
how our current system is leaving millions of women without the affordable, quality care
they need.
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V.
SUGGESTED DISCUSSION QUESTIONS FOR HEALTH REFORM EVENTS
The questions below could be used for any health reform events in your community.
Overall Questions
 How can we reform our health care system at the national level to improve quality of care,
lower costs for our families, and assure quality affordable health care for all Americans?
What specific ideas do you have on this topic?
 What specific challenges are people/representatives facing on health care?
 Do you feel that this is an urgent problem requiring action this year?
 How can health care reform at the national level help support the work of our states to
address the health care challenges our families are facing?
 What do you see as the highest priorities that we must address with health reform?
Cost
 How are rising health care costs impeding businesses and families?
 What steps would you recommend taking to reduce overall costs and cost growth?
Quality/Coverage/Access
 What types of prevention and wellness programs do you recommend/support?
 What types of incentives are needed to support healthy behaviors and value consciousness?
 What kinds of things can the public sector and the private sector do together to make
America healthier and to increase access to coverage for more Americans?
 In terms of expanding coverage – what do you think the role of the public and private sectors
should be?
Process Questions
 How can Congress and the Administration better involve the American public in health
reform?
 How are circumstances surrounding health reform different now as opposed to in 1993?
 What steps are you going to take to help enact health reform?
VI.
HEALTH REFORM TALKING POINTS

Reform has been delayed for too long, and it cannot wait any longer.

Every day in America, families are struggling with the crushing cost of health care that
threatens their financial stability, leaves them exposed to higher premiums and deductibles,
and puts them at risk for a possible loss of health insurance as employers struggle to provide
adequate health care coverage.

Americans value their relationship with their doctors and the care they receive, but as costs
rise and insurance benefits erode, they are asking for reform that protects what works and
fixes what is broken.
5

Since 2000, employer-sponsored health insurance premiums have nearly doubled, and health
care premiums have grown three times faster than wages. Even for people with health care,
all it takes is one stroke of bad luck to become one of the nearly 46 million uninsured – or the
millions who have health care, but can’t afford it.

Today, there are people who say we need to defer health care reform – that at a time of
economic crisis, we’ll have to accept the status quo because we cannot afford to fix our
health care system. What these people fail to acknowledge is that the skyrocketing cost of
health care – costs that are straining family budgets, crippling businesses, and consuming
government budgets – is one of the greatest threats there is to America’s fiscal health.

That is why we cannot delay this discussion any longer. Health care reform is no longer just
a moral imperative, it is a fiscal imperative. If we want to create jobs and rebuild our
economy, then we must address the crushing cost of health care this year.

While previous attempts at health care reform have failed, this time is different. This time,
the call for reform is coming from the bottom up, from all across the spectrum – from
doctors, nurses, and patients; unions and businesses; hospitals, health care providers, and
community groups; mayors, county officials, legislators, and governors; and Democrats and
Republicans.

In early May, many of these same stakeholders that led the charge to block reform in 1993
came together to say that reform can no longer wait. These industry groups – insurance
companies and hospitals, drug companies and doctors, and labor – are coming together to do
their part to reduce the annual health care spending growth rate. The same organization that
brought us the famous Harry and Louise ads has now come together to acknowledge that
even Harry and Louise want and need health care reform.

Our community discussions will further the process of determining how we can lower costs;
guarantee choice of doctors, hospitals, and insurance plans; and assure quality affordable
health care for all Americans. The President’s goal is to enact health care reform by the end
of this year.

In the past few months, Congress and the President have done more to advance the goal of
providing quality, affordable health care to all Americans than has been done in the past
decade. They have provided and protected coverage for eleven million children from
working families, and for seven million Americans who have lost their jobs in this downturn.
They have made the largest investment in history in preventive care and wellness; invested in
computerized medical records that will save money, eliminate waste, ensure privacy, and
save lives; and launched a new effort to find a cure for cancer in our time. As well, Congress
passed a budget that includes a historic commitment to health reform. This action is a key
step forward, and it did not happen when we last attempted to reform health care 15 years
ago.
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
The President acknowledges that all parties won’t always see eye to eye as the details of
health care reform are determined. But there are many areas of agreement that do exist, and
these will serve as the starting point of this process.

We can all agree that we need to eliminate fraud, waste, and abuse in government health
programs and hold insurance and drug companies accountable by ensuring that people are
not overcharged for prescription drugs, or discriminated against for pre-existing conditions.
We can agree that if we want to bring down skyrocketing costs, we’ll need to stress patientcentered care that invests in prevention and wellness so that we prevent the debilitating and
costly treatments that increase costs.

We can also agree that if we want to cover all Americans, we cannot make the mistake of
trying to fix what is not broken. That is why if people have insurance and doctors they like,
they will be able to keep them.

Finally, we can agree that if we want to translate these goals into policies, we need a process
that is as transparent and inclusive as possible.

In this effort, every voice must be heard. Every idea must be considered. Every option must
be on the table. Everyone must accept that no one will get everything they want, and no
proposal for reform will be perfect. But when it comes to addressing our health care
challenge, we can no longer let the perfect be the enemy of the essential.
VII.
OVERVIEW OF THE PROBLEM (from “The Costs of Inaction: The Urgent Need for
Health Reform,” available at www.HealthReform.gov)
1.
ESCALATING HEALTH CARE COSTS
Families, business, and state and federal budgets are straining under skyrocketing health
care costs.





Employer-sponsored health insurance premiums have nearly doubled since 2000, a rate three
times faster than cumulative wage increases.6
The United States spent approximately $2.2 trillion on health care in 2007, or $7,421 per
person.7 This comes to 16.2% of GDP, nearly twice the average of other developed nations.8
Health care costs doubled from 1996 to 2006, and they are projected to rise to 25% of GDP
in 2025 and 49% in 2082.9
The rising cost of health care is driving up the cost of Medicare and Medicaid. As a result,
the proportion of spending attributable to Medicare and Medicaid in the health system is
expected to rise from 4% of GDP in 2007 to 19% of GDP in 2082, making it the principle
driving force behind rising federal spending in the decades to come.10
Health care costs add $1,525 to the price of every General Motors vehicle. The company
spent $4.6 billion on health care in 2007, more than the cost of steel.11
7





2.
As a result of these crushing health care costs, American businesses are losing their ability to
compete in the global marketplace. Health care at General Motors puts the company at a $5
billion disadvantage against Toyota, which spends $1,400 less on health care per vehicle.12,13
The average cost of an employer-based family insurance policy in 2008 was $12,680, which
was nearly the annual earnings of a full-time minimum wage job.14
Half of all personal bankruptcies are at least partly the result of medical expenses.15
The typical elderly couple may have to save nearly $300,000 to pay for health costs not
covered by Medicare alone.16
Eight in ten Americans are dissatisfied with the total cost of health care,17 and over half
report paying for the cost of a major illness as a major problem.18
DIMINISHING ACCESS TO CARE
Millions of Americans do not have health coverage, or have inadequate coverage. As our
economic challenges multiply, the problem of health care access grows.









3.
From 2000 to 2007, the proportion of non-elderly Americans covered by employer-based
health insurance fell from 66% to 61%.19
An estimated 87 million people – one in every three Americans under the age of 65 – were
uninsured at some point in 2007 and 2008.20
More than 80% of the uninsured are in working families.21,22
Children without insurance have decreased access to well-child care, immunizations, basic
dental services, and prescription medication. Uninsured adults similarly have less access to
needed preventive care, and when sick, they are more likely to experience poorer health
outcomes.23
This in turn leads to lost workplace productivity and greater risk of illness and death, at a cost
of $65 to $135 billion per year.24,25,26
However, when the uninsured do obtain health care coverage, access to effective clinical
services and health outcomes improve.27
In the current economic crisis, even people with insurance are forgoing needed medical care,
including prescription medications and doctor visits, because of inability to pay copayments
and deductibles.28
In the past 4 years, the number of people above 200% of the poverty line who spend more
than 10% of their income on health care has more than tripled. About half of them report
difficulty paying bills.29
People with insurance also report difficulty accessing care when they live in areas with high
uninsurance rates, and physicians in these regions believe that they cannot make medical
decisions in the best interest of their patients.30
PERSISTENT GAPS IN QUALITY
In spite of the vast resources invested, the health care system has not yet reached the goal
of high-quality care.

Across 37 performance indicators, the United States achieved an overall score of 65 out of a
possible 100.31
8



Only 60% of obese adults were given advice on exercise, and just over half of children
received advice on healthy eating.32
Hospitals, on average, have still not met recommended targets for treating heart attacks in a
timely manner.33
If all states improved diabetes control to the level of the top four best performing states, at
least 39,000 fewer patients would have been admitted for uncontrolled diabetes in 2004,
potentially saving $216.7 million.34
Patient safety initiatives have the potential to save thousands of lives.


Up to 98,000 Americans die each year as a result of medical errors, more than motor vehicle
accidents, breast cancer, and AIDS.35
The United States also lags behind other nations in the use of error-reducing techniques, such
as health information technology.36
Disparities in care among different subpopulations must be addressed.


Ethnic and racial minorities are often less likely to receive recommended care, as are people
with lower income or lower educational status.37
They are also more likely to be uninsured, more likely to leave the emergency room without
being seen, and more likely to experience poor communication with their physicians.38
HEALTH INSURANCE COVERAGE OF THE TOTAL POPULATION,
STATES (2006-2007), U.S. (2007)
Medicare
Other
Public
Insurance
Total
Population
39,296,423
36,155,452
3,253,122
298,215,356
592,260
621,825
41,597
4,542,036
Percent
Uninsured
Uninsured
Employer
Individual
Medicaid
United States
15.3%
45,657,193
159,311,384
14,541,782
Alabama
13.6%
618,913
2,495,543
171,898
Alaska
17.7%
115,824
353,556
24,822
78,798
42,926
36,920
652,846
Arizona
19.6%
1,237,322
3,006,581
258,341
1,007,333
729,679
68,883
6,308,138
Arkansas
17.5%
485,849
1,294,972
127,632
440,675
380,969
46,820
2,776,917
California
18.5%
6,701,890
17,772,178
2,420,619
5,793,999
3,200,361
274,296
36,163,342
Colorado
16.9%
813,188
2,737,376
334,677
408,037
433,325
97,111
4,823,714
Connecticut
9.4%
325,516
2,113,966
139,521
396,535
458,715
24,549
3,458,802
Delaware
11.7%
100,560
510,142
25,358
93,589
119,306
8,630
857,585
District of
Columbia
10.6%
60,803
302,773
32,667
118,630
56,767
3,487
575,128
Florida
20.7%
3,738,230
8,500,588
950,809
1,727,980
2,889,417
222,872
18,029,897
Georgia
17.7%
1,660,156
5,165,605
340,362
1,143,260
925,891
137,426
9,372,700
Hawaii
8.3%
103,025
763,405
42,851
136,415
154,028
35,746
1,235,471
Idaho
14.7%
217,759
804,937
95,190
160,530
189,631
16,127
1,484,175
Illinois
13.7%
1,737,876
7,381,685
565,817
1,452,029
1,437,483
67,254
12,642,143
Indiana
11.6%
732,256
3,832,574
241,215
685,776
774,590
27,811
6,294,222
9
Iowa
9.9%
291,009
1,722,416
167,032
371,479
376,990
10,528
2,939,454
Kansas
12.6%
340,373
1,486,043
174,793
315,874
349,542
42,776
2,709,402
Kentucky
14.6%
604,929
2,130,397
171,941
637,491
560,977
45,793
4,151,528
Louisiana
20.2%
848,463
1,924,791
193,756
661,582
541,974
25,967
4,196,532
Maine
9.1%
118,935
687,310
63,175
246,605
176,773
17,166
1,309,964
Maryland
13.8%
769,007
3,394,077
219,516
489,195
644,463
49,543
5,565,801
Massachusetts
7.9%
498,451
3,777,434
280,693
979,539
786,682
12,756
6,335,555
Michigan
11.0%
1,096,821
5,761,698
379,262
1,279,096
1,378,958
44,400
9,940,235
Minnesota
8.8%
453,544
3,154,070
325,149
581,320
626,320
24,515
5,164,919
Mississippi
19.8%
572,555
1,293,798
130,481
550,649
300,617
41,011
2,889,110
Missouri
13.0%
750,218
3,122,307
321,795
722,692
828,154
45,025
5,790,191
Montana
16.4%
153,006
447,965
75,774
116,615
124,316
13,511
931,186
Nebraska
12.8%
224,689
1,015,327
128,522
158,499
196,497
29,041
1,752,575
Nevada
18.4%
468,808
1,463,174
109,964
171,322
305,448
28,359
2,547,075
New Hampshire
11.0%
143,754
846,833
59,065
82,576
167,552
8,669
1,308,450
New Jersey
15.6%
1,344,323
5,176,338
290,752
701,556
1,054,727
27,746
8,595,443
New Mexico
22.8%
441,351
819,437
95,016
306,512
235,428
40,349
1,938,093
New York
13.6%
2,590,364
9,915,597
672,495
3,641,829
2,166,402
59,349
19,046,037
North Carolina
17.2%
1,547,212
4,510,282
435,781
1,185,291
1,138,071
153,565
8,970,201
North Dakota
11.2%
68,412
343,475
62,847
53,523
76,622
8,032
612,912
Ohio
10.9%
1,229,769
6,580,161
484,430
1,457,308
1,422,018
112,076
11,285,761
Oklahoma
18.5%
646,363
1,672,318
142,019
470,767
461,432
98,994
3,491,892
Oregon
17.4%
648,169
1,943,329
231,049
410,084
457,012
39,072
3,728,717
Pennsylvania
9.8%
1,206,115
7,089,670
648,477
1,486,994
1,853,004
32,155
12,316,416
Rhode Island
9.7%
101,869
589,274
43,493
187,363
114,510
9,058
1,045,567
South Carolina
16.2%
696,484
2,197,541
178,889
593,484
560,653
72,549
4,299,599
South Dakota
11.0%
85,566
421,830
63,647
77,433
111,964
16,731
777,171
Tennessee
14.1%
845,728
3,004,975
306,748
886,699
821,009
140,469
6,005,629
Texas
24.9%
5,832,884
10,918,949
1,043,274
2,902,073
2,426,647
282,240
23,406,068
Utah
15.1%
391,392
1,542,039
181,458
243,067
218,913
16,926
2,593,795
Vermont
10.7%
66,140
331,851
22,454
114,255
76,646
4,703
616,049
Virginia
14.2%
1,070,636
4,404,621
299,998
595,747
890,563
252,464
7,514,029
Washington
11.7%
741,450
3,636,450
328,871
800,480
717,922
134,592
6,359,764
West Virginia
13.8%
249,384
915,965
36,304
295,357
283,410
21,501
1,801,922
Wisconsin
8.5%
465,762
3,349,515
292,561
654,387
665,968
39,608
5,467,801
Wyoming
14.2%
72,811
279,398
35,251
48,066
69,566
9,046
514,138
Sources: Urban Institute and Kaiser Commission on Medicaid and the Uninsured estimates based on the Census
Bureau's March 2007 and 2008 Current Population Survey (CPS: Annual Social and Economic Supplements).
Notes:
 Percentages may not sum to 100% due to rounding effects.
 For current Medicaid and Medicare enrollment figures, please refer to the Medicaid & CHIP and “Medicare”
sections, respectively, which report enrollment data from the Centers for Medicare and Medicaid Services
(CMS).
 CHIP and individuals eligible for both Medicare and Medicaid (dual eligibles) are included in Medicaid.
 Other Public (Federal) includes individuals covered through the military or Veterans Administration in
federally-funded programs such as TRICARE (formerly CHAMPUS) as well as some non-elderly Medicare
enrollees.
10
1
Kaiser Family Foundation Employer Health Benefits 2008 Annual Survey, Chart 1.9, available at
http://ehbs.kff.org/
2
Office of the Actuary, Centers for Medicare and Medicaid Services, National Health Expenditure 2. Data for
2007. U.S. Department of Health and Human Services, available at
http://www.cms.hhs.gov/NationalHealthExpendData/02_NationalHealthAccountsHistorical.asp#TopOfPage.
3
Organisation for Economic Cooperation and Development. OECD Health Data 2008.
4
McKinsey Global Institute, Accounting for the Cost of Health Care in the United States (Washington, DC:
McKinsey Global Institute, January 2007).
5
P.R. Orszag, Growth in Health Care Costs: Statement Before the Committee on the Budget, 4. United States Senate
(Washington, DC: Congressional Budget Office, Jan 31 2008), available at
http://www.cbo.gov/doc.cfm?index=8948.
6
Kaiser Family Foundation & Health Research and Educational Trust, Employer Health Benefits 2008 Annual
Survey. (Menlo Park, CA: Kaiser Family Foundation, 2008). http://ehbs.kff.org/?page=abstract&id=1
7
Office of the Actuary, Centers for Medicare and Medicaid Services, National Health Expenditure Data for 2007.
U.S. Department of Health and Human Services.
http://www.cms.hhs.gov/NationalHealthExpendData/02_NationalHealthAccountsHistorical.asp#TopOfPage
8
Organisation for Economic Cooperation and Development. OECD Health Data 2008.
9
P.R. Orszag, Growth in Health Care Costs: Statement Before the Committee on the Budget, United States Senate,
(Washington, DC: Congressional Budget Office, Jan 31 2008). http://www.cbo.gov/doc.cfm?index=8948
10 P.R. Orszag, Growth in Health Care Costs: Statement Before the Committee on the Budget, United States Senate,
(Washington, DC: Congressional Budget Office, Jan 31 2008). http://www.cbo.gov/doc.cfm?index=8948
11
R. Wagoner, Testimony before the House Financial Services Committee, December 5, 2008.
http://thinkprogress.org/2008/12/05/gm-health-care-reform/
12
R. Wagoner, Testimony before the House Financial Services Committee, December 5, 2008.
http://thinkprogress.org/2008/12/05/gm-health-care-reform/
13
G.F. Will. There’s more health care than steel in GM price tag. Deseret News, May 1, 2005.
http://findarticles.com/p/articles/mi_qn4188/is_20050501/ai_n14608247
14
Kaiser Family Foundation & Health Research and Educational Trust, Employer Health Benefits 2008 Annual
Survey. (Menlo Park, CA: Kaiser Family Foundation, 2008). http://ehbs.kff.org/?page=abstract&id=1
15
Himmelstein, D, E. Warren, D. Thorne, and S. Woolhander, “Illness and Injury as Contributors to Bankruptcy, “
Health Affairs Web Exclusive W5-63, 02 February , 2005.
16
Employee Benefit Research Institute, Savings Needed to Fund Health Insurance and Health Care Expenses in
Retirement, (Washington, DC: EBRI Issue Brief #295, July 2006).
17
Gallup Poll. Nov. 11-14, 2007. http://www.pollingreport.com/health3.htm
18
Pew Research Center for the People & the Press survey. March 8-12, 2006.
http://www.pollingreport.com/health3.htm
19
Kaiser Family Foundation, The Uninsured: A Primer, Key Facts about Americans without Health Insurance,
(Menlo Park, CA: Kaiser Family Foundation, 2008).
20
Families USA and The Lewin Group. Americans at Risk: One in Three Uninsured.
http://www.familiesusa.org/assets/pdfs/americans-at-risk.pdf
21
Kaiser Family Foundation, The Uninsured: A Primer, Key Facts about Americans without Health Insurance,
(Menlo Park, CA: Kaiser Family Foundation, 2008).
22
Families USA and The Lewin Group. Americans at Risk: One in Three Uninsured.
http://www.familiesusa.org/assets/pdfs/americans-at-risk.pdf
23
Institute of Medicine, America's Uninsured Crisis: Consequences for Health and Health Care. (Washington, DC:
National Academies Press, February 2009).
24
Institute of Medicine, Hidden Costs, Value Lost: Uninsurance in America. (Washington, DC: National
Academies Press, June 2003).
25
S. Dorn, “Uninsured and Dying Because of It: Updating the Institute of Medicine Analysis on the Impact of
Uninsurance on Mortality” (Washington, DC: The Urban Institute, 2008).
11
26
J. Hadley, “Insurance Coverage, Medical Care Use, and Short-Term Health Changes Following an Unintended
Injury or the Onset of a Chronic Condition,” JAMA 2007; 297 (10) : 1073-1084;.
27
Institute of Medicine, America's Uninsured Crisis: Consequences for Health and Health Care. (Washington, DC:
National Academies Press, February 2009).
28
The Kaiser Commission on Medicaid and the Uninsured. Snapshots from the Kitchen Table: Family Budgets and
Health Care. http://www.kff.org/uninsured/7849.cfm (accessed March 13, 2009).
29
C. Schoen, S.R. Collins, J.L. Kriss, et al. How many are underinsured? Trends among U.S. adults, 2003 and
2007. Health Affairs 2008; 27(4): w298-w309.
http://content.healthaffairs.org/cgi/reprint/hlthaff.27.4.w298v1?ijkey=rhRn2Tr4HAKZ.&keytype=ref&siteid=health
aff
30
Institute of Medicine, America's Uninsured Crisis: Consequences for Health and Health Care. (Washington, DC:
National Academies Press, February 2009).
31
The Commonwealth Fund. Why Not the Best? Results from a National Scorecard on U.S. Health System
Performance. July 17, 2008. http://www.commonwealthfund.org/Content/Publications/FundReports/2008/Jul/Why-Not-the-Best--Results-from-the-National-Scorecard-on-U-S--Health-System-Performance-2008.aspx (accessed March 13, 2009).
32
Agency for Healthcare Research and Quality. National Healthcare Quality Report 2007.
33
Agency for Healthcare Research and Quality. National Healthcare Quality Report 2007.
34
Agency for Healthcare Research and Quality. National Healthcare Quality Report 2007.
35
Institute of Medicine, To Err is Human: Building a Safer Health Care System (Washington, DC: National
Academies Press, 2000).
36
G.F. Anderson et al., “Health Care Spending and Use of Information Technology in OECD Countries,” Health
Affairs 2006; 25(3): 819-831.
37
Agency for Healthcare Research and Quality. National Healthcare Disparities Report 2007.
38
Agency for Healthcare Research and Quality. National Healthcare Disparities Report 2007.
12