Statistics and Health Care Reform in the United States

The signature domestic accomplishment of the Obama Administration thus far has been the enactment of health care reform in March 2010, the Patient Protection and Affordable Care Act (PPACA). Whatever its consequences, PPACA is one of the most significant pieces of social policy legislation in the history of the United States. Professor Gruber reviews the background and context of this historic legislation. I wish to discuss some issues related to health care reform that may be of particular interest to readers of Significance. The central theme of my review is that it is strikingly difficult to resolve basic questions about the health care system in the United States, and hence it is difficult to evaluate PPACA. The issues of inference are complex, far more complex than usually portrayed in media coverage, Congressional testimony, and government reports. Before delving into the challenges of inference, it is important to highlight the size and complexity of the task of reforming the U.S. health care system. The health care system takes up 17.1% of the GDP of the United States which is equivalent to the total GDP of the United Kingdom. By this metric, regulating and managing the U.S. health care system is the equivalent of managing and regulating all of the goods and services produced in the U.K., the world’s sixth largest economy. Not only is the U.S. health care system massive, it is also exceedingly diverse. For example, the health care system functions very differently in a state like Massachusetts than it does in a state like Texas. Massachusetts is known for its academic medical centers, biomedical research, highquality health care, and it is a state in which only about 9% of the population was uninsured before it enacted its own health care reform in 2006. After this reform, universal coverage has almost been achieved, with 97% of all residents covered as of 2009.1 In contrast, Texas has an uninsured rate of about 25%. During the debate over the Massachusetts health care plan, proponents could argue that reform did not require new revenues because that state had a low proportion of uninsured