Healthcare has been a major socio-economic and political topic for Americans during the last decade, more so since President Barack Obama has taken office with a pledge to reform the current system. According to United States Census Bureau, there are forty-seven million Americans without health insurance (2007, p. 19). Furthermore, Cathy Schoen, Sara R. Collins, Jennifer L. Kriss, et. al., report that twenty-five more million Americans with health insurance are underinsured (2007). This paper provides a survey of the current healthcare situation in United States and argues for the implementation of a single-payer, publicly-funded, universal health insurance provider.

Before we survey the health insurance system that exists today, or lackthereof, we first must discuss the traditional market-based insurance that has existed from the end of World War II to the early 70’s. In the traditional insurance market, the patient purchases an insurance policy from a provider by paying a monthly premium. In turn, the insurance company pays the healthcare provider for services rendered. Unfortunately, this has led to high costs because healthcare is a normal good with a classic diminishing marginal utility curve. The patient demands more services, and the doctor is happy to provide them. There are incentives for both the patient and the doctor to overuse. The more services the doctor performs, the more he is paid and the more utility the patient receives.

Since insurance services are provided under a contract, traditional insurance providers cannot immediately increase premiums to compensate for overuse, and since demand is inversely proportional with price--as the price of a product increases, a less quantity of it will be demanded--they cannot increase premiums without consequences because employers are free to choose another provider. This has badly affected providers such as Blue Cross Blue Shield, still in operation today, which led to the creation of Health Management Organisations (HMO), by president Nixon. According to Bolnick, Howard J.,  Murphy, James J., and Schield, Jill, price of healthcare rose 15% per year during the 1970’s (2001, p. 96). Popular opinion during the decade was that if the doctor insures the patient, the doctor will not have an incentive to provide more services than necessary because he or she will lose income. Obviously, a family doctor alone cannot insure his patients, which led to the grouping of doctors, which forms a ‘network’. An HMO is a network of health providers.

Another popular type of insurer is a PPO (preferred provider organisation). The difference between an HMO and PPO is that in an HMO, the patient must see a general doctor (gatekeeper). That doctor will send him to the specialist he needs. In a PPO, the patient can see directly the specialist he needs in network or out of network. This flexibility makes PPO premiums more expensive. This system creates waste if the patient chooses the wrong doctor. The insurance company will pay for the consultation minus the co-pay fee. Nevertheless, both are considered ‘managed care’ because they create protocols for care and review doctor records to make sure that there is no overuse of health services.

The majority of businesses in this country are small businesses. It is the American Dream to be one’s own boss. We have to cover the self-employed too with Health Savings Accounts.  Cardon, James H., and Showalter, Mark H. argue, ‘with adverse selection and an initial pooling equilibrium comprised of “sick” and “healthy” consumers, introducing HSAs can, but does not necessarily, lead to a new pooling equilibrium. The new equilibrium results in a higher coinsurance rate, an increase in expected utility for healthy consumers, and a decrease in expected utility for sick consumers’ (March 2007, p. 375). This says that the sick will never benefit from an HSA, and that they will be expected to share more of the costs of risk through a higher co-insurance rate. 

However, if the deductible is $5,000 on a self-employed or self-bought insurance plan, which is quite common according to a simple search, at the time of this writing, on popular insurance marketplace web sites, such as eHealthInsurance.com, HealthPlanOne.com, HealthInsurance.com, and InsureMonkey.com, there is no incentive to fund one. The maximum contributions that can be made per year for an individual in 2009 is $3,000 according to the IRS publication 525. It is not enough to cover the high deductible. John McCain’s plan was to increase the funding ceiling to $5,000 if he was elected president. Republicans still advocate it. If his plan was implemented, insurance companies would have to pay once a patient has consumed his account. However, what will stop insurance companies from increasing deductibles to $6,000 or more? Why should one buy insurance if the insurance company will never pay? Additionally, the self-employed are forced to pay self-employment tax on contributions to this account as well as to couple it with a high-deductible insurance plan. Notice that employees of corporations are not required to buy an insurance policy. They also pay no taxes. Once the deductible is met for a given year, the insurance policy will pay.

If the corporation provides a horrible insurance policy with a high deductible and is unwilling to decrease the burden of said deductible by providing a Health Reimbursement Account, an employee may self-insure using a Health Savings Account. It is very similar to an Individual Retirement Account. The balance rolls over from year to year. Contributions are tax-deductible. Medical expenses can be paid without tax liability. Non-medical debits are taxed, but can be tax-deferred, taxes will be paid at a future date, and not at the time of funding (investing), if the account is debited at retirement, for example. It sounds good on paper, but unhealthy people will never use it. They will never be able to save. There is an incentive for healthy individuals to leave insurance plans for self-insurance and they may never accumulate enough to pay for serious operations such as heart or brain surgery, which will result in medical bankruptcy.

Another popular choice for corporate self-insurance implemented by employers is a Health Reimbursement Account. The difference between this account and the Medical Expense Savings account is that employers can choose whether they permit rollover from year to year. Employers like it because claims are tax-deductible. Employees like it because contributions can be excluded from gross pay. There is an incentive to fund the account to shield income from taxes. This account does not require a high-deductible insurance contract. Therefore, it can solely be used for self-insurance. Unfortunately, it cannot be used  by the self-employed. High earners also have limitations to contributions and reimbursements. It also has high overhead costs because the rules and requirements are self-contradictory and very opaque. I believe that it is not a reliable method to self insure.

Private health insurance has resulted in many health services not being covered, forcing the residents of United States to retain costs as opposed to insuring. This is not advisable for infrequent, but severe incidents. For example, a restaurant will insure against fire, a severe and infrequent incident, but will retain the costs of broken plates, a not severe and frequent incident. Insurance policies do not generally cover dental and vision. Additionally, to further cut overuse, patients are forced to pay co-pays because they are less likely to visit a doctor if they have to share some of the cost, which has led to the formation of consumer-based self-insurance programmes such as the Medical Expense Flexible Spending Account (FSA). It is a tax-free savings account pre-funded by employers to attract employees. It cannot be used to pay for premiums. It is used to pay for co-payments, vision, and dental. It is renewed every year, and if a patient fails to use it, it does not roll over. It further increases overuse due to the use it or lose it policy. Additionally, since it is pre-funded, an employee can also use it on day one and terminate employment on day two. Jack, William, Levinson, Arik, and Rahardja, Sjamsu have found that people are less likely to increase their insurance coverage if they retain. They have also highlighted that the co-insurance, the sharing of risk between an insurance provider and insurance consumer, rate has increased by 7% since FSAs have been introduced (2001, p. 2287).

The general public believes that the United States is a market-based, private insurance nation. It is not. According to the US Census Bureau, about thirty per cent of health insurance is provided by the federal government (2008, p. 27). Now that we have covered private insurance and consumer-driven medical expense retaining plans, we must cover publicly funded insurance. The United States federal government provides many socially funded plans. First, Medicare, the system every news-pundit loves to hate--the system that will go bankrupt along with Social Security before this generation retires--is a publicly funded insurance programme that provides health insurance to retirees sixty-five years of age and older. It has deductibles, co-payments, coinsurance clauses. It also has a big cap in prescription drug coverage, forcing beneficiaries to use their retirement savings. It is common knowledge that the elderly have high healthcare needs.

Medicaid is publicly funded, means tested (based on income), social protection for the poor. It is funded by both the federal government and the state governments, while wholly administered by each state and supervised by the federal government. Thus, the poor should be protected. They should be healthier than privately insured, middle class individuals? No, they are not. According to Ramírez de Arellano, Anetted and Wolfe, Sidney M. MD, sixty per cent of the low-income, low-means citizens of this country are not covered, which are part of the 47 million Americans who are not insured (2007, p. 19). Due to high cost, some states have enrolled Medicaid beneficiaries into private managed care plans. The forty per cent of the poor that are covered by Medicaid, to receive benefits, they must fight a private bureaucracy, a state bureaucracy, and a federal bureaucracy to make sure that what they need is covered. Moreover, Medicaid has a large overhead cost because according to Fuchs, Victor R., and Emanuel, Ezekiel, J. ‘Means-tested insurance requires costly determination of eligibility, imposes high marginal tax rates on recipients because the subsidies fall or disappear as income rises, encourages evasion of reported income, and generates discontinuities of coverage as recipients move into and out of eligibility’ (2005, p. 1401).

Since Medicaid is means-tested, excessively complicated, and only covers some of the poor, politicians have had a moral dilemma about how to insure children of low-income and modest-income families whose income is too high to be eligible for Medicaid, up to 235% of the federal poverty level. Thus, in 1997, the State Children’s Health Insurance Program (SCHIP) was created. In Georgia, it is called PeachCare for Kids. It insures children until the age of 18. Similar to Medicaid, it is funded by both federal and state governments. Unfortunately, there are families who are not eligible for SCHIP and unable to purchase private health insurance. Espe, Erik has found that the number of uninsured children continues to rise. 19.7% of children are uninsured--10 years after SCHIP was created (2007, p. 15).

What about our war heroes? Do they fare better? The Veterans Health Administration is a publicly funded programme. In my opinion, it is the best-performing government health programme. According to Frank, Austin, Pizer Steven, and Hendricks, Ann, it has low overhead costs and it is permitted to negotiate prescription drug prices--it pays sixty per cent lower than Medicaid, which is not allowed to negotiate in favour of paying market prices (December 2008, p. 1081). Interest groups have prevented Congress from allowing Medicare to negotiate drug prices. However, soldiers are not covered while they are transitioned from active duty to veteran benefits. This means that a soldier who has left active duty for civilian employment and is unable to purchase private health insurance is in the same situation as those that have not served until he is old and covered by veteran benefits. 

A soldier’s family is not covered under the Veterans Health Administration. It is covered by yet another programme: TRICARE. It further splits into sub-programmes. First, TRICARE Standard, where the beneficiary pays co-payments, deductibles, and other out-of-pocket expenses. The premiums are paid by the government. They can use any civilian healthcare provider. Second, TRICARE Extra, which is a PPO--the beneficiary only pays the insurance premiums and must use in-network providers. Third, TRICARE Prime, an HMO, where the beneficiary pays co-payments. Retired career military members pay an annual fee. Fourth, TRICARE Reserve Select, which is only for active duty Reserve and National Guard members. They must pay monthly premiums, co-payments, deductibles, and other out-of-pocket expenses.

We have forgotten one group that is poor, almost extinct, for which the United States government are trying to pay reparations for the genocide that inspired Hitler. The Indian Health Service covers native Americans. However, the federal government are pushing native Americans to manage their own healthcare. In other words, they do not want to do it. According to Roubideaux Yvette, Zuckerman Enid, and Zuckerman Mel, fifty-three per cent of healthcare is managed by tribes, which give priority to their own. It is also severely underfunded with poor care overall (2004). That is, poor native Americans cannot afford private health insurance, are not covered by Medicaid, and cannot move out of poverty because they may not receive healthcare from another tribe.

Lastly, the Federal Employees Health Benefits Program covers all the employees of the Executive Branch of the federal government. President Obama supports it, and wants a temporary system where individuals have a similar option (2008). It creates an insurance exchange where insurance companies create plans and compete for your business. But, according to Oberlander Jonathan, it lacks reliable cost cutting measures. It just shifts costs from employers to the government. If payroll tax is set too low, they’ll choose to pay it instead of buying insurance (2008, p. 783). According to Enthoven, Alain, it has failed because insurance companies slice and dice the market instead of competing (1989 p. 39). They also make it very hard to shop around by making plans abnormally complex and impossible to compare.

Since 47 million are uninsured, and no for-profit doctor will see them and pro-bono clinics are overwhelmed, those that need care will visit the emergency room, that is government by the Emergency Medical Treatment and Active Labor Act (EMTALA), which forces hospitals to treat patients regardless of ability to pay and citizenship. Americans destroy their credit knowing that they cannot pay to save their lives. The costs are shifted to those able to pay in the form of larger bills which result in higher deductibles and premiums. According to Krug, the use of the emergency room has increased, even for simple, non-emergency care. There were 108 million ER visits in 2000, a 600% increase since 1958 (2004, p. 878).

The overly complicated system surveyed above has created a terrible burden on American society. We are the biggest spenders in the world on healthcare, yet according to the World Health Organization, we are in thirty-seventh place in overall health system performance. Some may argue that if the system is good for the Shah of Iran or another dictator seeking medical treatment in United States, it is good for all. That assumption is false. Those with ability to pay can see any specialist in the world, which may be located in United States. Katz, Steven J., et al. have found that there are not as many Canadian refugees flowing across the United States border as Republicans claim. Between 1997-1998, the majority of healthcare facilities surveyed in border states have claimed that they have seen fewer than ten Canadian patients. The Canadian provinces also pay for their treatment (2002, p. 24).

It is assumed that more healthcare is better care. Economists categorise healthcare as a normal good with a diminishing marginal utility curve. I disagree. The normal good assumption cannot be explained by the next few cases. A patient does not know what medication he needs and how much of it he needs; otherwise, he would self-medicate. If medicine was a normal good, how can one explain that my grandmother ignored heart-failure signs and waited until she had a heart attack. She knew the symptoms. My other grandmother refused to see a psychiatrist and jumped from the third floor instead. She did survive. My mother ignored cavities until her teeth fell out of fear of dentists. I refused to be vaccinated out of fear of needles and became sick. All these cases have occurred in a publicly-funded system. None of us had to carry our wallets to see the doctor to get treated, yet all of us refused to take advantage of ‘free’ medical services and were worse for it.

We respect the scheduled maintenance of our cars. We change the oil every 3,000 miles, but we do not respect our bodies. Preventive care is almost non-existent--a bold statement--but, due to the high costs of healthcare, we do not go to evaluations. Instead of treating the costs of healthcare, we see advertisements on television from organisations or government agencies to go have our prostates or breasts evaluated for cancer. Americans know that lives are saved when cancer is detected early and know that they should be evaluated early--they just cannot afford the out-of-pockets costs.

There is a significant rise in emergency room care because the poor abstain from treatment of chronic conditions due to the cost of healthcare and their inability to purchase health insurance. When it is too late, they visit the emergency room, which creates massive costs. It is cheaper to detect a disease early or to receive a scheduled treatment for a chronic condition then to wait until paramedics gurney them into the emergency room. Chronic conditions require long-term chronic care management, which includes both education and motivation of the patient to participate in treatments.

Patients are not the only ones who must purchase insurance: doctors must do so as well, not only for their healthcare, but also for their practice. Malpractice lawsuits have driven doctors out of business because they cannot afford the premiums in some states. Those that still practise have to charge more for rendered services to pay for the premiums. Malpractice lawsuits have a negative externality on healthcare providers. In a survey by the Physicians’ Foundation, 150,000 doctors, about 49%, claimed that in the next three years, they will either decrease the number of patients they see or stop practising entirely (2008).

There is a new trend in bankruptcies in America. It may shock the reader to learn that it has nothing to do with big spending on cars, flat-screen televisions, boats, and credit card debt. According to Himmelstein, David, et al., over sixty per cent of bankruptcies in United States are because of medical reasons (2009). They occur because the patient was uninsured, underinsured, or the because the insurance company refuses to pay the claim. One would expect a healthcare system to have positive externalities. This is not the case in United States. I find it laughable that insurance companies are demanding subsidies to counteract rising costs from the government. Government subsidies, also called Pigovian subsidies, or negative Pigovian taxes, are meant to encourage positive externalities, not keep the status quo of negative externalities created by the healthcare industry.

Insurance companies demand healthy individuals in hope that they will pay premiums for as long as possible before a claim is received. They do not only refuse to cover pre-existing conditions, or cover them after a number of years have passed, they also refuse to provide any type of insurance. An American may be able to afford some health insurance plan, but no insurance company is willing to have him as a beneficiary. CIGNA slashed eight million accounts over the last few years because they were not profitable. In other words, they had to pay claims. No insurance company will have them, at least not at the same premium and deductibles.

Medical directors receive bonuses if they prevent care. They are doctors who instead of practising medicine evaluate claims. They have the power to grant or deny a claim based on whether or not it is necessary. That doctor who has been manoeuvring a pen instead of scalpel has the power to contradict a claim by a patient’s surgeon. His loyalty is not to the customer--the beneficiary--but to the company and to the shareholders. If they do not maintain a certain ratio of granted to denied claims, they will be removed.

On Unix-based and Unix-inspired operating systems such as Linux, one often has hidden configuration files in his home directory. In most unices, your home directory is /home/username; on Apple Macintosh, it is /Users/username. These files are created by the operating system, applications, programs, and most often, manually. Dotfiles.org is a popular website for finding user-uploaded configuration files. Creating your own configuration files is tedious, error prone, and requires many hours or even days of reading documentation or man pages. It is best to embrace and extend by copying and pasting from Dotfiles.org.

Even though this article is primarily targeted at those which are comfortable with the command line since these configuration files are mostly for command line programs, it also benefits those that are not. For example, on Mac, most applications store their preference files in /Users/username/Library/Preferences. One could put said directory under version control. Should an option be changed in an Application for the worst, and the user does not remember how to change it back, all he must do is close the application, revert the directory to the base state and relaunch the application. 

Since creating these files is a labourious process, it is best to mange and store configuration files in a repository off site. You will be able to track changes and revert if a new configuration change breaks programs. Any version control system may be used. The most popular open-source systems are Subversion, Git, Mercurial, and Bazaar.

All have advantages and disadvantages. If you are on Ubuntu, you will most likely use Bazaar. It is developed by Canonical, the makers of Ubuntu, and you will use it with Launchpad. Support should be easy to find in the Ubuntu Forums. Mercurial is independently developed and the main competitor to Git. It is faster and more popular than Bazaar. The main hosting service is BitBucket. It has a decent interface. Even though it is more popular, there is less support for it than for Bazaar. It does not have a big community such as Ubuntu. Git was created for the Linux kernel by Linux Tovarlords. As such, it is very popular, not to mention, abnormally fast. Support can be easily found.  Though, it does not have the best CLI interface, and there is no decent GUI for it, you will love GitHub. Probably 70% of the Git repositories are hosted there.

For this tutorial, we will use Subversion, which has been in the wild for almost a decade. It is also pre-installed on Mac OS X 10.5 Leopard. There are many  graphical user interface clients for it. On Mac, there are Versions, which has recently received the Apple Design Award 2009, and Cornerstone, on Windows TortoiseSVN, on Linux eSVN, RapidSVN (cross platform), KDESvn, and many others. There are also many repository hosting companies with pretty and usable interfaces. Be aware that this article is not about version control. It discusses the bare minimum required for this tutorial to work. You may read a more in depth, but by no means comprehensive, tutorial on Subversion in an article written by Christ Nagele, one of the people behind Beanstalk, Subversion for Designers.

First, we will create a directory to store the configuration files. Traditionally, it is called etc, and Linux users may want to create /home/username/etc. I chose to call it Preferences since it better matches the Mac naming conventions: /Users/sorin/Preferences.

Next we have to move the configuration files from  /Users/sorin to /Users/Sorin/Preferences. We can use the command line or we can use Finder. Using Finder also requires the temporary use of the command line because Apple do not believe that Mac users should be able to easily access hidden files. Hidden files in Unix are called dot files because they begin with a dot: .bashrc. This is the configuration file for Bash, the shell that runs inside the Terminal. 

We must enable hidden files in Finder. Launch Applications > Utilities > Terminal and paste:

defaults write com.apple.finder AppleShowAllFiles TRUE; killall Finder

You can reverse the change later by pasting:

defaults write com.apple.finder AppleShowAllFiles FALSE; killall Finder

Once you have enabled hidden files, select the configuration files and folders you wish to put under version control and drag them to the Preferences folder. Then remove the dot from in front of the file to make them unhidden. From now own, you will not have to enable hidden files to easily find and edit them. They will also be displayed in Spotlight searches.

It is much easier to move and rename the files from the command line. Most likely you will not want to move all the hidden files and folders. There can be tens of them and not all are important. Select the ones you wan to move by appending file names before the semi-colon in the first line. Then paste this in Terminal.

for entry in .bashrc .vimrc .profile
do

new_name=`echo $entry | sed -e 's/\.//g'`
mv $entry Preferences/$new_name

done

Regardless of which methods you chose, the result should be similar to this screen-shot.

Next, we must create symbolic links, or shortcuts, in the home directory to point to the new location of the configuration files. I have written a script that automatically creates the symbolic links. It is safe to use. It backs up files that already exist in a directory called .deploy_backup in your home directory instead of overwriting. Just place deploy.rb in Preferences and execute it in Terminal by typing ./deploy.rb. Do not forget to change its permissions to an executable file first with chmod u+x deploy.rb.

You will see symbolic links in your home folder.

We have not taken such effort to just be able to easily edit and search configuration files with Spotlight; we want to store them offsite on someone else's server to make sure we never lose them. Get yourself a free Subversion repository hosting account at Beanstalk. It is a very easy to use application.

Once, you have created an account, you can access it online at http://username.beanstalkapp.com. Log-in then go to the Repositories tab and create a repository. I called mine personal. You may name it anything you wish. The repository is accessible via Subversion at http://username.svn.beanstalkapp.com/repositoryname. You will be prompted for your username and password. We have to import our Preferences folder into the repository. We will use the svn import command in Terminal to import all files into the repository.  Once the import process is done, unfortunately, due to the way Subversion works, our configuration files have been imported, but are not yet tracked. We have to check them out first. Since Subversion does not overwrite existing files, we have to check them out in a temporary location.  

Alternatively, in Versions, we can go to File > Import. Select the Preferences folder and click Import. Then click the Checkout icon to checkout our files to Preferences2. Do not forget to edit the bookmark created to point to Preferences and not Preferences2.

Versions makes it easy to import and checkout files.

Once your repository is set, you are free to modify the configuration files as you see fit and never have to worry about making detrimental changes. You can always revert to the older version. In the screen-shot bellow, I have modified vimrc to change the Terminal title to 'Shell' when it exists instead of 'Thanks for flying Vim'. This is reflected by the letter 'M' at the begging of the line. Versions reflects the change by displaying a pencil icon next to the file.

If  you want to use my configuration files, you may get them at http://sorin.svn.beanstalkapp.com/personal/trunk/Preferences. Just execute deploy.rb. Be advised that MacPorts and iTerm are required as well as the following ports (packages). The .bashrc should work on Linux without problems. I have encapsulated Mac-only settings. If you find bugs or improvements that can be made, please don't hesitate to email me.

bash-completion @1.0_1 (active)
coreutils @7.4_0+with_default_names (active)
ctags @5.7_0 (active)
fortune @6.2.0-RELEASE_0 (active)

1. Unzip creamsn0w.zip
2. Place iPhone carrier support IPCC files in addons. Simple extracted DEBs in ZIP format are also supported.
3. Double-click install.
4. Launch redsn0w.
5. Deselect Cydia. Select 'Icy'.

• T-Mobile US Carrier Support Bundles 1.0.10 (more info)
• Battery Percentage Indicator 3.1.2
• Emoji 3.1.2
• System Partition Lock 3.1.2 (Locks your system partition for security reasons)
• Tethering Patch 3G 3.1.2 (Enables tethering, iPhone 3G only)