Americans are good at solving problems. We’ve walked on the moon, invented the artificial heart, and discovered a cure for polio. Yet forty-six million of us don’t have the basic health care that people of most other industrialized nations take for granted.

Jonathan Oberlander is trying to figure out what we can do to fix health care in this country. He teaches health policy to future doctors at Carolina, and co-edited a three-volume guide dedicated to the topic in 2005. He studies Medicare, Medicaid, and health policy at the state level, and believes in the potential for universal health care in the United States.

Universal health care was one of the biggest issues of Bill Clinton’s campaign in the early 1990s. Yet after eight years in the White House his administration was unable to make good on campaign promises. The Democratic takeover of both the House and Senate has forced the issue back onto the agenda, so much so that President Bush featured health care as a top priority in his State of the Union address of 2007.

So why has the United States had such a difficult time constructing a national health care system? Oberlander says it’s because of the three Is: interests, institutions, and ideology.

First, interests. According to Oberlander, the people without health coverage in the United States don’t have much in common besides being uninsured. They don’t belong to any political party, are not in the same line of work, and aren’t even in the same age bracket. They do share the burden of being disproportionately low-income workers with no friends in Washington. Unfortunately, the uninsured also don’t have much in common with those who continuously fight against universal health care: insurance companies, doctors, medical suppliers, and corporate health-care providers. Those against universal coverage are organized and connected to powerful lobbyists in Washington, while those who need the health care are left to fend for themselves.

By institutions, Oberlander is referring directly to the federal government. “The way to think about the American political system is as a series of hurdles,” he says. New legislation must pass through several committees in the House of Representatives and the Senate before becoming the law of the land. Every committee, every debate, every vote represents a hurdle. “If the opponents of health reform trip you up once­­ — just once — historically, they win. Whereas the proponents have to pass every hurdle.”

Finally, ideology. Americans value self-sufficiency. “Opponents of national health insurance are able to play on the almost genetic fear of centralized power of public policy in this country,” Oberlander says. We also don’t like taxes, so a quick discussion of taxation paid by European counterparts to cover health care costs turns a lot of people off to the idea of national health care. Throw in some horror stores of Canadians having to wait in long lines for critical care, and most Americans dismiss universal health coverage altogether.

So is there a system that works somewhere in the world? Oberlander admits that nobody seems to have a perfect solution to the problem of covering health care costs for an entire population.

One term that comes up again and again in the discussion of national health care is “rationed health care,” which, Oberlander says, usually means putting limits on access to potentially beneficial services. Countries with government-funded health care such as Britain and Canada must ration their services to control costs. Oberlander started studying a real example of rationed health care in the United States — the Oregon Health Plan. A state-run service that was based on the premise that health care is already rationed in the United States, as people with no insurance sometimes forgo necessary medical care because they cannot afford it, the Oregon plan set out to cover everyone living at or below “the poverty line.” In 1999, that meant any family of four earning $16,700 or less.

Oregon was going to pay for its health plan by rationing services to Medicaid patients and, ironically, using tax revenue from tobacco sales. But Oberlander says the plan was only temporarily successful, and Oregon is again struggling to preserve and improve the health of its most needy citizens.

Oberlander has some ideas about how to bring about universal health coverage in our country. He thinks we should start with the states. “People are opposed to big federal programs,” he says, but if states accept federal money to start plans that meet the needs of that state alone, “I think that’s something you could build support around. It means that Massachusetts is going to have a health care system that fits Massachusetts, but North Carolina is going to have something very different.”

Oberlander is now trying to decipher what went wrong in Oregon. He says that the Oregon Health Plan is a fascinating example of health care policy in the United States, “but really a fascinating example of failure, which is very common in health care policy. We have a lot more failure than success.”

Jessica McCann was a student who formerly contributed to Endeavors.

Jonathan Oberlander is an associate professor of social medicine, health policy, and administration. His article “Health Reform Interrupted: The Unraveling of the Oregon Health Plan” was published in the January, 2007 issue of the journal Health Affairs. He won the Phillip and Ruth Hettleman Prize for Artistic and Scholarly Achievement by Young Faculty at Carolina in 2006.