An Unaffordable Commodity

The Debate

The rights of human beings is an intriguing debate. Ideally, all humans would have equal rights, and those rights would include affordable access to quality health care. Ideally, all humans would also have access to clean drinking water, adequate nutrition, and non-polluted air. Realistically, we know this is not the case. Realistically, we know that too many nations have little to no regard for the lives of some of their people, and universal health care is not a priority.

Article one of the United Nations Universal Declaration of Human Rights states that “all human beings are born free and equal in dignity and rights.” Article twenty-five grants everyone “the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing, and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control” (UN General Assembly, 1948). Health care as a right or commodity, however, seems to be determined by the nations. Some countries, including Argentina, Austria, Australia, Belgium, Brazil, Canada, Chile, China, Cuba, Costa Rica, Cyprus, Denmark, Finland, France, Germany, Greece, Iceland, Ireland, Israel, Italy, Japan, Luxembourg, the Netherlands, New Zealand, Oman, Portugal, Russia, Saudi Arabia, Spain, Sweden, South Korea, Sri Lanka, Ukraine, and the United Kingdom, have some version of a public health care system. That leaves the entire continent of Africa (South Africa is working on a universal plan), parts of Central and South America, portions of Asia, a few countries in Europe and the Middle East, and the United States of America without any form of universal health care for its citizens.

Historical Contributions

The issue of whether health care is or should be a right has been part of political platforms in the United States for a century. The 26th President of the United States, Theodore Roosevelt, was the first U.S. President to call for universal health care and national health insurance. President Truman was unsuccessful in his efforts to enact a national health insurance law (Hacker, 1996). President Eisenhower “oversaw the addition of disability insurance to Social Security, the extension of public medical provision to dependents of military personnel, the growth of governmental assistance for medical research, and the enactment of the 1960 Kerr-Mills program to help states pay for medical care for the elderly” (Hacker, n.d.). Lyndon Johnson’s Administration in 1965 saw the creation of Medicare and Medicaid, which replaced the Kerr-Mills program. The Clinton plan failed to pass Congress likely due to the enormity of the plan and the mandates it imposed, but did pass the States Children’s Health Insurance Program (SCHIP) as an extension of the Social Security Act. The Obama administration expanded the State Children’s Health Insurance Program (SCHIP) in February 2009 to include coverage to eleven million children (Obama, Feb. 4, 2009). The Obama Administration now sets its sights on reforming health care.

So the question remains: Why doesn’t the United States have a national health care program? Many arguments against nationalizing health care have surfaced over the years. Some of these arguments include: our government can’t afford to provide universal health care, and the tax increases required to pay for such a program would be excessive and unfair; worries over rationing and wait times, which is a complaint in some countries with national plans; patients and doctors should make health decisions, not governments; capitalism versus fears of socialism; limits on profits or care. Lobbying groups including the American Medical Association (AMA), the National Federation of Independent Businesses (NFIB), Health Insurance Association of America (HIAA), and other advocacy groups spent decades fighting legislation aimed at curing the ailments of our current system. Politics have dictated the progress made thus far and the lack of further comprehensive action.

Current Situation

Our current situation looks bleak. In the United States, health care is a commodity that 46 million Americans cannot afford. According to the 2007 US Census Bureau, 45.7 million Americans were uninsured, and another 25 million were underinsured (Reinberg, 2008), yet the U.S. Department of Health and Human Services (Azar II, 2006) reports that the United States spends roughly 16% of its GDP, $2 trillion on health expenditures. “According to the Institute of Medicine, a lack of health insurance accounts for 18,000 deaths per year in the United States” (Grumbach, n.d.). The U.S. spends over $7000 per capita on health care, which is more than twice that of other industrialized nations. Our life expectancy is thirtieth in the world at 78 years. Japan is first at 83 years. (Associated Press, June 12, 2008). Our infant mortality rate in 2006 was 6.3 out of every 1000 live births, thirty-third in the world (UN, 2007).

Accessibility to affordable health insurance continues to be a problem for roughly twenty percent of Americans. The largest provider of health insurance in the United States is the private employer sector, which provides insurance to about sixty percent of Americans, which has seen insurance premiums increase 98 percent between the years 2000 and 2007 (Daschle, 2008, p. 188). Government programs, including Medicare, Medicaid, SCHIP, Indian Health Services and Veterans Affairsprovide health insurance to selected groups of Americans. COBRA was extended due to the recent rise in unemployment and is being subsidized under the American Recovery and Reinvestment Act. “Nearly 80 percent of Americans are covered through the employer-based system, Medicaid, the State Children’s Health Insurance Program and Medicare” (Daschle, 2008, p. 145). There are still nearly 50 million Americans without any form of health insurance.

These government programs are not without their flaws. First, all of the aforementioned plans have substantial differences in coverage. Medicare, a fee-for-service plan, includes hospital insurance under Part A, but Part B Medical Insurance and the Part D Prescription Drug Coverage are supplemental and require most participants to pay a monthly premium (CMS, n.d.). While Medicare is now widely well thought of, and has helped to ensure quality of health care in their requirements for payment, fraudulent practices are still being identified. Medicaid provides health insurance to the “medically needy” (CMS, n.d.), and eligibility is determined by the state of residence. Additionally, Medicaid may pay for Medicare Part B and Part D if the enrollee is eligible. Medicaid funding waxes and wanes according to the budget allowances of the state so coverage changes from one fiscal year to the next. To further complicate the situation, SCHIP is part of Medicaid in some states, but in others it stands alone. The goal of SCHIP is to offer insurance to children whose families aren’t eligible for Medicaid, but can’t afford private insurance. Again, the states determine eligibility and benefits (CMS, n.d.). Veterans Affairs requires annual enrollment and puts veterans in a priority system, based on levels of disability and income. The covered priority levels are based on the amount Congress budgets to the VA every year (VA, 2008).

Ezekiel Emanuel (2002) identifies the unemployment factor, which has become only more relevant in the past months; “Increases in unemployment and increases in health care premiums mean more people will lose their health insurance. Decreases in corporate profits means that those still insured will have skimpier benefit packages and bear more of the premium price with higher copayments.” The U.S. Department of Labor estimates the unemployment rate through January 2009 at 7.6% (Bureau of Labor Statistics, 2009). With 60% of Americans insured through their employer, the number of uninsured people will surely rise.

Employment doesn’t necessarily mean insurance coverage. “Small-business employees are one of the fastest-growing segments of the uninsured” (Daschle, 2008, p18).

Cost of Care

The Institute of Medicine (2006) discusses the costs of health care associated with hospitals, and specifically emergency departments: “EDs today provide much of the medical care for patients without medical insurance.” Because of the increasing number of people relying on emergency departments for care that could and should have been obtained in a primary care setting, or for medical attention for a situation that could have been avoided, there is serious overcrowding, which results in limited privacy, longer wait times, and less or no continuity of care. The IOM blames high costs of emergency department care to several factors: the high medical malpractice insurance premiums of physicians and specialists, which are even higher in emergency medical care; lack of health information systems prevent physicians in the ED from having access to the patient’s medical histories, including medications and lab results; inefficiency in processes between the ED, lab, radiology and other departments; and lack of cooperation and communication between 911 dispatchers, emergency medical service providers, and emergency department personnel. Further, hospital emergency rooms receiving federal subsidies are required to provide care, whether the patient is insured or not, whether the patient is a citizen or not. These unpaid bills are passed on to sources who do pay in the form of inflated costs. Higher costs to insurance companies translate to higher premiums for employers or individuals. Higher costs to government programs translate to higher taxes or less coverage.

Tom Daschle (2008) writes about the skyrocketing health care costs. “One problem is that powerful “supply-side” forces exist in our health-care system. Physicians both diagnose and treat illness – in economic terms, they create and satisfy demand” (p. 9). Pharmaceutical companies contribute to this problem with their efforts to keep generic drugs off the market and in their direct to consumer marketing. “Manufacturers of both drugs and medical devices often pay for conferences and shower doctors with gifts as they try to expand the market for their products” (p. 10). “ Between 1998 and 2006, pharmaceutical companies and other manufacturers of health-care products spent over a billion dollars on lobbying…” (p. 194). In many cases, medications already exist that worked just as well as a new, more expensive drugs. In many cases, the result of expensive medical testing will not change the course of treatment. Other times expensive technology and equipment is used unnecessarily.

Daschle also blames American culture, agreeing with David Mechanic (2008) that “more and more of what were once seen as social, behavioral, or normative aspects of everyday life, or as normal processes of aging, are now framed in a medical context…” American culture often insists on medical treatment for “conditions” such as impotence, restless legs and hyperactive children. Convenience is another factor that proves to be wasteful. Hospitals in neighboring towns operate in a competitive nature rather than a cooperative nature. When every hospital tries to offer the most elaborate birthing suites, the highest state of the art oncology department, a new cardiac catheterization lab, and a convenient kidney dialysis clinic, they are being irresponsible, especially when these services are offered just a short distance away. Imagine a woman giving birth in a cozy living room setting while her mother gets her chemotherapy treatment just a floor above, her husband can have dialysis between contractions, and her sister is having an MRI for a sore shoulder. Afterward, they can all have cheeseburgers and fries delivered to their room from the extensive twenty-four hour cafeteria along with the latte they got from Starbucks in the hospital lobby, so that perhaps they can utilize the cardiac cath lab the following day. Let’s take it one step further, and expect it at little or no cost.

There are still other areas where inflating costs of health care exist. “Between 25 and 31% of our money goes to marketing and administrative waste, compared to 3% in Medicare” (Grumbach, n.d.). These administrative costs include “overhead, underwriting, billing, sales and marketing, as well as huge profits and exorbitant executive pay” (PNHP, n.d.). NFIB (2007) adds “through excessive malpractice judgments, we penalize good doctors practicing good medicine when their patients happen to experience bad outcomes.”

What Works for other Countries?

“When other countries achieve what the U.S. says it would like to attain, it makes good sense to look abroad” (Seedhouse, p. 62). Of the thirty-five countries that provide some kind of health care program to their citizens, there must be some experiences to draw on. T.R. Reid outlines four basic models in an upcoming book titled “We’re Number 37” which is scheduled to be published in early 2009. The four models outlined include:

• The Beveridge Model. In this single payer model, health care is provided and financed by the government through tax payments. Hospitals and clinics are owned by the government. Great Britain, Spain and New Zealand use this model.
• The Bismarck Model. Germany, France and Japan are among the nations using this multi-payer model in which insurance systems are required to cover everyone, but they do not make profits and they are tightly regulated.
• The National Health Insurance Model. Canada is a classic example of the NHI model, using private-sector providers, but is paid for by a government run program that all citizens pay into. Because of the enormous buying power, they can negotiate prices for pharmaceuticals and medical devices. The plan controls costs by limiting medical services they pay for or by making patients wait to be treated for non-emergency problems.
• The Out-of-Pocket Model is just that, out-of-pocket. This model is most common in poor countries with low life expectancy and high infant mortality where payment is often made in potatoes or goat’s milk.

“Most of the world’s highest-ranking health-care systems employ some kind of a “single-payer” strategy” (Daschle, 2008, pp. 143-44). Fears of socialism, fueled by special interest groups have been the largest obstacles in adopting a single-payer system similar to Canada’s (and other industrialized nation’s) system. Canada offers all of its residents comprehensive health care and does so at a cost far lower than the cost per capita in the U.S. Canada’s system provides that all ten provinces maintain their own health insurance plans that satisfy the government mandated criteria. Elaine Bernard from Harvard University explains Canada’s system:

The Canadian system is a carefully crafted hybrid reflecting the many political compromises entailed in adopting a major social program in face of a powerful opposition. The system can be described as a publicly-funded, privately-provided, universal, comprehensive, affordable, single-payer provincially administered national health care system.

Power to the States

Several states have grown weary waiting for federal legislation providing health care to their citizens. Hawaii, California, Oregon and Massachusetts are among the states that have made attempts to ensure health care benefits to all residents in differing plans.

Hawaii was the first state to mandate universal coverage, but has been struggling to enforce it for thirty-five years (Flowers, 2009). Colorado has formed a Blue Ribbon Commission for Healthcare Reform, which is weighing a myriad of proposals attempting to provide comprehensive coverage for all residents (Colorado, n.d.).

Oregon offers subsidies under its Family Health Insurance Assistance Program to people who are employed but do not have group plans offered through the employer. While this plan is designed to lower the number of uninsured Oregonians, it is currently taking no new applicants, and there is a wait time of almost two years. The Oregon Health Plan offers health care to its members at little or no cost, based on income, age, and medical condition. The OHP standard benefits package includes preventive care, and there are plans that can be chosen from and premiums paid out of pocket to supplement OHP, which is termed OHP Plus. (Oregon, n.d.).

Massachusetts has adopted a mandatory insurance program requiring all residents to purchase insurance or face a tax penalty. Subsidies are provided for low-income residents. While Massachusetts can boast it is now “finding that more than 97 percent of Massachusetts residents have health insurance, with only 2.6 percent of state residents remaining uninsured” (DHCFP, n.d.), the price of coverage is creating difficult situations for families. They are forced to either choose plans with low premiums that are not comprehensive in coverage or require high deductibles, or high premiums that many are finding unaffordable (PNHP, n.d.).

California Governor Arnold Schwarzenegger has introduced a plan similar to the one Obama has suggested to Congress. It involves subsidizing the insurance industry, bargaining with pharmaceutical giants for less expensive drugs, insurance mandates, increasing Medi-Cal payments to persuade hospitals to stay open, and allows tax credits to make coverage more affordable (Assembly Bill X1, 2007). has made attempts for decreasing the number of uninsured through several pieces of legislation, but with current budget shortfalls, any progress is in serious jeopardy. Other efforts have been made in California to convert to a single-payer system, but opposition remains strong.

While nearly every state tries on its own version of a state health care plan, there is lack of evidence to support that any of them will work

Brainstorming Proposals

Options that have been proposed for reform include mandating insurance, transition to a single-payer universal coverage plan similar to Canada’s or following another country’s model, expansion of Medicare to cover the uninsured, expansion of Medicaid to cover more poverty level families, and expansion of the Federal Employee Health Benefits Program.

The Physicians for a National Health Plan (PNHP) is a nonprofit organization comprised of physicians, medical students, and other health professionals who support a single payer system under which all Americans would receive necessary medical care, physicians would be paid a on a fee-for-service basis or by salary from hospitals, hospitals would run on a global budget, and a health planning board would purchase and manage medical equipment. Modest taxes would replace health insurance premiums and deductibles, and the costs would be further offset by the current costs of administration of private insurance programs (PNHP, n.d.).

The American Nurses Association “remains committed to the principle that health care is a human right and that all persons are entitled to ready access to affordable, high-quality health care services” (ANA, 2008). It is the ANA’s position that “everyone should have access to a standard package of essential health services.” The ANA’s Health System Reform Agenda of 2008 identifies the critical issues of health care reform as access, quality, cost and workforce. The problem of access and cost can be addressed by the creation of a standard package of essential health care services with co-payments based on the person’s ability to pay, and making it mandatory in all insurance programs, both public and private. People could then purchase supplemental care if they so wished. This would promote primary health care, but also responsibility in use of medical resources. The ANA also believes Medicare should be expanded, allowing employers and individuals to buy in. Another accessibility problem is the hours that clinic keep. If primary care settings are more accommodating in their scheduling, they may be utilized more, rather than urgent care and emergency rooms which cost significantly more. Quality of health care is addressed by increasing staffing, funding for computerized medical records, investment and research in evidence-based practice and incentives for implementation of best practices, increasing the delivery of primary care in public settings, and chronic disease management programs. Workforce issues can be curbed by pushing hospitals toward Magnet status which will help with recruitment and retention; loan repayment programs, scholarships, and tax credits for tuition; and financial incentives for working in underserved areas.

The AFL-CIO (2008) believes HSAs and Medicare Part D do not work. They do believe that Medicare and SCHIP are beneficial and should be expanded. The AFL-CIO’s plan for health care reform includes controls on cost, quality care, primary health care for families, responsibility in use of medical resources, freedom to choose care providers, and regulation.

Con Turned Pro

Groups that have lobbied against health care reforms, universal health care, and/or national health insurance in the past have seen that the current programs, or lack thereof, are having catastrophic effects on the people they represent and the economy of our country. Several groups have issued updated statements on their position regarding health care reform, and several have written proposals for change.

The HIAA, now known as the America’s Health Insurance Plans (AHIP), now agrees with the need for universal coverage, more investment in public health infrastructure and a reduction in unnecessary spending. The AHIP (2008) believes that the way to restructure the current health system is through controlling cost, ensuring equity and value, reforming insurance market rules, and achieving universal coverage.

The Institute of Medicine has developed four recommendations. First, improve hospital efficiency and patient flow through computerized medical records, and twenty-three hour observation units for example. Second, develop a coordinated, regionalized, accountable system including improved communication, utilization of other regional hospitals based on their specialties, and reporting standards of practice measurements. Third, pay appropriate attention to the care of children, who need different care than adults. Last, the IOM recommends increased governmental resources to facilities that serve a disproportionate number of uninsured patients (IOM, 2006).

Physicians are beginning to jump on the bandwagon as well. The AMA has issued a proposal significantly different from their previous position. Their three pillars of foundation include “assistance based on need, freedom of choice, and market innovation and fairness” (AMA, 2008). The proposal calls for regulations to ensure that health insurance companies are not allowed to drive the up premiums for the healthy population to compensate for more vulnerable populations. It also calls for responsible use of the health care system, by “obtaining health insurance without waiting until illness strikes or medical attention is needed. People who are uninsured despite being able to afford coverage should face tax implications” (AMA, 2008).

There are some key points, offered by the AMA, that most everyone agrees on as part of the solution to our health care crisis: reducing the burden of preventable disease; making health care delivery more efficient; reducing non-clinical health system costs that do not contribute to patient care; and promoting value-based decision-making (AMA, 2008). “The AMA proposes streamlined, more uniform health insurance market regulations.”

The Near Future

Tom Daschle believes a board, similar to the Federal Reserve, should be created and charged with the task of ensuring transparency and analysis of research to develop evidence-based practice recommendations. He believes current programs, including private insurance, should be strengthened, and the Federal Employee Health Benefits Program (which would provide a basic set of benefits to everybody) should be expanded and open to employers and individuals to buy into. Those that can’t afford to purchase insurance would get aid based on income. The board he proposes would pay “providers based on their adherence to evidence-based guidelines” (Daschle, 2008), which would set guidelines for value and cost. While he has withdrawn his nomination as Secretary of Health and Human Services, he will likely continue to fight for health reform as he has done for decades.

The health care reform plan that President Obama and Vice President Biden are proposing “strengthens employer coverage, makes insurance companies accountable and ensures patient choice of doctor and care without government interference (White House, 2009).” The plan addresses the problem of insurance companies charging outrageous premiums for high risk individuals or denying them altogether, offers tax credits to small businesses having difficulty offering a group plan to their employees because of the high costs, addresses the high cost of medical malpractice insurance premiums, and requires coverage for preventive medicine. The 2010 fiscal year budget includes the establishment of a reserve fund in the amount of $630 billion dollars over ten years to finance reform but acknowledges that this amount is merely a down payment and that additional funding will be required. The American Recovery and Reinvestment Act includes “$19 billion for health information technology, $1 billion for comparative effectiveness research and subsidies for the newly unemployed to maintain their health insurance” (DHHS, 2009). It builds on existing programs and adds research and information technology to the budget. It is in no way a universal health plan. It is not even a national health plan. It does, however, devote a significant amount of money to the beginnings of reform. The details of the reform bill will be discussed beginning the week of March 2, 2009 in a health summit which will include “businesses and workers, doctors and health providers, Democrats and Republicans (Obama, Feb. 24, 2009).”

Compiling Ideas for Change

There may be no tried and true plan that will transform the current crisis while pleasing all politicians, advocacy groups, care providers and individuals. There are ways to improve the current situation.

Changing attitudes will be the first obstacle.

…U.S. doctors employ new procedures or use expensive high-tech equipment even when there is little scientific evidence that the benefits to the patient will be worth the costs. Some analysts believe that up to 30 percent of the care we receive today is unnecessary. Many patients with insurance want any care that might do some good, and plenty of doctors will oblige them. Sometimes doctors do things they don’t believe are medically necessary because they want to defend themselves against lawsuits. (Daschle, 2008, p. 122)

Care providers should be using best practice models to ensure quality care in the most cost effective manner. Patients should be aware of the costs, risks and benefits of any procedure and be given alternatives. Educating patients will become even more important.

Focus on primary health rather than secondary or tertiary will be obtained when relationships between care providers and individuals are fostered, and individuals can pay (or have coverage) for their end of the relationship. Education and follow up will be key to this transition. Further, public or community settings such as schools, churches, community centers, workplaces, etc will be integral parts of preventive coalitions.

Regulations imposed on insurance companies and pharmaceutical companies will eliminate their influence on the demand for health care. Some states, Minnesota, Vermont and Maine, require pharmaceutical companies to disclose marketing costs, including payments made to physicians. Legislation passed to eliminate direct to consumer marketing of pharmaceuticals and medical devices to people who can not purchase these things without prescription or referral, will decrease wasteful spending.

Medical malpractice insurance premiums can be reduced if insurance companies are paying out less in awards. Some states already have caps on the amounts awarded for non-economic damages (amounts awarded for pain and suffering, loss of society and companionship), but there is no consistency from state to state.

Wisconsin, for example, recently enacted a new cap on non-economic damages after the last cap was declared unconstitutional by the state Supreme Court. The current cap on non-economic damages is $750,000. There is no cap on past medical expenses, future medical expenses, or loss of income. Wrongful death awards cap out at $350,000 for adults and $500,000 for children. The Supreme Court of Wisconsin recently ruled on the Bartholemew case that both non-economic damages and wrongful death damages could be awarded. The highest rates of malpractice awards are in California and the Eastern states. Minnesota and Iowa have no fund that care providers pay into, like Wisconsin’s Patient Compensation Fund, but have lower malpractice insurance premiums because they have fewer lawsuits. Louisiana has a cap of $150,000 on everything, including wrongful death. The Centers for Medicare and Medicaid Services is expected to add a new rule that any damages in excess of $1 million must be reported so that Medicare and Medicaid are not paying for services that have been compensated as a result of payment of future medical costs awards. (Wedekind, 2009).

Development of efficiency standards, including computerized health information systems and best practice standards will provide more appropriate care and better utilization of resources. Quality and continuity of care will also improve.

Establishment of a national health board, as described in Tom Daschle’s book, which is modeled after the U.S. Federal Reserve would and enforce transition to a more comprehensive, responsible system. Daschle (2008) charges this Federal Health Board with providing transparency in the medical practice and could “help define evidence-based health benefits and lower overall spending by determining which medicines, treatments, and procedures are most effective.” This board should also regulate insurance companies and the marketing of drugs.

Conclusion

The World Health Organization urges in the World Health Report 2008 that countries return to a primary health care system, including a “holistic approach to health care formally launched 30 years ago” during the Alma-Ata International Conference on Primary Health Care in 1978. The WHO concludes that “inequities in access to care and in health outcomes are usually greatest in cases where health is treated as a commodity and care is driven by profitability. The results are predictable: unnecessary tests and procedures, more frequent and longer hospital stays, higher overall costs, and exclusion of people who cannot pay” (WHO, 2008).

“It is simply unconscionable that in a nation as wealthy and powerful as ours, citizens are forced to go without medical care that could relieve their suffering and extend their lives” (Daschle, 2008, p197). “Most other industrialized nations manage to pay for universal health care without levying special taxes on corporations or even mandating that employers provide coverage to their workers” (p. 20). The Bush Administration requested $711 billion for defense spending for the fiscal year 2009 (Hellman, 2008). Surely a country that spends as much as the rest of the world combined in military defense can grant each of its citizens the right to quality, affordable health care.

President Barack Obama said in his speech to Congress on February 24, 2009, “let there be no doubt: health care reform cannot wait, it must not wait and it will not wait another year” (Obama, 2009). Let us hope that change is on the horizon.

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