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Guest Editorial: Reforming Healthcare in America
Healthcare costs in the US continue to rise two to three times the consumer price index.1 Yet while healthcare spending per capita in the US far exceeds every major industrialized nation, our healthcare system lags,2 with large numbers of premature3 and preventable4 deaths. The US is ranked 37th in the World Health Organization’s5 (WHO) rating of 191 countries in the year 2000. Recent articles in the New York Times6 and Newsweek7 and the PBS TV series Frontline8 underscore such information.
Although medical science and technology in the US are among the most advanced in the world and we have the facilities and physical infrastructure to adequately care for our citizens, we lack the ability to provide quality care to all Americans at sustainable costs. The US Census Bureau9 reports that in 2006, 47 million US citizens were uninsured. As costs rise, many people with insurance find out-of-pocket expenses (share of premium, co-pays, deductibles, in- or out-of-network, pharmacy expenses, and the like) so expensive they will forego medical visits, tests, and prescribed treatment; thus, the number of these underinsured Americans also has risen exponentially.10
Subsidizing healthcare provision has a history of problems.11 Over several decades since the early 1900s, Germany, Europe, and Scandinavian countries developed and implemented systems of universal healthcare while American healthcare reflected intermittent conflicts among the American Medical Association, insurance companies, and politicians. Amid opposition from insurance groups and the AMA, President Johnson signed national healthcare policy — Medicare and Medicaid — into law.
Healthcare problems worsened. Insurance companies provided temporary band-aids — patchwork solutions to healthcare issues that have become the standard in the US despite their repeated failures. Cases in point: medical loss is the term used by insurance companies for payments issued by them to healthcare providers14 and pharmaceutical companies continue to raise prices. Like the insurance industry, the medical industry responds to stock markets, shareholders, and their executives under pressure to record ever-increasing profits.12,13
Currently, healthcare costs consume 16% of our Gross Domestic Product. They are projected to rise to 20% by 2015 and to 30% by 2030.15 If health risk burdens are not shared by key stakeholders, insurance providers will continue to be selective in coverage and pricing, escalating the crisis. Many physicians are dissatisfied with insurance plans and increasing numbers have withdrawn their participation.16,17
The 2008 US presidential candidates have not openly recognized the catastrophic role insurance companies have played in creating the current healthcare crisis. Obama18 supports universal healthcare but offers no means (eg, insurance regulations) to enforce it and McCain19 favors consumer- (market) driven healthcare via tax credits but such credits are not sufficient to pay premiums. Although (per their platforms) we should not expect true healthcare reform until 2012, it is critical to consider what reform would be appropriate. Do we want universal healthcare — ie, uniform coverage for all US residents? Like our environment, public schools, and national security, should healthcare become part of the common or public good?
A well-planned healthcare policy should incorporate certain principles — systematic, uniform, universal care that incorporates systemwide change to provide all aspects of essential (prevention, emergency, acute, chronic, maternal, mental, long-term, gender-specific, and end-of-life), quality medical care.20 A unified healthcare system with constantly updated standards of care is more likely to deliver high quality care while minimizing costs. Medicare, despite criticisms, works better than most other insurances and has the potential to provide quality care to all US residents at minimal costs.21
A well-planned healthcare policy should be a community and a national goal. In my suburban Philadelphia community, Bucks Voices for Healthcare Reform, an organization of residents, meets every 2 to 3 weeks. Educational programs about healthcare are presented to local groups. A website (www.buckshealthcare.org) has been established for information and debate. An on-going survey addresses principles of reform and how individual health plans incorporate such principles. Periodically (usually monthly) emails are sent to update a growing membership.22
Nationally, Physicians for a National Health Program23 has worked for healthcare reform since 1987. This organization advocates a single-payor health plan that promotes government-funded, privately run healthcare to meet the nation’s needs. Eliminating employment-based plans will give US business a great advantage and would ensure portability of healthcare. Automobile, homeowner, malpractice, and workman compensation insurance premiums would be reduced because medical care would be covered. The need for separate military and veterans’ medical service would be eliminated. Providers would benefit because reduction of overhead billing cost and waste would offset healthcare inflation. As part of this plan, waiting time would be monitored, boosting the numbers of primary care providers and improving care in underserved areas. Covering all US residents via a single-payor national plan also would expand employment in healthcare without raising costs. Relevant legislation — HR 676 — has been sponsored by 90 Congressmen in the US House of Representatives.
Whatever changes we pursue, we will need to work together to reform healthcare. We beseech clinicians to be part of the healthcare change endeavor.
1. National Coalition on Healthcare. Available at: www.nchc.org/facts/cost.shtml. Accessed July 29, 2008.
2. Organisation for Economic Cooperation and Development. Available at: www.oecd.org/health/healthdata. Accessed July 29, 2008.
3. Care without Coverage. Institute of Medicine 2002. Available by calling (888) 624-8373.
4. Dunham W. France best, US worst in preventable death ranking. Available at: www.reuters.com/article/latestCrisis/idUSN07651650. Accessed July 29, 2008.
5. World Health Organization: WHO Assesses the World’s Health Systems. Available at: www.who.int/whr/2000/media_centre/press_release/en/print.html. Accessed July 29, 2008.
6. Abelson R, Freudenheim M. Even the insured feel strain of health costs. The New York Times. May 4, 2008. Available at: www.nytimes.com/2008/05/04/business/04insure.html?th&emc=th. Accessed July 29, 2008.
7. Begley S. The myth of ‘best in the world.’ Newsweek. March 22, 2008. Available at: www.newsweek.com/id/128635. Accessed July 29, 2008.
8. Public Broadcasting Station. Sick around the world. Frontline. Aired April 15, 2008. Available at: www.pbs.org/wgbh/pages/frontline/sickaroundtheworld. Accessed July 29, 2008.
9. US Census Bureau. Income, poverty, and health insurance. August 2007. Available at: www.census.gov/. Accessed July 29, 2008.
10. Cathy Schoen et al. The Commonwealth Fund. June 13, 2005. Available by calling (301) 656-7401.
11. Nichols WS, ed. The Insurance Monitor. 1919;67(7):38.
12. Fortune 500 Rankings 1995–2004. Available at: www.kff.org/insurance. Accessed July 29, 2008.
13. Reinhardt UE. Perspectives on the pharmaceutical industry. Health Affairs. 2001;20(5):136.
14. Bethely JG. Health plans make more, spend less. American Medical News. March 6, 2006. Available at: www.ama-assn.org/amednews/2006/03/06/bisd0306.htm. Accessed July 29, 2008.
15. The long-term budget outlook and opinions for slowing the growth of health care costs. Available at: www.cbo.gov. Accessed July 29, 2008.
16. Boutique medicine draws mixed reactions from doctors: expensive service lauded by patients for individualized care. NBC11 News. Available at: http://www.nbc11.com/mariannefavro/16125470/detail.html. Accessed July 29, 2008.
17. Ciavaglia J. $1,500 price tag on your health. Courier Times. June 7, 2007. Available at: http://www.phillyburbs.com. Accessed July 29, 2008.
18. Plan for a healthy America. Available at: www.barackobama.com. Accessed July 29, 2008.
19. Straight talk on health system reform. Available at: www.johnmccain.com. Accessed July 29, 2008.
20. www.nchc.org/materials/studies/reform.pdf. Accessed July 29, 2008.
21. Dartmouth Institute for Health Policy and Clinical practice. Available at: www.dartmouthatlas.org. Accessed July 29, 2008.
22. Bucks Voices for Healthcare Reform. Available at: http://buckshealthcare.org/. Accessed July 29, 2008.
23. Physicians for National Health Program. Available at: www.pnhp.org. Accessed July 29, 2008.
