The expansion of Medicaid under the Patient Protection and Affordable Care Act (ACA or Obamacare) was not the first attempt the United States government made to increase the number of people with health insurance. In 1945, the Truman administration introduced a Universal Health Care (UHC) plan. Many Americans with insurance insecurity, most notably Black Americans and poor white Americans, would benefit from this healthcare plan. During this time, health insurance was only guaranteed for those with certain jobs, many of which Blacks and poor white Americans were unable to secure at the time, which resulted in them having to pay out-of-pocket for any wanted healthcare services. This reality pushed Truman to propose UHC within the United States because it would allow “all people and communities [to] use the promotive, preventative, curative, rehabilitative and palliative health services they need of sufficient quality…, while also ensuring that the use of these services does not expose the user to financial hardship.”
We’ve been spending a
lot of time these past few years debating healthcare reform. First the
Affordable Care Act was debated, passed, implemented, and almost continuously
litigated since. Lately the concept of Medicare For All, or variations on
it, has been the hot policy debate. Other smaller but still important
issues like high prescription drug prices or surprise billing have also
received significant attention.
As worthy as these all
are, a new study suggests that focusing on them may be missing the
point. If we’re not addressing wealth disparities, we’re unlikely to
address health disparities.
It has been well
documented that there are considerable health disparities in the U.S.,
attributable to socioeconomic status, race/ethnicity, gender, even geography, among other
factors. Few would deny that they exist. Many policy experts and
politicians seem to believe that if we could simply increase health insurance
coverage, we could go a long way to addressing these disparities, since coverage
should reduce financial burdens that may be serving as barriers to care that
may be contributing to them.
Universal coverage may
well be a good goal for many reasons, but we should temper our expectations
about what it might achieve in terms of leveling the health playing field.
It is now well established that Americans, in large majorities, favor universal health coverage. As witnessed in the first two Democratic debates, how we get there (Single Payer vs. extension of Obamacare) is another matter altogether.
295 million Americans have some form of health coverage (though increasing numbers are under-insured and vulnerable to the crushing effects of medical debt). That leaves 28 million uninsured, an issue easily resolved, according to former Obama staffer, Ezekiel Emanuel MD, through auto-enrollment, that is changing some existing policies to “enable the government agencies, hospitals, insurers and other organizations to enroll people in health insurance automatically when they show up for care or other benefits like food stamps.”
If one accepts it’s as easy as that, does that really bring to heel a Medical-Industrial Complex that has systematically focused on profitability over planning, and cures over care, while expending twice as much as all other developed nations? In other words, can America successfully expand health care as a right to all of its citizens without focusing on cost efficiency?
The simple answer is “no”, for two reasons. First, excess profitability = greed = waste = inequity = unacceptable variability and poor outcomes. Second, equitable expansion of universal, high quality access to care requires capturing and carefully reapplying existing resources.
It is estimated that concrete policy changes could capture between $100 billion and $200 billion in waste in the short term primarily through three sources.
In 1807, in an effort to spite the British and French for shipping interference (and forced recruitment of American citizens into military service), the United States Congress passed an Embargo Act, effectively shutting down trade with these two countries. Britain and France quickly found other trading partners; the US, then limited in our capacity to sell products outside our borders, was left with a devastated economy and a gaping hole in our face. It took only weeks before Congress passed a loophole; they repealed the act within 15 months of its passing. It was a great lesson in unintended consequences.
Today, ignoring history, both Republicans and Democrats seem to spar continuously around healthcare: whether the message is about tearing down the Affordable Care Act or about some version of Medicare (For-All, For Whoever Wants It, For America, or For Better or Worse), both parties are terribly wrong.
Assuming the social imperative for healthcare is to eliminate preventable morbidity and disability (and associated costs) and improve (or sustain) quality of health of all our citizens (in order to help as many of them as possible remain productive, contributing members of society), another approach to ‘universal care” would be to flip the figure/ground relationship for our current efforts: instead of developing better payment systems, let’s develop and commit to a universal clinical operating framework that ensures that every member of society has the same opportunity to optimize their health status.
“Centralizing” the methodology around a universal model for how we plan for care, and allocate resources to ensure care plan goal achievement, would be far more valuable to society than centralizing the sources of funds to pay for care, because then we’d know what we’re paying for.
Within the ever-widening array of Democratic contenders for the Presidency, the “Medicare-for-all” debate continues to simmer. It was only six weeks ago that Kamala Harris’s vocal support drew fire from not one, but two billionaire political rivals. Michael Bloomberg, looking for support in New Hampshire declared, “I think we could never afford that. We are talking about trillions of dollars… [that] would bankrupt us for a long time.” Fellow billionaire candidate Howard Schultz added, “That’s not correct. That’s not American.”
Remarkably, neither man made the connection between large-scale health reform’s potential savings (pegged to save 15% of our $4 trillion annual spend according to health economists) and the thoughtful application of these newly captured resources to all U.S. citizens without discrimination. Bloomberg’s own 2017 Health System Efficiency Ratings listed the U.S. 50th out of 55, trailed only by Jordan, Columbia, Azerbaijan, Brazil, Russia. Yet he seemed unable to connect addressing waste with future affordability.
Schultz was similarly short sighted. While acknowledging that the
manmade opioid epidemic, mental health crises, and income inequality are
“systemic problems” and at levels “the likes of which we have not had in a long
time”, he failed to connect the cause (a remarkable dysfunctional and
inequitable health care system) with these effects.
As I outline in “Code Blue: Inside the Medical Industrial Complex” (Grove Atlantic/ June 4, 2019), today’s greatest risk to continued progress and movement toward universal coverage and rational health planning is sloppy nomenclature. To avoid talking past each other, we need to define the terms of this debate while agreeing on common end points.
Avik Roy has done the unthinkable. In a recent op-ed title he used “conservative’s case” and “universal healthcare” in the same sentence. And bridged these disparate words by the preposition for.
Spoiler alert: Roy has asked Republicans to embrace universal healthcare.
The Twitterverse is abuzz. An angry Gary P. Jackson, a self-affirmed conservative, tweeted:
“there is NEVER a conservative case for Marxism….especially Universal healthcare.”
Stated differently, universal healthcare is the worst form of Marxism except for all other forms of Marxism.
Thus far Roy has not been asked to produce his birth certificate, which is just as well. Roy, a prolific Forbes columnist and a scholar at the Manhattan Institute, was healthcare policy adviser to Mitt Romney. He is not a cheerleader of the Affordable Care Act.
There are things one may disagree with Roy. However, his short treatise, How Medicaid Fails the Poor, was impressive, as it deftly dealt with Medicaid’s structural problems. That a right-of-center policy analyst would write a book with that title is one of the many ironies I am now accustomed to encountering (the other delicious irony was the love of Cadillac health plans by unions).
“…[conservatives] have to agree that universal coverage is a morally worthy goal.”
The arguments put forward by Roy are pure common sense. No one objects to public education as “socialized education.” If conservatives are afraid that universal healthcare means big government, government is already heavily involved in healthcare.
And not just Medicare, which a certain tea party placard asked the government to keep its hands off! Continue reading…
I was surprised when the Opening Ceremonies of the Olympics in London honored two of my favorite institutions: the National Health Service and the World Wide Web. I was not surprised when LA Times sports writer Diane Pucin posted the following tweet: “For the life of me, though, am still baffled by NHS tribute at opening ceremonies. Like a tribute to United Health Care or something in US.” @swaldman responded to the sports writer with “Well, maybe, if United Health Care were government-run and a source of national pride.”
I was not surprised when Meredith Vieira and Matt Lauer of NBC admitted they had no idea why Tim Berners-Lee was being honored by sending out a tweet. Ever since I read his book Weaving the Web: The Original Design and Ultimate Destiny of the World Wide Web by Its Inventor (HarperSanFrancisco, 1999), Berners-Lee has been one of my heroes. Finally locating my hard copy of the book in the guest bedroom where my son Colin used to sleep, I quickly located the marked passage I was looking for:
“People have sometimes asked me whether I am upset that I have not made a lot of money from the Web. In fact, I made some quite conscious decisions about which way to take my life. These I would not change…. What does distress me, though, is how important a question it seems to be to some.
When I moved to Canada in 2008, I was a die-hard conservative Republican. So when I found out that we were going to be covered by Canada’s Universal Health Care, I was somewhat disgusted. This meant we couldn’t choose our own health coverage, or even opt out if we wanted too. It also meant that abortion was covered by our taxes, something I had always believed was horrible. I believed based on my politics that government mandated health care was a violation of my freedom.
When I got pregnant shortly after moving, I was apprehensive. Would I even be able to have a home birth like I had experienced with my first 2 babies? Universal Health Care meant less choice right? So I would be forced to do whatever the medical system dictated regardless of my feelings, because of the government mandate. I even talked some of having my baby across the border in the US, where I could pay out of pocket for whatever birth I wanted. So imagine my surprise when I discovered that Midwives were not only covered by the Universal health care, they were encouraged! Even for hospital births. In Canada, Midwives and Dr’s were both respected, and often worked together.
We’ve discussed it before. Why are costs so much higher in US healthcare compared to other countries? The Washington Post has a pointless article which seems to answer with the tautology costs are high because healthcare in America costs more. How much more? Well, we spend nearly twice as much per capita as the next nearest country while failing to provide universal coverage.
In the WaPo article they make a big deal of the costs of individual procedures like MRI being over a thousand in the US compared to $280 in France, but this is a simplistic analysis, and I think it misses the point as most authors do when discussing this issue. The reason things costs more is because in order to subsidize the hidden costs of medical care, providers charge more for imaging and procedures. For instance, Atul Gawande, in his New Yorker piece “The Cost Conundrum” wonders why it is that costs are higher to treat the same conditions in rural areas and in a major academic centers like UCLA than at a highly specialized private hospitals like the Mayo Clinic? I think the reason is it’s not nearly as expensive to administer and provide care for a select group of insured midwesterners at the Mayo than it is to provide care to the underserved in the poor areas of inner-cities and in poor rural locations.