Do We Really Want Broad Access to Health Care?
http://www.100md.com
《新英格兰医药杂志》
Now that the presidential election is over, the real work on the issue of access to health care should begin. The work will be difficult — and probably impossible to accomplish unless the health care profession helps the U.S. public to confront some unpleasant truths.
One might have thought that an election that hinged on "moral values" would generate serious discussion of one of our most fundamental "values" issues — that is, whether we really believe that broader health insurance coverage should be a high priority. The candidates were asked to debate on the basis of their values on issues such as abortion, stem-cell research, and same-sex marriage. But their rather marked disagreement on how to increase access to health care was never treated as a "values" issue, perhaps because voters were unwilling to have their own values tested on this topic.
Americans may say they believe that instituting broader coverage is the right thing to do, yet everyone prefers to change the subject when the discussion turns to how to pay for it. We can understand why candidates seeking election shy away from the implication that they might raise taxes. But we believe that the medical profession must look within itself, collectively and individually, and ask whether we truly want broader coverage. If we do, we must be open, honest, and direct about what will be required — beginning with publicly advocating for the higher taxes or employer mandates needed to achieve this goal.
Our Aim Is Low
During the campaign, both candidates said that they supported the goal of access to health care for all,1 but dollars mean more than words when it comes to covering the uninsured. Senator John Kerry's proposals would have cost about $653 billion over the next 10 years and would have extended coverage to about 27 million of the 45 million uninsured Americans. President George W. Bush's plan includes refundable tax credits and encouragement of the pooling of purchasing power by small employers. This plan would increase federal spending by about $90 billion over the next 10 years and extend coverage to an estimated 2.4 million people, or about 5 percent of the uninsured.
The absence of any real effort by the Bush administration to make more than a dent in the problem of the uninsured reflects the basic ambivalence of Americans about the role of government. On the one hand, we are quite interested in the government benefits that affect us directly, such as Social Security, Medicare, veterans' benefits, and certain key tax subsidies. On the other hand, we have a historical and cultural bias against large, intrusive, regulatory actions undertaken by the government, especially when they involve increasing taxes.
The antitax movement has only become stronger and more widespread since the passage of Proposition 13 in California in 1978. Two years ago, in the hotbed of liberalism known as Massachusetts, 45 percent of voters voted to repeal the state income tax. Politicians in virtually all federal, state, and local offices are asked to promise not to raise taxes as if they were taking some kind of loyalty oath, even though our federal tax level as a percentage of the gross domestic product is the lowest since 1959.2
This political environment provides fertile ground for the notion that the marketplace should solve health care problems. Part of the appeal of this concept is that the marketplace cannot directly levy taxes and is therefore seen as less threatening to individuals' interests than government is. To date, however, market-based solutions have had only modest success in controlling costs, and few people even pretend that markets can help the one of every six persons who is currently uninsured and cannot even afford to enter the market.
The Challenge of the Uninsured
The antitax movement should be recognized for what it is, the main enemy of those who truly seek to meet the needs of the 45 million uninsured Americans. Admitting that we are living with two irreconcilable values — we want to see ourselves as a caring people, but we don't want our taxes to go up — is unpleasant. For that reason, we work hard to protect our self-image by means of elaborate fantasies.
We tell ourselves that the uninsured have only themselves to blame for their situation, whereas the truth is that about 80 percent of them are either employed or dependents of those who are employed.3 The uninsured work hard, often at agricultural, retail, and service jobs, yet they fall between the cracks of our health insurance system.
We tell ourselves that they are actually getting care despite our flawed system. And in a sense, they are receiving limited care for their more dramatic crises. As a society, we don't want to see childbirth occur in the street or an obviously broken bone ignored. We are willing to pay enough to move the care indoors and out of sight. But we are not willing to provide coverage for the chronic conditions and preventive care that might enable the uninsured to lead more productive and happier lives.
From decades of health services research, we know that having health insurance makes a difference. The uninsured are more likely to postpone care and less likely to receive preventive care than those with insurance. They are twice as likely as the insured to be hospitalized for the avoidable complications of diabetes and hypertension. The facts are beyond dispute. The question is whether we care enough to do what every other industrialized nation has done — provide coverage for all.
Three Failures
Three times in the past few decades we have confronted the challenge of broadening access to health care, and three times we have failed to meet it. In 1974, President Richard Nixon made a bold, even noble proposal of broad health insurance coverage. Nixon had two options for financing his proposal: an increase in taxes or — the option he chose — an employer mandate (i.e., a requirement that employers provide health insurance to their employees). Conservatives attacked the employer mandate as a hidden tax, and liberals attacked the extent of coverage as not going far enough. Nixon's proposal died in the congressional cross fire. In 1979, President Jimmy Carter put forth a similar proposal, which met a similar fate. The political dynamics that prevented progress then were no different with a Democratic president than they had been under Nixon, a Republican.
The most resounding defeat occurred a decade ago, when President Bill Clinton put forth a health-insurance proposal that, like Nixon's and Carter's, was financed by an employer mandate. Critics at the time, and since, complained about the plan's complexity, but it was the opposition by small businesses to the employer mandate that killed the proposal.
The real issue was, as it always has been, how to pay for broader coverage. Our nation and the Congress faced this issue squarely and made a decision. We gave a higher priority to avoiding an increase in taxes and its closely related cousin, an employer mandate, than we did to providing coverage for 45 million uninsured people.
Confronting the Truth about Ourselves
How can a country as idealistic and generous as the United States fail repeatedly to accomplish in health care coverage what every other industrialized nation has achieved? One explanation may be that we are not so idealistic or generous as we would like to believe we are. Although there are various issues surrounding plans for broader coverage, the overriding concern in each of the previous defeats has been our reluctance to have to pay by means of taxes or mandates for health care for others.
Our self-image was forged in crises such as the Depression, World War II, and the Civil Rights Movement, in times when the idea of sacrifice for the greater good was a political rallying cry. Over the past 30 years, however, we have become a relatively affluent nation of consumers who are focused more on the rights and desires of individuals than on the needs of the community. Many conservatives use the phrase "rugged individualism" to describe this outlook. Liberals might use a harsher, more grating word, "selfishness." We don't know at what point rugged individualism becomes self-centeredness and self-centeredness, selfishness, but somewhere in that transition health care reform died in 1974, 1979, and 1994.
The Costs of Broad Access
How much would broad access to health insurance cost? In 2003, the Institute of Medicine's Committee on the Consequences of Uninsurance published analyses in which it concluded that the incremental costs of health services that the uninsured could be expected to use, were they to gain coverage, range from $34 billion to $69 billion (2001 dollars) (Table 1).4 These new estimated costs would amount to 2.8 to 5.6 percent of national spending for personal health care services, or about half of the 8.7 percent increase in spending that actually occurred between 2000 and 2001.
Table 1. Estimated Annual Costs of Health Care Services for Uninsured Persons and the Expected Economic Value of Providing Them with Insurance.
We recognize that this "prescription" is not without pain. And we acknowledge that much of any new funding would flow to health care organizations such as our own that do not turn anyone away because of lack of insurance. We also recognize that the ultimate costs of broad access to health care might well be somewhat higher than these estimates, because most health insurance proposals have additional goals, such as seeking fairness for the employers who currently offer coverage. Any major initiative to broaden access to health insurance can influence the coverage of those currently insured; some will have their insurance improved, and others who now have private insurance will drop such coverage in favor of any new public plan. The costs could be on the same scale as the occupation of Iraq.
If broad access to health care is ever to be more than a campaign sound bite, it cannot be a casual commitment. Americans must understand that they are going to make real sacrifices for other Americans. Currently, the anguish caused by annual increases in health care costs is offset by the knowledge that because of each year's medical progress, we are "buying a better product," potentially for ourselves, should we become ill. A one-time increase of 50 percent in the rate of rising health care costs that benefits someone else is a more difficult sell.
Would there be a return on investment for these new costs to society? The Committee on the Consequences of Uninsurance estimated that diminished health due to inadequate insurance leads to societal costs of $65 billion to $130 billion per year (Table 1). Such losses might be avoided if broad access to health insurance were to reduce the rates of morbidity and mortality among the uninsured to levels similar to those among people with insurance. As a country, however, we get stuck, because these benefits do not directly affect the people and the employers who would be asked to pay more for the broader access to care.
A Defining Moment
A cynical but smart bet would be that the United States will not make meaningful progress toward expanding health care coverage during the remaining years of the Bush administration. Assuming this is the case, the number of uninsured persons can be expected to rise and access to care by the uninsured is likely to narrow, because it is increasingly difficult for health care providers to give away care for free.
What should health care providers do if they really believe health care is a right of all people but still understand the political realities? At least in the near term, the United States is not likely to adopt the government-based approaches of the United Kingdom, Canada, and many other Western countries.5 Instead, we think that proponents of broader access should advocate a new balance, one that buffers the defects of a corporate-market model yet avoids the centralized power that many fear in a government model. This new balance would have its own formidable political challenges. It must include a mechanism to finance care for all our people, a mechanism that will inevitably include the need for new taxes, mandates, or both. We believe that a fundamental and defining question for all health care providers who support broad access to health care is this: Are you willing to advocate publicly for higher taxes? If enough of us state the simple truth that this is necessary, we may create a political environment in which our leaders may eventually be able to lead on this issue.
At the same time, we must attempt to balance markets and regulation as a way to control health care costs. Health care providers must work to ensure that we provide only necessary, efficient, and high-quality services. Even with our best efforts to reduce waste and bureaucracy, however, and even with a willingness to let health care continue to increase as a percentage of the gross national product, we may well find that at some point we will need to limit or ration services, according to market forces or to budgetary allocations.
Our prescription — higher taxes and possibly rationing — is hardly the platform of a winning ticket for any political candidate. But now that the 2004 presidential election is over, it's time to get serious about health care. And health care professionals should lead the way and begin the truth-telling about the "tough medicine" that will be required if we are to live up to our ideals.
Source Information
From Partners HealthCare System and Harvard Medical School — both in Boston.
Address reprint requests to Dr. Mongan at Partners HealthCare System, Prudential Tower, 11th Fl., 800 Boylston St., Boston, MA 02199, or at jmongan@partners.org.
References
Bush GW, Kerry JF. Health care coverage and drug costs -- the candidates speak out. N Engl J Med 2004;351:1815-1819.
Office of Management and Budget. Fiscal year 2005 budget. (Accessed February 16, 2005, at http://www.taxpolicycenter.org/TaxFacts/TFDB/TFTemplate.cfm?Docid=205.)
Kaiser Commission on Medicaid and the Uninsured. Health insurance coverage in America: 2002 data update. Menlo Park, Calif.: Kaiser Family Foundation, December 2003. (Accessed March 9, 2005, at http://www.kff.org/uninsured/4154.cfm.)
Institute of Medicine, Committee on the Consequences of Uninsurance. Hidden costs, value lost: uninsurance in America. Washington, D.C.: National Academies Press, 2003.
Budetti PP. 10 Years beyond the Health Security Act failure: subsequent developments and persistent problems. JAMA 2004;292:2000-2006.(James J. Mongan, M.D., an)
One might have thought that an election that hinged on "moral values" would generate serious discussion of one of our most fundamental "values" issues — that is, whether we really believe that broader health insurance coverage should be a high priority. The candidates were asked to debate on the basis of their values on issues such as abortion, stem-cell research, and same-sex marriage. But their rather marked disagreement on how to increase access to health care was never treated as a "values" issue, perhaps because voters were unwilling to have their own values tested on this topic.
Americans may say they believe that instituting broader coverage is the right thing to do, yet everyone prefers to change the subject when the discussion turns to how to pay for it. We can understand why candidates seeking election shy away from the implication that they might raise taxes. But we believe that the medical profession must look within itself, collectively and individually, and ask whether we truly want broader coverage. If we do, we must be open, honest, and direct about what will be required — beginning with publicly advocating for the higher taxes or employer mandates needed to achieve this goal.
Our Aim Is Low
During the campaign, both candidates said that they supported the goal of access to health care for all,1 but dollars mean more than words when it comes to covering the uninsured. Senator John Kerry's proposals would have cost about $653 billion over the next 10 years and would have extended coverage to about 27 million of the 45 million uninsured Americans. President George W. Bush's plan includes refundable tax credits and encouragement of the pooling of purchasing power by small employers. This plan would increase federal spending by about $90 billion over the next 10 years and extend coverage to an estimated 2.4 million people, or about 5 percent of the uninsured.
The absence of any real effort by the Bush administration to make more than a dent in the problem of the uninsured reflects the basic ambivalence of Americans about the role of government. On the one hand, we are quite interested in the government benefits that affect us directly, such as Social Security, Medicare, veterans' benefits, and certain key tax subsidies. On the other hand, we have a historical and cultural bias against large, intrusive, regulatory actions undertaken by the government, especially when they involve increasing taxes.
The antitax movement has only become stronger and more widespread since the passage of Proposition 13 in California in 1978. Two years ago, in the hotbed of liberalism known as Massachusetts, 45 percent of voters voted to repeal the state income tax. Politicians in virtually all federal, state, and local offices are asked to promise not to raise taxes as if they were taking some kind of loyalty oath, even though our federal tax level as a percentage of the gross domestic product is the lowest since 1959.2
This political environment provides fertile ground for the notion that the marketplace should solve health care problems. Part of the appeal of this concept is that the marketplace cannot directly levy taxes and is therefore seen as less threatening to individuals' interests than government is. To date, however, market-based solutions have had only modest success in controlling costs, and few people even pretend that markets can help the one of every six persons who is currently uninsured and cannot even afford to enter the market.
The Challenge of the Uninsured
The antitax movement should be recognized for what it is, the main enemy of those who truly seek to meet the needs of the 45 million uninsured Americans. Admitting that we are living with two irreconcilable values — we want to see ourselves as a caring people, but we don't want our taxes to go up — is unpleasant. For that reason, we work hard to protect our self-image by means of elaborate fantasies.
We tell ourselves that the uninsured have only themselves to blame for their situation, whereas the truth is that about 80 percent of them are either employed or dependents of those who are employed.3 The uninsured work hard, often at agricultural, retail, and service jobs, yet they fall between the cracks of our health insurance system.
We tell ourselves that they are actually getting care despite our flawed system. And in a sense, they are receiving limited care for their more dramatic crises. As a society, we don't want to see childbirth occur in the street or an obviously broken bone ignored. We are willing to pay enough to move the care indoors and out of sight. But we are not willing to provide coverage for the chronic conditions and preventive care that might enable the uninsured to lead more productive and happier lives.
From decades of health services research, we know that having health insurance makes a difference. The uninsured are more likely to postpone care and less likely to receive preventive care than those with insurance. They are twice as likely as the insured to be hospitalized for the avoidable complications of diabetes and hypertension. The facts are beyond dispute. The question is whether we care enough to do what every other industrialized nation has done — provide coverage for all.
Three Failures
Three times in the past few decades we have confronted the challenge of broadening access to health care, and three times we have failed to meet it. In 1974, President Richard Nixon made a bold, even noble proposal of broad health insurance coverage. Nixon had two options for financing his proposal: an increase in taxes or — the option he chose — an employer mandate (i.e., a requirement that employers provide health insurance to their employees). Conservatives attacked the employer mandate as a hidden tax, and liberals attacked the extent of coverage as not going far enough. Nixon's proposal died in the congressional cross fire. In 1979, President Jimmy Carter put forth a similar proposal, which met a similar fate. The political dynamics that prevented progress then were no different with a Democratic president than they had been under Nixon, a Republican.
The most resounding defeat occurred a decade ago, when President Bill Clinton put forth a health-insurance proposal that, like Nixon's and Carter's, was financed by an employer mandate. Critics at the time, and since, complained about the plan's complexity, but it was the opposition by small businesses to the employer mandate that killed the proposal.
The real issue was, as it always has been, how to pay for broader coverage. Our nation and the Congress faced this issue squarely and made a decision. We gave a higher priority to avoiding an increase in taxes and its closely related cousin, an employer mandate, than we did to providing coverage for 45 million uninsured people.
Confronting the Truth about Ourselves
How can a country as idealistic and generous as the United States fail repeatedly to accomplish in health care coverage what every other industrialized nation has achieved? One explanation may be that we are not so idealistic or generous as we would like to believe we are. Although there are various issues surrounding plans for broader coverage, the overriding concern in each of the previous defeats has been our reluctance to have to pay by means of taxes or mandates for health care for others.
Our self-image was forged in crises such as the Depression, World War II, and the Civil Rights Movement, in times when the idea of sacrifice for the greater good was a political rallying cry. Over the past 30 years, however, we have become a relatively affluent nation of consumers who are focused more on the rights and desires of individuals than on the needs of the community. Many conservatives use the phrase "rugged individualism" to describe this outlook. Liberals might use a harsher, more grating word, "selfishness." We don't know at what point rugged individualism becomes self-centeredness and self-centeredness, selfishness, but somewhere in that transition health care reform died in 1974, 1979, and 1994.
The Costs of Broad Access
How much would broad access to health insurance cost? In 2003, the Institute of Medicine's Committee on the Consequences of Uninsurance published analyses in which it concluded that the incremental costs of health services that the uninsured could be expected to use, were they to gain coverage, range from $34 billion to $69 billion (2001 dollars) (Table 1).4 These new estimated costs would amount to 2.8 to 5.6 percent of national spending for personal health care services, or about half of the 8.7 percent increase in spending that actually occurred between 2000 and 2001.
Table 1. Estimated Annual Costs of Health Care Services for Uninsured Persons and the Expected Economic Value of Providing Them with Insurance.
We recognize that this "prescription" is not without pain. And we acknowledge that much of any new funding would flow to health care organizations such as our own that do not turn anyone away because of lack of insurance. We also recognize that the ultimate costs of broad access to health care might well be somewhat higher than these estimates, because most health insurance proposals have additional goals, such as seeking fairness for the employers who currently offer coverage. Any major initiative to broaden access to health insurance can influence the coverage of those currently insured; some will have their insurance improved, and others who now have private insurance will drop such coverage in favor of any new public plan. The costs could be on the same scale as the occupation of Iraq.
If broad access to health care is ever to be more than a campaign sound bite, it cannot be a casual commitment. Americans must understand that they are going to make real sacrifices for other Americans. Currently, the anguish caused by annual increases in health care costs is offset by the knowledge that because of each year's medical progress, we are "buying a better product," potentially for ourselves, should we become ill. A one-time increase of 50 percent in the rate of rising health care costs that benefits someone else is a more difficult sell.
Would there be a return on investment for these new costs to society? The Committee on the Consequences of Uninsurance estimated that diminished health due to inadequate insurance leads to societal costs of $65 billion to $130 billion per year (Table 1). Such losses might be avoided if broad access to health insurance were to reduce the rates of morbidity and mortality among the uninsured to levels similar to those among people with insurance. As a country, however, we get stuck, because these benefits do not directly affect the people and the employers who would be asked to pay more for the broader access to care.
A Defining Moment
A cynical but smart bet would be that the United States will not make meaningful progress toward expanding health care coverage during the remaining years of the Bush administration. Assuming this is the case, the number of uninsured persons can be expected to rise and access to care by the uninsured is likely to narrow, because it is increasingly difficult for health care providers to give away care for free.
What should health care providers do if they really believe health care is a right of all people but still understand the political realities? At least in the near term, the United States is not likely to adopt the government-based approaches of the United Kingdom, Canada, and many other Western countries.5 Instead, we think that proponents of broader access should advocate a new balance, one that buffers the defects of a corporate-market model yet avoids the centralized power that many fear in a government model. This new balance would have its own formidable political challenges. It must include a mechanism to finance care for all our people, a mechanism that will inevitably include the need for new taxes, mandates, or both. We believe that a fundamental and defining question for all health care providers who support broad access to health care is this: Are you willing to advocate publicly for higher taxes? If enough of us state the simple truth that this is necessary, we may create a political environment in which our leaders may eventually be able to lead on this issue.
At the same time, we must attempt to balance markets and regulation as a way to control health care costs. Health care providers must work to ensure that we provide only necessary, efficient, and high-quality services. Even with our best efforts to reduce waste and bureaucracy, however, and even with a willingness to let health care continue to increase as a percentage of the gross national product, we may well find that at some point we will need to limit or ration services, according to market forces or to budgetary allocations.
Our prescription — higher taxes and possibly rationing — is hardly the platform of a winning ticket for any political candidate. But now that the 2004 presidential election is over, it's time to get serious about health care. And health care professionals should lead the way and begin the truth-telling about the "tough medicine" that will be required if we are to live up to our ideals.
Source Information
From Partners HealthCare System and Harvard Medical School — both in Boston.
Address reprint requests to Dr. Mongan at Partners HealthCare System, Prudential Tower, 11th Fl., 800 Boylston St., Boston, MA 02199, or at jmongan@partners.org.
References
Bush GW, Kerry JF. Health care coverage and drug costs -- the candidates speak out. N Engl J Med 2004;351:1815-1819.
Office of Management and Budget. Fiscal year 2005 budget. (Accessed February 16, 2005, at http://www.taxpolicycenter.org/TaxFacts/TFDB/TFTemplate.cfm?Docid=205.)
Kaiser Commission on Medicaid and the Uninsured. Health insurance coverage in America: 2002 data update. Menlo Park, Calif.: Kaiser Family Foundation, December 2003. (Accessed March 9, 2005, at http://www.kff.org/uninsured/4154.cfm.)
Institute of Medicine, Committee on the Consequences of Uninsurance. Hidden costs, value lost: uninsurance in America. Washington, D.C.: National Academies Press, 2003.
Budetti PP. 10 Years beyond the Health Security Act failure: subsequent developments and persistent problems. JAMA 2004;292:2000-2006.(James J. Mongan, M.D., an)