Despite President Obama's pledge to oversee a major reform of the U.S. health-care system relatively soon, the effort appears to be stalled in Congress. Tom O'Rourke, a professor emeritus of community health, has studied health-care reform and systems outside the United States, and has written on both topics. He shared his views on efforts to pass landmark health-care legislation in the U.S. in an interview with News Bureau health sciences editor Melissa Mitchell.
With what appears to be zero-progress on reaching a consensus on health-care reform any time soon, what would happen if Congress ultimately fails to reach an agreement? In effect, if they do nothing?
We can expect more of the same that we've had for decades. Premiums will rise several times faster than wages. Businesses will continue to reduce employee coverage and/or shift more costs to employees. Others will just stop providing coverage. Millions more will lose health insurance if they lose or change jobs. The ranks of the uninsured and underinsured will continue to swell. Those insured will have even more limited choices of both plans and providers.
Rising costs and employer inability to sustain cost increases will result in millions moving from full- to part-time work, thus reducing average income even further. Health care will be more expensive for those fortunate to have coverage, as providers shift cost to care for the uninsured, setting up a vicious cycle where even more people can't afford insurance. Others won't even be able to get insurance because of a pre-existing condition. Millions of Americans will continue to live one medical emergency away from bankruptcy. The proportion of bankruptcies attributable to medical problems rose by 49.6 percent between 2001 and 2007. Illness and medical bills were linked to 62 percent of all personal bankruptcies in 2007. Most were middle class, had attended college, owned a home and were insured.
Health-care providers, such as physicians and nurses, will spend even more time dealing with insurers and health plans. An estimated $700 billion or about one-third of total health-care spending of $2 trillion-plus will be spent on tests and treatments that cannot be shown to improve health. The relative health status of the U.S. population, already one of the poorest of industrial countries, will continue to deteriorate and fail to keep pace with gains in health outcomes achieved in other countries.
Finally, the ability to curtail unnecessary and/or ineffective treatments will be diminished, thus adding to costs and impeding improved quality of care.
President Obama is now advocating a system that would allow people who already have health-care benefits to keep those plans, while those currently uninsured could opt into a so-called "public plan." Do you think that's a sound proposal?
That depends on what the final version of the public option looks like. Right now, the public option - as proposed - is doomed to fail. That's because hospitals and doctors would still need elaborate billing and cost-tracking systems. Overhead costs, even for an efficiently operated public option, would be far greater than that for traditional Medicare since, unlike Medicare, the public option would have to incur significant costs to compete in the marketplace. That's what makes Medicare relatively efficient - it doesn't have to compete. It automatically enrolls seniors at 65, deducts premiums through Social Security and incurs no costs for marketing or determining the costs for different risk pools. Unlike with private insurers, there is only one risk pool.
And what about the notion of mandated coverage ... is that really feasible?
Feasible yes, but it depends on the merit of what is mandated. How would you like to be required to purchase an SUV using leaded gas that's prone to rollover? Or a faulty smoke detector for every house or a shiny lead-painted toy for every child? As it stands now, Congress would make it a federal offense to not purchase faulty insurance.
What will work? In other words, how do we effectively achieve real reform?
President Obama has previously stated that if we were starting from scratch, a single-payer publicly financed and privately operated system would be preferable. Unfortunately, he has backed off because of provider and health-industry opposition. A single-payer system could realize about $400 billion in annual savings - enough to cover the uninsured and improve the coverage for most Americans.
Short of a single-payer plan, a public option could work if it contained:
- a pre-population with millions of people, representing a large pool to avoid the cost of marketing and contracting with thousands of providers.
- substantial subsidies to individuals choosing the public option.
- low overhead rates of reimbursement similar to current Medicare rates - about 20 percent lower than what private insurers command.
Also, the insurance industry could not offer a stripped-down, inadequate coverage plan to undercut the public option. The insurance industry has to be required to offer the same minimum level of benefits as the public option. It could offer a higher level if it chose.
Ultimately, the issue is straightforward and not as complex as the health providers and politicians would like you to believe. Should health care be viewed as a for-profit commodity or a human service? Go with the first and you get what we have. Go with the second and you have what virtually every industrial country has achieved.
If you could pick a country (or countries) to serve as a model for the U.S., which would you suggest? Why?
While I certainly wouldn't advocate for the total adoption of any other country's system, I think that the commonalities of systems of industrial countries such as Germany, France and Japan to the U.S. may be informative and capable of being adapted for the U.S. While each has its own unique system, all three are similar to the U.S. in that most coverage is through the workplace, using private insurers with services provided by private practitioners receiving a fee for service. However, unlike the U.S., their governments ensure universal access, a comprehensive benefit package to all citizens with a uniform payment to physicians and hospitals, and play a role in restraining growth of expenditures to providers.