Universal Health Insurance-Redux

South Carolina Nurse, The, Apr-Jun 2003 by Bailey, Lynn

It's back! The idea of universal care - a set of uniform healthcare benefits available and affordable for all Americans has quietly returned after a decade in exile. Underneath the partisan bickering in Washington over the patients' bill of rights, Medicare reform and Medicare prescription drug benefits, thoughtful Congressional leaders, both conservative and liberal, have concluded that piecemeal solutions aren't solving our healthcare problems. Sen. John Breaux, the moderate Democratic senator from Louisiana has concluded "the health care system is collapsing around us."

What's being quietly discussed, isn't the universal healthcare insurance scheme proposed in the early 1990s. It isn't the fully paid for administered by the federal government plan outlined by the Clintons. The current concept is a "universal" plan building on Medicare to cover the unemployed, small businesses, the "retired too young for Medicare," and working families with incomes too high to be eligible for Medicaid.

It is a national plan with limited benefits available to all. It would assure catastrophic care for serious illness or hospitalization. It would also include preventive services for children and perhaps some type of prescription drug benefit for the elderly.

In an op-ed piece in the New York Times, (Oct. 13, 2002) Marcia Angell, MD the former editor in chief of the New England Journal of Medicine, calls for a single payer health insurance program. Senators Orin Hatch, Republican of Utah and Ron Wyden, Democrat from Oregon have collaborated on a bill to reform our healthcare system through an organized process of citizen involvement. Big businesses are looking favorably at "universal insurance" as their way out of the cycle of rising employee health plan costs.

Businesses have come to understand the high costs of hospital care, the major driver in rapidly rising healthcare costs, is the direct result of the care provided to the growing population of the uninsured. Businesses are also sobered by their own experience with managed care controlling Healthcare costs.

The economic boom of the 1990s failed to dramatically reduce the number of uninsured Americans. The current recession has hit state budgets hard. Across the country states are considering reductions in Medicaid benefits to meet budget shortfalls.

The Institute of Medicine released in March 2003, a new study-A Shared Destiny Effects of Uninsumnce on Individuals, Families, and Communities, that examines the effects of the uninsured on communities. Health care providers suffer significant adverse consequences in communities with high level of uninsured. Communities with high levels of uninsured have reduced access to inpatient services, specialty health services and emergency and trauma services. High levels of the uninsured hampers a community's hospitals revenue base. Eighty-five percent of the care delivered to the uninsured is financed by the public sector-directly or indirectly from tax payers. High rates of uninsured may also place the general population at an increased risk for public health problems such as HIV, flu epidemics, or bio-terrorist event.

In the July/August issue of Health Affairs, Drs. Steffie Woolhandler and David Himmelstein, conclude the current tax-financed share of healthcare spending is 60%, much higher than most people think. We are in fact paying for a national health insurance system but not getting it. Much of the tax financing is going on off the radar screen and behind the scenes and is not directly accounted for. If this financing were more direct and visible, people would feel less threatened by the smaller tax increase a more rational health insurance plan would require.

Ten years of incremental changes and market-oriented efforts have resulted in a healthcare system unsatisfactory to EVERYONE-physicians, nurses, hospitals, payers, and especially to patients. In our "market" healthcare system, medical care is simply a commodity. Insurers and providers compete to avoid the expensive or uninsured patients. We hide the game of patient hot potato behind volumes of oversight and paperwork- all this adding to health care costs and not making us healthier.

Follow the healthcare dollar: everyone gets their cut. Private insurance get between 10 and 25% of premiums to administration, marketing and profits. Lets not forget the array of insurance brokers, utilization review companies, disease management companies, lawyers, consultants, billing services, data/information management firms, and reimbursement specialists, etc. Each takes a cut. Multiple insurance companies only increase the complexity and costs to the system.

Princeton health economist, Uwe Reinhardt, Princeton, calls this "pigs at the healthcare trough." If half the insurance premium actually reaches doctors, I'm surprised. Patients and their doctors end up at the bottom of this food chain.

The perverse incentive is not to control costs. Each "little piggy" wants more customers. No one wants the customers who can't pay. All market-based attempts at incremental reform encounter a dilemma of access and costs. Expand access and costs rise-lower costs reduce access. How do you reduce access if people aren't healthier?