makes health care reform so controversial is its complexity. Nearly one
of every five dollars in our wallets will be spent on health care.
Health care obeys almost none of our conventional rules of economics;
for instance, as health care costs go up, health care needs do not go
down. And it is a sword of Damocles hanging over all our heads – most
American families are one hospitalization away from financial
essay rearranges what most of us already know in a fashion that may make
understanding health care reform easier. The format is three questions
with three answers each, each answer accompanied by appropriate
documentation. The goal is not to justify a specific solution, but
increase appreciation of the nature of the problem so any proposed
solution can be evaluated.
Why do we need health care reform?
is not rhetorical. Many elected officials state unequivocally that the
US enjoys the “best health care in the world (1-8).” It is difficult
to substantiate this belief.
The US pays twice as much annually for health care as the average
industrialized nation. This is true on a per capita basis and percent of
gross domestic product (GDP) (9,10). Correcting for smoking, obesity,
traffic fatalities, race, and homicides makes no perceptible difference (11). We spend more on health care than any other nation in the world.
If US citizens were twice as healthy, we could accept twice the
spending. But on most measures of public health, we rank at or near the
bottom of industrialized countries. In such basic
health care measures [mm1] as
maternal mortality (12,13), lives lost to preventable and treatable
disease (14-16), and even foot amputations per 100,000 diabetics
our record is dismal.
The medical, financial, and social consequences of our expensive,
ineffective health care system are devastating. We are the only
industrialized country which allows families to lose homes, limbs, or
lives when they lack money for health care (18,19). Medically-related
bankruptcy, which accounts for most personal bankruptcies in the US
(20), is nearly absent in other industrialized countries.
What are the goals of health care reform?
reform proposals define success with intermediate variables that fail to
reflect meaningful and measurable endpoints. Examples of such
intermediate endpoints are percentage of citizens with insurance
policies, reductions in federal spending, decreased use of physician
services. But ultimately, reform must achieve three goals.
Access to health care when we need it. [mm1] A
plan caring for citizens who are young, healthy, and employed but expels
them when they become old, sick, poor, or jobless is not reform. Most
Americans purchase health insurance through their employers (21). As the
average worker changes jobs nearly a dozen times before reaching 40
years old (22) and changes insurance companies on average every six
years (23), there are many vulnerable periods in which insurance (and
access to health care) can be lost. This lost access does not happen in
other industrialized countries (17-19). It should not happen here.
Reduced costs does not mean redistributed costs. Solutions that shift
spending among patients, insurance companies, employers, and employees
are not reform. Annual per capita spending and percent of gross domestic
product dedicated to health care are the ultimate measures of cost.
Improved public health.
We want more than lower costs. We want better health.
How do successful health care systems provide better care to more people
for less money?
health care programs of our industrialized neighbors in North America,
Europe, the Pacific Rim, and East Asia all provide better care to more
people for less money (9,10,12,14,15). Although they bear little
resemblance to each other (17,18), they share three common
characteristics missing from the American private health insurance
care access includes everyone regardless of health. Unlike the US, other industrialized countries
provide lifetime access to all citizens regardless of age, health,
employment, or economic status (24). The US is alone in fragmenting its
population and then discriminating against the sick, either by
restricting access or charging higher prices. We are the only country
that considers it acceptable that some citizens have no access to health
care. Even our publically subsidized health care programs exclude some
citizens whose lack of income prevents access to health care (25). Other
countries allow all citizens access to needed care regardless of
or no cost sharing.
Other industrialized nations encourage inexpensive primary and
preventative care to decrease subsequent need for expensive emergent or
intensive [mm1] care.
We are unique in using high deductibles, large co-pays, and excluded
conditions to discourage citizens from seeking health care (26).
Financing by publically accountable, transparent, not for profit
We are the only country in which private insurance companies use medical
underwriting to fragment populations into risk pools, and then base
benefits and premiums on the likelihood of needing care (17). In other
industrialized countries, such discrimination is outlawed. Financing
agencies remain beholden to the health care interests of patients, not
to the financial needs of owners, and must make their policies,
benefits, and payments open to public inspection.
of such publically accountable, transparent, not-for-profit systems are
mandated insurance, two tier private and/or public insurance, and single
payer (27). Single payer is
a system of universal care with low cost sharing that uses one publically accountable, transparent, not for profit financing
agency (28). [mm1] Single
payer nations include Japan, Canada, Iceland, the United Kingdom,
Sweden, Norway, Finland, Italy, Portugal, and Spain. Domestic examples
of single payer or variants of single payer are multi-employer health
plans, the Veterans Health Administration, TriCare for uniformed
services, Medicare, and Medicaid.
essay attempts to eliminate factors which distract or polarize health
care discussions. Many debaters use health care reform as a tool to
advance other platforms such as human rights or smaller government.
While such platforms may be important in the public arena, they fracture
health care discussions with issues largely unrelated to the urgency,
goals, or options for health care reform.
to the third question have several important implications.
reform proposal to succeed, it must first address the root cause of our
dysfunctional health care system that consumes too much money while
providing too little care. That root cause is our method of financing
care that impedes access to health care rather than promoting access.
American health care reform must begin by improving financing
before attempting to improve delivery.
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