Wednesday, November 18, 2009

How important is it really to provide health coverage to all?

Many issues relating to health reform are creating deep divisions among Americans, including taxes, mandates, and the public plan option. Yet I had assumed that there was a general consensus that everyone should have access to affordable coverage, and the disagreement was mostly over how to achieve it, not whether this should be a major objective.

I was wrong: many critics of the current effort believe that covering everyone is not all that important, at least when compared to other priorities.

For instance, the House GOP's health reform proposal, according to the Congressional Budget Office, would reduce "the number of nonelderly people without health insurance by about 3 million in 2019 and leaving about 52 million nonelderly residents uninsured. The share of legal nonelderly residents with insurance coverage in 2019 - 83 percent - would be roughly in line with the current share." Instead, the GOP plan focuses more on providing more (and less costly) coverage options for people who already have health insurance.

In a recent Washington Post column, Robert Samuelson makes the case why providing health insurance to everyone is less important than keeping government spending under control:

" . . almost everyone thinks that people in need of essential medical care should get it; ideally, everyone would have health insurance. The pursuit of these worthy goals can easily be projected as a high-minded exercise for the public good. It's false for two reasons. First, the country has other goals - including preventing financial crises and minimizing the crushing effects of high deficits or taxes on the economy and younger Americans -- that 'health-care reform' would jeopardize. And second, the benefits of 'reform' are exaggerated. Sure, many Americans would feel less fearful about losing insurance; but there are cheaper ways to limit insecurity."

Is Samuelson right that the issue is mostly about reducing "insecurity?" For many of the uninsured, it is much more than that. According to a new Harvard study, people without health insurance are 40 percent higher risk of death than those with health insurance, and 45,000 Americans of them die each year as a consequence. Similarly, in 2002, the Institute of Medicine found people without health insurance are more likely to suffer poor health and die prematurely. And in 2008, the Urban Institute updated the IOM report and estimated that 137,000 people died from 2000 through 2006 because they lacked health insurance, including 22,000 people in 2006.

Providing all Americans with access to affordable health insurance coverage is a top priority for the American College of Physicians, and one of the many reasons why the College has expressed support for many of the key policies in H.R. 3962.

I am ambivalent about the question of whether health care is a right, but I firmly believe, as does the ACP, that covering everyone is the right thing to do. I don't disagree that the country has other important goals, as Samuelson argues, like minimizing crushing deficits. But if the annual death toll of not having coverage is akin to the total U.S. deaths suffered during the Vietnam War, how can preventing such deaths not be an essential purpose of health reform?

Today's questions: Do you believe that uninsured people are more likely to die prematurely? Do you believe that providing all Americans with health coverage should be an essential purpose of health reform?


Arvind said...

You have already answered the first question in your post. Sometimes, I wonder why you even post questions, because you sure do a good job of answering your questions.

The answer to the 2nd question is "No" according to me; for the following reasons -
1) The govt already has programs to cover those that don't have jobs (Medicaid) and are retired (Medicare). So the question becomes - who are these folks that are still uninsured? And what is the best way to make health coverage available to these folks? In my experience, a vast minority of the uninsured are those that simply don't want to be insured because they don't find value in buying health insurance (I agree with their premise). So that leaves us trying to cover those that want health coverage but cannot get one. So, why shake up the whole system in order to cover a few? I agree with Samuelson that if we are able to reinvigorate the economy and create better paying jobs, we can allow these uninsured folks that want to buy coverage to do so, because they can afford it and find value in it. Delinking health insurance from employment is the first critical step to make coverage "universal". It is time to move away from being a nanny state; it is not the government's (and tax payer's) duty to ensure that everybody is covered; at the expense of the financial security of future generations of Americans.

Steve Lucas said...

First, I personally distinguish between health insurance and access to health care. I feel these are two distinct issues with different solutions. Like most I want people to have access to needed care. Notice the emphasis on needed care.

The problem with health insurance is it often includes politically motivated mandates. A recent WSJ article highlighted a retired couple, not yet eligible for Medicare, with a catastrophic policy costing 10% of their monthly income. They were notified by the state that this policy did not meet state requirements, and they would need to pay more for a state sponsored policy.

Dr. Jeffery S. Flier in a Nov. 18 WSJ Op-ed makes some important points:

"Our health-care system suffers from problems of cost, access and quality and needs major reform.

And deep flaws in Medicare and Medicaid drive spending without optimizing care.

.... whatever its shape, the final legislation that will emerge from Congress will markedly accelerate national health-care spending rather than restrain it."

The rest of the article supports these concepts.

In traveling to Canada, France and the UK access is the issue. They have a foundation of front line physicians who can start and guide the medical process for their patients. Help with the decision process and to the extent possible be an advocate.

While far from perfect, and many would say in need of change, the focus is on access. Germany is now dealing with a ballooning medical budget as it tries to deal with growing insurance cost.

Access is the key, not insurance.

Steve Lucas

Jay Larson MD said...

Our health care system is very expensive…diagnostics, medications, procedures, and hospitalizations. For many (not most) insurance is pretty much needed to access the system without bankruptcy if a major illness occurs.

Chronic disease is best managed early to reduce the risk of expensive consequences and to maintain quality of life.

Because of cost issues those without financial resources use the “prayer” plan…they pray they don’t get ill or have an accident. There are times that the prayer plan fails and expensive treatments are used to treat complications that may have been prevented.

If they do not have the financial resources to cover the cost of their treatment, then other members of society pay for the treatment through higher insurance premiums etc… Health care is paid for one way or another.

Yes, there are people who choose not to obtain insurance, but there are many in their 50’s and 60’s that have enough medical issues that they will be denied health insurance coverage flat out. I have seen this scenario many times. People leave their job with a group plan and that is it for insurance coverage until they are 65 and get Medicare. These are people who want to get insurance but just can’t.

I know that if I tried to get even a catastrophic plan, I would be denied. I am generally healthy but have had some medical issues in the past. Currently I am covered by my wife’s employer’s group plan. If she leaves her job, I too will have to use the prayer plan.

Steve Lucas said...

Almost four years ago my youngest brother, 47, died of liver failure, alcoholic. While he was covered by Medicaid, all the insurance in the world would not have changed his situation. Angry and defiant to the end he blamed others, and the medical community, for his health problems.

In today's WSJ Health Blog we see the following tax increases in one article:

Tax on high-end health insurance plans: $149.1 billion
Capping flexible spending accounts at $2,500: $14.6 billion
Fees for drug makers: $22.2 billion
Fees for medical device makers: $19.3 billion
Fees for health insurance companies: $60.4 billion
Higher floor for deducting medical expenses: $15.2 billion
Higher payroll tax for top earners: $53.8 billion
Tax on cosmetic surgery: $5.8 billion Photo

While another headlines how only 3 or 4 million will go to a public plan.

There has to be better way. Allow a bare bones catastrophic policy, with no exclusions, to be marketed across state lines. Allow deductions for monthly medical payments directly to doctors for office visits and minor care. Tort reform. The list goes on.

I just do not see how making what we got bigger is going to solve our problem of allowing people to see a doctor.

Steve Lucas

Anonymous said...

Its all about chasing shadows.
By that I mean latching on to this or that latest, most innovative idea that some self styled money making guru has put out in the hope it’ll go viral and make them a lot of money off the backs of all the headless chickens who will follow them blindly down a blind alley. Its a shame but a truism nonetheless that people will follow where someone they see as an expert leads. Even if they lead them to certain disaster, which is what most of the gurus tend to do to their flocks.
The trick is to recognize a shadow when you see it!