UNIVERSAL CARE: Plugging the System’s Holes
Managed care's cost-cutting tactics have created a market for "lemons" in which "pernicious managed care" edges out "good clinical managed care," says Dr. Donald Light of the University of Pennsylvania Health System, writing a policy brief in the current Annals of Internal Medicine. Good managed care will come only when it is coupled with universal health insurance, Light argues, saying that efforts to raise patients' rights standards will only increase the number of uninsured. As it stands, half of all U.S. employers do not offer health benefits, and nearly 44 million Americans lack health insurance. If you add that figure to the number who have "inadequate policies," he says, "fully one-fourth of persons in the United States face personal impoverishment should they face a medical catastrophe." According to Light, about half of all full-time workers with incomes below the federal poverty line lack health insurance, either due to the prohibitive cost of buying an individual policy -- some 26% to 40% of their income --or because their employers do not offer the benefit. Indeed, Light argues, the "social contract" linking employers and their employees is "breaking down," noting that employers are hiring more part-time workers and shifting larger proportions of health care premiums to their employees.
Building the Case
Although several programs have tried to patch up the system, Light says, pointing to the Health Insurance Portability and Accountability Act, far fewer people than expected have enrolled, in part because "lobbyists get exceptions, complexities and loopholes inserted into the legislation." He writes that today's voluntary system "costs at least three times as much to administer and is less likely to cover sick and poor persons than a universal system." The current system also ties medical choices to reimbursement, weighing the salary of providers against "their best clinical judgement" and subjecting them to micromanagement. However, a national system could "set firm but fair budgetary limits ... provide free professional training for physicians ... and use the clout of large insurance pools to negotiate low prices for pharmaceutical products." Without universal coverage, Light concludes, "all players are rewarded for gaming the system and for exploiting the most vulnerable persons" (4/20 issue).
Write It in Stone
The "world-class mess" of health care in the U.S. deserves "nothing short of a constitutional amendment [that] will prevent us from continuing to turn our backs on the health care problem," argue Dr. Frank Davidoff of the American College of Physicians and Dr. Robert Reinecke of Jefferson Medical College in an accompanying editorial in AIM. The authors recommend a constitutional amendment that would guarantee all citizens "equal access to basic and essential health care." By keeping the language of the amendment broad, they contend, its implementation would be flexible and free of "legislative micromanagement" exemplified in enacting the Clean Air Act. The amendment is worth putting on the table, they write, at the very least to spark debate that "may help break the social and political gridlock that now stands in the way of universal access." They conclude, "Debate can help us face the present reality that we already ration health care and do so in arbitrary and capricious ways: by excluding people from it and, as pointed out by Light, by creating instability in the system that perversely rewards inappropriate care" (4/20 issue).