Extend health care to all Americans

October 10, 2004|By Alfred Sommer

THE ESTIMATED number of Americans without health insurance recently jumped another 1.4 million.

Our country is facing a health care crisis. The largest and most embarrassing aspect is the now 45 million Americans who lack basic health insurance and therefore have difficulty getting the essential preventive and treatment services they need. Of the 30 countries in the Organization for Economic Co-operation and Development, only the United States, Turkey and Mexico deny their citizens the basic human right of health cost coverage. It is well within our capacity to join the rest of the developed world.

State and federal governments already pay one-third to one-half of all essential costs of health care and hospitalization. To the vast federal health care systems run by the Departments of Defense and Veterans Affairs, add payments to the Federal Employee Health Benefits program, state employee plans, local safety-net services and the vast entitlements of Medicaid and Medicare.

The problem is that the remainder is largely paid through a patchwork of employer based insurance plans. Insurance companies want to make a profit and employers want to minimize their premiums. Both want to reduce the risk of actually paying for somebody's care.

The problem is further compounded for small business, the self-employed and the unemployed. In a large company, the costs for a few individuals needing catastrophic care - say, for HIV, a brain tumor or a serious injury - can be spread over thousands of relatively healthy young workers, so the impact on the insurance companies' profits and on the premiums they charge is negligible. For small businesses, a catastrophically expensive health care claim for one individual can make future premiums unaffordable for that person's coworkers. Some large companies, such as McDonald's, further claim that they cannot compete on price if they must also pay their workers health benefits.

These problems are not insurmountable. At least two solutions can be found.

The first is to join Canada and Britain in having the government pay for all essential services. This "single-payer" approach simply means everyone's costs are paid from a single purse; individual, unusual costs have little impact on total costs of those insured. This is how our Medicare system works for the elderly. It does not mean that the health services sector needs to be run by the government, as it is in Britain's National Health Service. Most Canadians choose their own physicians and hospitals, just as most of America's elderly do. Anyone wishing to purchase additional services is free to do so.

There is an additional economic benefit to single payer health systems: if essential health care services are paid through taxes, not wages, the costs to U.S. corporations are more competitive with those of other countries. And "service sector" employers such as McDonald's are not burdened by these benefits.

This approach would most rationalize and reform our crumbling patchwork of inefficient coverage systems. It would also require radical reform at the federal level.

A more modest but powerfully effective approach has been slowly wending its way through the Maryland legislature since it was first introduced four years ago.

The Maryland Citizens Health Initiative leaves our present health care delivery system largely untouched. It merely insists that all businesses, small and large, pay for the health care premiums of their employees. These costs are kept modest because the number insured would be large and relatively young and healthy. Unusually high costs of any single employee would be spread widely. Employers either buy the health premiums directly or pay a fee to have the state purchase them.

Service companies such as McDonald's need not fear loss of competitiveness: They all must pay for the essential care of all their employees. The cost of hamburgers may rise slightly, but equally. It is unlikely Marylanders would drive to West Virginia simply to save 25 cents on a burger.

Those who are poor and unemployed presently receive comparatively poor, episodic and fragmented services paid from government coffers through safety-net services, Medicaid and other patchwork systems. A fully rational system would ultimately accept this societal responsibility head on and adopt a single approach to insuring essential health services for all. Increased access to essential preventive and curative services would make it more likely that patients would access care at an earlier, less-costly stage, instead of delaying care until their disease is more advanced and more costly to treat.

Sooner or later, we need to reform our health care system and guarantee access to essential health services for all our citizens. This will ultimately cost a bit more, in burgers or in taxes, but it will vastly improve the health of all our citizens.

The time to act is now - before America's dismal health insurance coverage gets even worse, to our enduring shame.

Dr. Alfred Sommer is dean of the Johns Hopkins Bloomberg School of Public Health.

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