Excerpts from Ourselves Growing Older
NATIONAL HEALTH REFORM
THE CRISIS: COST, ACCESS, AND QUALITY
The "crisis" in the American health- and medical-care system has been regularly announced since the early sixties. Today reform of the system comes near the top of the country's urgent political agenda for many reasons:
1. Cost. The costs to government, the economy, individuals, and families have become excessive and are rapidly spiraling out of control. Industry and business claim they are unable to compete because health benefits increasingly erode profits. Some charge that one sector of the economy-- manufacturing-- is actually subsidizing another-- the health industries-- through what they pay for employee's health insurance.22 In fact, paying for health care now consumes so much of our GDP (Gross Domestic Product), currently approaching 15 percent and projected to go up to 20 percent if nothing changes,23 that health-care costs are themselves a threat to the nation’s whole economy and economic survival.24
The President and members of Congress claim that the economy and the deficit problem cannot be addressed successfully without controlling health-care costs, especially those of government programs like Medicaid and Medicare.25 Too much of what we spend dose not even go for medical care. Administrative costs, waste, and fraud are estimated to account for a third of our costs. The more slowly our economy grows, the more costly the whole system becomes, resulting in fewer and fewer people who can afford to pay for health or medical care and must depend on government programs.
2. Access. Close to 40 million Americans lack health insurance and are without access to health care, and the number is rising.26 Another large segment of the population is underinsured. As it is, only about half of those living below the poverty line receive health benefits through a public program; Medicaid reaches less than half of those eligible.27
3. Quality. Not only are we spending too much, but the more we spend the poorer our health becomes. We are not getting our money's worth.28 Even though the quality of car for everyone has become increasingly poor and uneven, quality issues have a sorry third place in debates over the present crisis.
Higher-quality care is presented as more costly, because it assumes quality equals expanded access to high-priced specialists and high-technology medicine. Lower quality is feared because it suggests that people who cannot afford to pay will endure "rationing" of needed services. We already ration care in grossly unfair ways that are also ultimately more costly. The idea of appropriate technology in health care has been slow in gaining acceptance. Yet many other medical experts have assured us that simply by eliminating waste and excessive medical treatments we could all be cared for right now.
Financing, payment mechanisms, and access are very important, but debating them has the effect of keeping our attention focused on them and away from other serious problems with health and medical care like the following:
4. Accountability. There are few mechanisms of accountability beyond lawsuits that are available to patients. Most genuine malpractice never becomes a suit. Of the suits, patients win only a tiny fraction, even if a few awards have become larger.29 Yet reform proposals suggest that patients will have even less access to redress than we do now. We need to fight for our right to create new mechanisms for making medical-care providers accountable, as well as to retain the only recourse we now have.
5. Equity. Comprehensive care that is the same for all eliminates the stigma of second-class status and changes relationships with employers, the welfare system, and providers of care. Tying coverage to employment penalized women more than men, since women's employment is more marginal, more frequently part-time, and in the smallest companies. It also creates a permanent two-class system within health services. If we completely cover and support the most vulnerable in society, especially women and their children, the whole society will gradually get healthier. Punishing them, denying them care, becomes maximally costly and eventually damages the health and well-being of the whole society.
Two-tier systems do not work, as our own presently existing programs make very clear. The most vulnerable, poorest, and sickest, who are also those with least access to adequate care, are also those most likely to be jettisoned or underserved due to local, state and federal budget cuts or political considerations. Ironically, the present obsession with cost control often leads to higher costs. People denied preventive and comprehensive care must receive expensive emergency care when in crisis and may even be overtreated as well because of the uncontrolled fee-for-service system. Emergency and crisis care in a two-class system are inevitably the most costly to taxpayers, who support public systems.
Sadly, too few people are willing to demand an equitable system based on American ideals of fairness and social justice. Many Americans today appear willing to tolerate a different and discriminatory quality of health and medical care services based on income and social class, or even race and age. Fighting for equity is crucial to the survival and dignity of elders, most of whom will always be women.
6. Women. System reforms that do not recognize women's unique relationship to the system as well as their own health needs will not work, any more than ignoring economic conditions, race and ethnicity can result in a system that meets people's needs.30
WHAT OTHER INDUSTRIALIZED COUNTRIES DO
Other industrialized countries, especially in Europe and Japan, are doing much better, spending about half as much as we do and getting much better results for what they pay for health- and medical-care services.31 For example, Canada, the United Kingdom, and most others provide universal care for less than 10 percent of their GDP.32 They do this through many different mechanisms, but most include:
- National planning
- Global budgeting and caps on charges
- Universal coverage, comprehensive benefits
- Price controls on the drug industry
- Technology assessment and uniform practice guidelines
- Controlling supplies of expensive equipment
- Emphasizing primary care and limiting the use of specialists
Other countries that manage their health- and medical-care systems better and get more favorable health results from spending less accomplish it by developing a national policy. In 1991, Canada, Germany, and Japan spent 72 percent of their total health expenditure on public health. These countries have better overall health statistics than the United States, which spent more per capita on health but spent only 44 percent of the total on public health.33 Governments make sure that investments in education, jobs, housing, and preventive public-health programs are more evenly balanced with what is spent on crisis medical care.34 To be fair, some countries exploit their female labor in the health and medical care system, and many of them have devised employer-dependant systems that are in trouble as the world economy continues to contract. But system costs are still nowhere near so out of control as ours, and most of their people are healthier, as shown by their lower infant mortality and higher life expectancy when compared with the United States' population.
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