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Perspectives |
1 From the Department of Radiological Sciences, University of California, Irvine Medical Center, Orange. Received February 13, 2001; revision requested, received, and accepted February 14. Address correspondence to the author, 18961 Castlegate Ln, Santa Ana, CA 92705 (e-mail: rmfriede@uci .edu).
Index terms: Radiology and radiologists, socioeconomic issues
Politicians have been avoiding a major health problem that is getting worse each year—the number of uninsured and underinsured people in the United States. They are the victims of a totally confused public health policy. The leaders of the medical community have not really faced up to this problem. The politicians and to a great extent the major medical societies appear to be unable to decide what society’s responsibility in health care should be to those who are unable to purchase basic coverage. The combination of the increasing number of Americans without health care insurance and the public reaction to the abuses of managed health care has again revived the debate about future health care reform.
The Census Bureau estimates that 44.3 million people in the United States had no health coverage in 1998 (1). In any given year, more than 60 million people are without health insurance for 1 month or more (1). Approximately 1 million Americans are being added to the uninsured each year, mainly the lower- to middle-income working families. With our present system, it has been estimated that 60 million Americans may be without health insurance by the year 2007 (2). The increasing number of uninsured and underinsured people has been accumulating for years while the federal government has only nibbled at the edges with such programs as children’s health care, breast cancer, human immunodeficiency virus (HIV), 24-hour hospital stay after childbirth, and the right of employees, if they can afford it, to continue their health insurance after leaving their jobs.
Multiple surveys conducted by institutions like the Robert Wood Johnson Foundation, the Henry J. Kaiser Family Foundation, and the Roper Center for Public Opinion Research have noted that the proportion of people naming the uninsured as the single most important issue was 35% in 1993 and 31% in 1999—impressive figures (3). A small majority, 55%, expressed willingness to pay some level of taxes to cover the uninsured. The majority (61%) thought that the uninsured should be offered a limited package of insurance benefits. Many individuals are not aware of the extent of the under- or uninsured, but the public in general seems willing to support basic medical coverage for this group.
Light (4) states that good health care requires four elements: continuity of care, stable physicians and caregivers, a stable patient population that can develop patient-physician relationships, and health insurance coverage that does not change or disappear. We have not been able to achieve this mix with managed health care. He states that 25% of the population of the United States, the noninsured and underinsured and many with poor employer-paid insurance, face impoverishment if they become seriously ill.
There is no law requiring employers to provide health insurance for their employees. Therefore, only 50% of U.S. employers offer health care benefits. More employers are hiring more temporary or part-time workers, to the point where 29% of employed individuals have such jobs and therefore do not get health care benefits (4).
Sometimes the government inadvertently creates more problems than it solves when it attempts to resolve the abuses of managed health care. As the government mandates increased care and introduces patients’ rights bills, the cost of health care insurance increases. The Lewin Group estimates that every 1% increase in health care premiums leads to 400,000 more individuals becoming uninsured (4). Since employers are not required by law to offer their employees health care benefits, as premiums rise, more will drop their health plans, swelling the ranks of the middle-class uninsured. In addition, employers have a strong incentive to keep premiums as low as possible, and as costs increase, more employers reduce their employee benefits, leaving employees with inadequate plans. As Angell (5) stated, one cannot legislate in isolation such things as patients’ and physicians’ rights, because in a competitive market they simply provoke reactions that nullify the social objectives of the legislation.
The history of health insurance (6,7) in the United States reveals that the first major attempt at compulsory health insurance occurred in 1917, when a proposal to provide coverage for workers earning less than $100 per month and their families was defeated in Congress. Premiums for this insurance were to be paid by employers, workers, and the government. The Social Security Act of 1935, a linchpin of President Roosevelt’s social plans, originally was to be combined with national health insurance (7). After opposition by the American Medical Association and insurance companies, Roosevelt thought that it was not worth the political fight. In 1939, Senator Wagner introduced a bill to provide federal aid to state health insurance programs, but it did not pass Congress. In 1965, after intense public pressure, Congress passed the Medicare and Medicaid Acts, the first major step toward national health insurance. It is interesting, as Terris (6) points out, that Congress faced two directions at the same time: toward national health insurance with Medicare, and toward charity medicine with Medicaid. During the 1970s, numerous health bills were introduced but not passed. Nixon was the first president to support the concept of HMOs, or health management organizations, for federal workers, and he also created several new federal departments that were concerned with health and the environment.
The last major effort toward national health insurance was made by President Clinton in 1993, an effort developed primarily by a group of private insurers and large U.S. corporations. It apparently was too much thrust too suddenly on the public. The plan was opposed by small businesses and a public afraid of the costs and the concept of the federal government controlling health policies. The "compromise" was managed health care, with its disorganized multiple conflicting programs from multiple insurers that were run by businessmen rather than by health care professionals. It appears that the recipients and providers of health care are unhappy with the results. Meanwhile, the percentage of people younger than age 65 without health care had increased to 18% by 1996 (6).
Boufford (7) points out that the debate instigated by the Clinton health care proposal was the first major debate on health insurance in this country in more than 30 years. Specific points were brought to the fore, including the public need for health security, the importance of preventive medicine and primary care, parity for mental health services, and the importance of long-term care. This led to federal action in specific areas such as breast cancer, HIV, diabetes, and children’s health care, but there was no desire to reinitiate another approach to national health care. Two major problems with these incremental programs are the difficulties in monitoring the effectiveness of the program and in determining how to measure quality of care. I believe we have a major need for universal health care, but neither labor unions, physicians, nor politicians are committed to a national health care system. It will be necessary to coalesce public opinion that essential health care is a necessary goal for this country for Congress to respond.
The United States is the only major industrial nation that has not provided essential health insurance for its entire population. The United States is the only industrialized nation that is concerned primarily with the private market in health care. After World War II, all other major industrial societies developed some form of national health insurance. Currently, 100% of the population of Canada, Japan, Sweden, and Britain is covered by national health insurance, as is 99% of the population of France (8). In the United States, roughly 40% of the population have public health care coverage (Medicare, Medicaid, federal employees), 15% are uninsured (18% of those younger than age 65), and the rest are covered by managed health care or other insurance (8). How does this relate to the percentage of the gross national product of each country that is spent on health care? In 1996, Britain spent 7.1%; Canada, 10.3%; Japan, 6.9%; and the United States, about 14% (8). In most countries, the expenditures relate to coverage of the population for essential health care, perhaps equated somewhere between Medicaid and Medicare.
I am sure that it is no surprise to note that we spend more on leisure enjoyment than on health care. In fact, we spend 22% more just on recreation, restaurant meals, tobacco, and foreign travel (2). Perhaps 14% of the gross national product is not an excessive amount to spend on health care.
Many of the European programs of national health insurers would probably be unacceptable to the general public in the United States. We would have to introduce "layered" care (9). This might consist of a basic program of coverage of essential health care for every individual, completely paid for by the government for those who are unable to afford the cost or partially paid for on a sliding scale by those who can afford the cost. The layered program might make universal health insurance more acceptable to the American public because it would allow the individual to purchase supplementary insurance to include other concepts. This might include more services such as choice of physician, absence of a gatekeeper, nonlimitation of pharmaceuticals, or more of the niceties of care. The treatment of disease and the availability of cure must be available to all.
We have tried indemnity insurance and found it too expensive and prone to abuse. We have tried charity care for the indigent and found it too uneven and unreliable. We have tried managed health care and found it too confusing, with a multiplicity of plans and ranges of care; the uninsured are left without substantial health care. What has held us back from national health insurance? I believe it is a combination of three major factors: first, opposition by insurers and organized medicine; second, the reluctance of either political party to antagonize business and medicine opposed to national health insurance; and third, the lack of a strong public consensus, which may partially relate to the association of universal health care with socialistic or communistic attitudes (10). It would have been impossible to convince physicians and patients to approach universal health care in the days of indemnity insurance, but the unhappiness with managed health care and the increasing costs make universal health care more approachable. Many physicians are already in an employee-like mode today. In 1999, 43% of physicians surveyed by the American Medical Association were employees in a group practice, hospital, medical school, or other health facility, although their method of reimbursement was variable (11).
Whatever our method of practicing medicine in the future, it will be within the framework of cost control. I hope that in the future the concept that health care is a national investment will be accepted. To get a better concept of the problems of universal health insurance, we can look at the problems inherent in education. Any national social program (ie, education) supported by tax revenue tends to be underfunded. Education has the advantage of a long history and established methodology. Despite this, it is chronically underfunded and struggling to maintain its integrity.
Any national health insurance plan supported by tax revenue will face the same funding problem and in addition will have to establish its methodology. The only working precedent is Medicaid, which could become the basic health program, with options for individuals or corporations to pay for increased benefits if desired.
The niceties of health care, such as having free choice of physician, no gatekeeper, and expanded pharmaceutical availability, are the extras that one must pay for. Ginzberg and Minogiannis (10) state that the Congressional Budget Office expects health care to increase in cost from $1 trillion in 1996 to $2 trillion in 2008; it could reach $4 trillion by 2025. Much of this relates to the increasing elderly population and the increasing incidence of chronic disease.
If universal health insurance is too big to obtain in a single step, perhaps we must approach national health insurance in incremental steps. The expansion of Medicaid coverage for the working poor and those who currently earn above the Medicaid maximums might be the first step. This would incorporate a large percentage of the 44 million people who are uninsured with Medicaid and reduce the cost effect of coverage for the entire population. Perhaps the next incremental step would be to require employers to provide health care coverage to employees. This might be done with the aid of tax credits. This would further reduce the uninsured group and move us closer to national health insurance.
I am certainly not qualified to suggest what type of universal care America will accept. I certainly believe it will require a form of layered care, with options that can be purchased. The ultimate insurer would be the federal government. The players would be the state governments or insurance conglomerates. As I previously stated, access to curative procedures is never an option but a part of essential care.
I have been criticized for my belief that basic health care is not a commodity to be sold like M&Ms, but an individual right. I cannot accept the concept of basic health care as a commodity—I believe that there is an obligation of our government to provide universal basic health care to all citizens, and that means that it will be supported by the tax base. Health care is and will continue to be expensive. It is an essential and costly social service to which every citizen is entitled. It should not provide a market in which money is made. Those providing health care should be reimbursed for their services, but it should not be a stock earning dividends where no service is provided. There is no justifiable profit to be made in chronic diseases or catastrophic illnesses for which services are not provided. There are many reasons why our health care costs are so much higher than those in European countries, including our high administrative costs, malpractice costs, excess use of technology and futile terminal care, high physician and hospital costs, and profit generated by health care.
It is important to realize that opinion polls showing a large majority of patients with managed health care coverage as satisfied with their coverage are often meaningless. This large majority is composed of the healthy individuals who are paying less for coverage and are satisfied simply because they haven’t needed to use their plan. The only meaningful polls would be those that include only individuals who have had serious illnesses or have chronic diseases and note their satisfaction with their current plan.
It is interesting when one reads physician letters in medical journals that state that many are still adamantly opposed to universal health insurance even though managed health care is failing. There is no hope of returning to indemnity insurance, and certainly the numerous managed health care plans are conflicting and are treating neither patients nor physicians fairly. It would seem to me that we first have to accept the phrase "universal health insurance" and then try to adapt it in a friendly fashion. Universal health insurance implies essential medical care to everyone, with charges varying according to the ability to pay, from free to moderate monthly charges. Within this structure, we can add a layered program as previously discussed.
Physicians do not necessarily have to be salaried within universal health insurance; they could be controlled as in Medicare with a stipulated income per service, although it would certainly be simpler if they were salaried. I believe we must work on the concept of universal health insurance, since there is no point in looking for a utopia that will never come. Let us accept something that is reasonable, is better than what we currently have, and provides reasonable and fair treatment to patients and physicians.
It appears that any action leading to universal health insurance in the United States would require the symbiosis of a crisis in health care (which we are approaching), strong leadership (not currently available), and public consensus (not present) (7). This suggests that for the near future we will take small incremental steps, attempts to patch areas of health concern, which will be costly and probably ineffective. I doubt that our current president will initiate any form of universal health care. However, I believe the crisis will come with the combination of the increasing underinsured population, the public dissatisfaction with managed health care, and the inevitable increase in health care costs. When the crisis arrives, we will have the consensus and, at that time, the leadership will step forward. Those who think the public would not accept national health insurance should consider that Medicare, founded in 1966 and in essence a form of national health insurance with copayments, has received a positive public response.
FOOTNOTES
Abbreviation: HIV = human immunodeficiency virus
REFERENCES
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  S. G. Federico, J. F. Steiner, B. Beaty, L. Crane, and A. Kempe Disruptions in Insurance Coverage: Patterns and Relationship to Health Care Access, Unmet Need, and Utilization Before Enrollment in the State Children's Health Insurance Program Pediatrics, October 1, 2007; 120(4): e1009 - e1016. [Abstract] [Full Text] [PDF]
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 R. M. Friedenberg Au Revoir, but Not Goodbye Radiology, August 1, 2004; 232(2): 319 - 323. [Full Text] [PDF]
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R. M. Friedenberg Rationing in Health Care: Changing the Patterns of Health Care Radiology, April 1, 2003; 227(1): 5 - 8. [Full Text] [PDF]
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