With liberty and health care for all

With 44 million uninsured and just about everybody else unhappy with annual cost hikes and HMO runarounds, it's fair to wonder if Americans are getting their money's worth from the world’s costliest health care system.

libertyCHRIS AND LISA WILSON WERE LIVING A just-about picture-perfect middle-class life in New York's Duchess County when America's health care crisis came pounding on their front door last spring. Chris had a mid-level management job with an IT services firm; the couple had recently purchased their own home; and Lisa was a stay-at-home mom to 10-year-old Max. But in May, his company battered by three years of a high-tech slowdown, Chris was laid off.

In addition to the normal problems and anxieties that accompany any job loss, the Wilsons found themselves facing a wholly new worry: finding affordable health insurance now that Chris had lost his company benefits. Like millions of other suddenly tenuously middle-class Americans, they tried to balance their monthly expenses against the security of a costly private health plan, but the nearly $700 they would have had to set aside each month just for basic coverage was too much. The Wilsons opted to hold their collective breath and hope for the best--or at least for a new full-time job with benefits.

"We had a 'choice'--we could pay the COBRA [the federally mandated group rate 'bridge' insurance for laid-off workers] or pay the mortgage," says Lisa Wilson.

Going without health insurance is a risk being accepted by an increasing number of Americans. Last year 44 million--more than 15 percent of the population--did not have health coverage, and an estimated additional 40 million were underinsured.

Those are shocking figures for a nation that spends more on health care than any other country in the world--almost $1.6 trillion in 2002, 15 percent of the nation's gross domestic product and an astounding $5,400 per capita. That's well over twice the per capita median of other Western economies and almost three times the per capita spending run up by the much-maligned Canadian system. In fact, our northern neighbor's single-payer network, long the foil of conservative pundits, is now fast becoming the pharmaceutical provider of choice for the U.S.'s cash-strapped seniors and state governments looking to trim costs.

At the same time record numbers went without health coverage of any sort, white- and blue-collar workers in the U.S. fortunate enough to have company-provided health packages have been forced to make record contributions to their plans, coughing up anywhere between 10 and 45 percent of their monthly premiums. At the high end of that scale it's little wonder that more low-paid, full-time workers are "choosing" to leave their health benefits on the table.

But making ever higher co-payments for health insurance premiums is becoming the lesser of two evils for many working Americans. As businesses confront double-digit increases in insurance rates for three straight years, many have simply dropped coverage altogether. Two years ago 65 percent of firms employing 200 or fewer workers provided health insurance. Today that number is down to 61 percent and falling. By some estimates, half of all labor disputes, like the ongoing grocery workers' strike in California, are centered around health care.

In the near future more companies will be forced to juggle plans, eliminate levels of care, shift costs to workers, or drop health benefits altogether, says Tom Hadrych, a vice president in compensation, benefits, and corporate services for DaimlerChrysler. "The trend is that fewer companies are providing fewer benefits, and that trend is going to continue." As more workers lose benefits, they will end up in the gentle embrace of the public system on the public nickel.

His company may have a vested interest in fixing health care since each increase reduces competitiveness and cuts into profits, but Hadrych says the problem is much bigger than its impact on U.S. corporations. The health care industry is on track to eventually lay claim to as much as 25 percent of the total U.S. economy.

"That means that you and I and anyone else who is on the bill-paying side of this has an interest in [resolving] the health care crisis," says Hadrych. The current "traveling" rate of increase is not sustainable, he suggests. In 5 to 10 years, he says, "something's going to have to change."

Prescription drug spending remained the fastest-growing item in health care in 2002, and drug costs are predicted to outstrip the overall growth in health care spending for the next 10 years, a projection that does not take into account the impact of the new Medicare drug benefit that begins in 2006. Many economists believe Medicare's drug package, a "reform" that explicitly prohibits cost-control mechanisms, will prove a windfall for pharmaceutical companies and lead to an even greater acceleration of prescription drug costs.

The short-term perspective offers little relief. The National Coalition on Health Care estimates that hard economic times and a continued runaway escalation of health insurance premiums and prescription drug costs could raise the number of uninsured to as many as 54 million people by 2006, when it estimates average family coverage could cost as much as $14,500 a year.

In response to the looming crisis, the current administration seems determined to move health care even deeper into the for-profit sector, recently giving Medicare a historic rate bump to encourage for-profit HMOs to include Medicare patients.

Those most likely to lack health insurance include large chunks of politically unthreatening demographics: young adults, part-time workers, people with low levels of education, Hispanics, or people born outside the U.S. But the profile of the "typical" uninsured U.S. resident is changing as more members of the middle class, like the Wilsons, find themselves downsized out of company plans. That changing profile portrays a cultural and economic crisis that reform advocates believe offers a historic opportunity to redefine health care in the United States.

All for one and one for all?
With so many now uninsured and the suffering and dissatisfaction so broadly distributed, could the U.S. public finally be willing to seriously consider a national health plan that will include everybody?

An ABC-Washington Post poll conducted last October indicates that average Americans may indeed be ready. The poll found that the public favors national health insurance to "the current health insurance system, in which most people get their health insurance from private employers, but some people have no insurance" by a 2-to-1 margin (62 percent to 32 percent). It reported that 8 in 10 people think it is important to cover all the uninsured "even if it means higher taxes."

Health Care reform,
round 2

In 1996, after 50 years of support, even the Democratic Party dropped national health insurance from its platform. But now, sensing the public disquiet, a decade after the political car wreck that was the Clinton health care reform effort, U.S. politicians are revisiting the problem. Most of the gang of Democrats running for president this year feature health care reform prominently in their campaigns, and the Bush administration has repeatedly trial-ballooned free-market options for shoring up the system.

The renewed interest could not have come at a more critical moment. According to the National Academy of Sciences, the U.S. system is approaching flat-line. In the culmination of a three-year study of the nation's uninsured, a committee of the academy's prestigious Institute of Medicine (IOM) for the first time formally recommended that the United States guarantee health insurance for every citizen.

"The lack of health insurance for tens of millions of Americans has serious negative consequences and economic costs not only for the uninsured themselves but also for their families, the communities they live in, and the whole country," the 16-member committee concluded. "The situation is dire and expected to worsen. The Committee urges Congress and the Administration to act immediately to eliminate this longstanding problem."

According to the IOM report, the U.S. economy loses $65 to $130 billion each year because of the poor health and premature deaths of the uninsured, and 18,000 Americans lose their lives unnecessarily. The IOM concluded that the nation must set a goal of achieving universal coverage by 2010.

When the report was released on January 14, Mary Sue Coleman, president of the University of Michigan and co-chair of the panel, said she hoped the IOM's uncharacteristically bold and direct recommendation could create the national momentum necessary to finally achieve universal coverage.

"There have been times in our history when we have galvanized ourselves to action," Coleman told reporters. "This may be one of those points in history."-- Kevin Clarke

Responding to the poll, Dr. Quentin Young, national coordinator of Physicians for a National Health Program (PNHP), says, "What's striking is not the high level of public support for reform; our system's been in critical condition for years. Support for reform is a no-brainer." What's striking, and shameful, according to Young, is the way elected officials ignore remedies such as a national single-payer plan because of opposition from powerful forces in the for-profit sector.

How did we get to this point? Widespread and, some would say, ill-conceived privatization of what had been the largely not-for-profit health care sector during the 1980s helped, but the problems with U.S. health care perhaps most relate to another example of American exceptionalism.

Alone among advanced Western economies, the United States relies on private insurance to provide health care to a substantial percentage of its citizens--a social good that is perceived in most other developed nations as a basic public service, little different from police or fire protection or public education and financed accordingly. For decades the idea of a federally bankrolled universal health care program has been dismissed by America's policymakers, despite the fact that the federal government already pays for nearly 60 percent of all health spending and almost half of all Americans already receive their health care through a direct federal or federally subsidized program such as Medicare, Medicaid, Veterans Administration, or federal retirement accounts.

Supporters of the health care status quo argue that health service is best left to the private sector, that such an enormous extension of federal social responsibility will result in bureaucratic bloat that is bound to be too costly and inefficient, and that America's current system provides the best, most technologically advanced care in the world.

But proponents of a major overhaul of the current system ask: Are we really getting our money's worth out of the world's costliest health care system?

Not the best in the West
U.S. health care is a study in painful contradictions, according to Father Michael Place, president of the Catholic Health Association, the U.S. church's national organization of not-for-profit health care providers. It offers the most advanced technology and pioneers some of the greatest biomedical breakthroughs, but despite its impressive successes in specialized treatment and acute care, he says, the system in the aggregate--specifically at the primary care level--has substantially degraded over the last two decades. He calls its failure to provide basic coverage to so many uninsured citizens a "national disgrace."

Those 44 million are only the most obviously vulnerable among us, but Place says everyone else may one day--soon--be unpleasantly surprised to discover how fragile the entire system is. "Implosion," he says, "is not inconceivable."

With relatively high infant mortality, low immunization rates and life expectancy, and poor access to care, outcomes from the U.S. health system do not compare favorably to health statistics generated by America's peers among the 30 members of the Organization for Economic Co-operation and Development. According to a 2000 World Health Organization report, the American system ranks 37th overall behind countries spending half as much or less per capita on health care such as France, Japan, Sweden, Canada, the United Kingdom, and Germany. In terms of "fairness," the U.S. ranks 54th, according to the WHO report.

That breakdown in "fairness" is on teeth-gnashing display in the waiting room purgatoriums of public hospitals and clinics across the country.

Don Raschid, a spokesperson at the John H. Stroger Jr. Hospital on Chicago's West Side, leads a tour of the enormous new facility's gleaming trauma center. The new ER and trauma facility--opened, along with the rest of this shiny new version of Cook County Hospital, in 2002--looks nothing like its grittily decrepit doppelgänger on TV's ER. Loaded with state-of-the-art equipment, bright lights, and salaried medical staff, it's one of the best trauma centers in the region. Any victim of a motor vehicle accident or gunshot wound--that's MVA or GSW in ER-speak--would be fortunate, kind of, to land here.

"If you come into our trauma unit with a heartbeat," says Raschid, "you've got a 98 percent chance of coming out of here alive."

Not far from the just-now mercifully uninhabited trauma room, much larger numbers have packed the hospital's well appointed waiting rooms. Raschid acknowledges that waits of three to seven hours are not unknown for non-acute care. Michael McDermott, an ER doctor coming off duty, says he has met patients who have waited even longer--12 hours or more, even patients who have slept overnight in the waiting room to make sure they got in to see a doctor in the morning. Yet this is the place more and more uninsured people are coming for what should be primary care.

McDermott says the system is overloaded, and even longer waits are inevitable. "You might be waiting a long time with a minor problem, but [for the uninsured] we are the only game in town."

The huddled masses at Cook County pass the time in a variety of different languages; they represent every ethnicity proud to call Chicago home and most of the grunt work taking place in the metropolitan area. They are united here--black, white, and brown--by the nation's great integration scheme: a lack of private insurance. Because of the long waits or because they are unable to miss a day's work, many of the uninsured simply walk away from these rooms despite their afflictions, missing "appointments" and care that might prevent them from suffering future physical breakdowns substantially more costly--to them and to taxpayers.

Dr. Claudia Fegan, president of Physicians for a National Health Program's board of directors, works at what could be called ground zero of the health care crisis. Though a good percentage of the patients at Cook County's John Sengstacke Ambulatory Care Center, where Fegan serves as medical director, are covered by Medicare and Medicaid, as much as 70 percent are uninsured working poor from the surrounding South Side Chicago neighborhoods--people whose income or age disqualifies them from government coverage and whose low-paying or irregular jobs disqualify them from anything else.

"We'll take anyone who comes in the door regardless of ability to pay," says Fegan. "We are the safety net for at least 35,000 people a year."

Hidden costs of private care
The resigned and exhausted expressions on the folks enduring the imperceptible progress of the snaking line at the prescription counter are a voiceless testimony: Sengstacke is the clinic of last resort. Here you can watch the health care system failing up close and impersonal.

Distracted by the everyday struggle that is life in a state of poverty, put off by physicians and bureaucrats, left to endure seemingly endless lines at free clinics to get basic care or prescription medicine they can't afford to buy on the open market, America's uninsured are in pretty bad shape. According to the bad news from the Institute of Medicine (see box on page 14), uninsured Americans get about half the medical care of people with insurance. They're sicker and more likely to die younger; thousands of them die "prematurely" each year.

Fegan is regularly frustrated in efforts to get basic diagnostic and preventative care for many of her chronically ill patients. "We can't get [diagnostic] treatment for someone with hypertension, but when they finally have a catastrophic stroke, then we'll step in and take care of them, when they could have remained productive members of society." This is not a hypothetical illustration of the system's little perversities. To Fegan, it's a reality she sees--and tries to mitigate--every week.

People with "good" insurance may be troubled to hear of such struggles among their fellow citizens but might feel a little distance owing to the cozy mental security offered by their company plans. Fegan urges such folks to wade through the fine print.

"You don't know how 'good' your insurance is until you actually have to use it," says Fegan. "There are no guarantees anymore in terms of what you get. No one has good insurance. If you have a catastrophic illness, you're going to find out the limits of your care pretty quickly." With lifetime total disbursements that a few months of acute care can rapidly devour, even insured Americans have a stake in altering the national course of health care, she says.

In September the 10,000 physician members of Fegan's PNHP announced their support for a single-payer, national health plan in a reform proposal that appeared in the Journal of the American Medical Association. According to PNHP, a single-payer structure could save the United States $286 billion in annual expenditures, more than enough to offset the cost of including all the nation's current uninsured and to cover all out-of-pocket prescription drug costs--not just for the nation's hard-pressed seniors, but for everyone.

Why is single payer less expensive? Primarily because it eliminates the multi-layered bureaucracy that makes the current system confusing to use and costly to administer. According to a study published in the International Journal of Health Services, the U.S. health care bureaucracy alone consumed about 31 percent of all 2002 health care expenditures--just under $400 billion. Administrative costs in Canada, by comparison, account for just 16 percent of total costs.

It's not hard to understand the discrepancy. U.S. health insurance companies maintain as many as 20 to 30 employees per 10,000 enrollees. In Canada, the Ontario Health Insurance Plan employs just 1.2 people for the same number of clients. Under a single-payer plan, instead of dealing with a paperwork blizzard of hundreds of different plans with different rules, pay scales, and procedures, hospitals and physicians would deal with a single insurance provider with a single set of rules.

Mohit Ghose, the director of public affairs for the American Association of Health Plans (AAHP), rejects the research PNHP uses to build its single-payer proposal, arguing that it mixes administrative apples and oranges. He thinks the cost savings the plan relies on would quickly evaporate if the proposal ever made its way out of academia and into the real world.

Single-payer proponents say other cost savings would result from a stronger negotiating hand for volume prescription medicine purchases and health care fee structures. It's those last bits that are likely to get the single-payer option into hot political water if it becomes a serious part of a health care reform discussion. There are clearly powerful forces at work in the health care market that would object to having their not-so-invisible hands slapped out of the health care cookie jar.

That's part of the reason the ill-fated Clinton reform effort did not even entertain the single-payer option, despite what the PNHP's Quentin Young describes as its clear advantages and appealing simplicity. Young, a Chicago-area physician for more than 50 years and the PNHP's own happy warrior, recalls how supporters of single payer were cut off by Hillary Clinton with a curt "It's not feasible" during the early stages of what would turn out to be a bombastic and fruitless reform megaproject.

" 'Not feasible,' " Young mutters, clearly still annoyed by the comment. "Now what exactly does that mean: 'Not feasible'? Did they mean it wouldn't work? Because it will work. That it's untested? Just look at all the other countries in the world who use it."

No, says Young, the movers and shakers behind the Clinton health care plan meant only that single payer was politically not feasible because too many special interests were lining up against it. " 'Not feasible': That has been [single payer's] curse," says Young, "But is there anything else that is feasible at this point?"

The Clinton debacle made the entire idea of health care reform politically toxic for a generation, says Young, who believes the system the nation has inherited since then is frankly a scam, a rip-off of the American taxpayer and worker. What prevents the single-payer remedy from gathering cultural traction, he says, is failure of vision, political cowardice, and the for-profit health care sector's ability to confuse and intimidate the general public with high-priced media campaigns.

What single payer is and isn't
One example: the ongoing public association of single-payer with "socialized medicine"--a system in which health care workers are state employees and facilities are owned by the government--or the widespread myth that a single-payer alternative would mean a new government bureaucracy "running" American health care. The PNHP plan requires only that the government pay for the system, not that it manage it.

But what will make the PNHP plan a difficult pill for American political culture to swallow is its demand that for-profit entities get out of health care--period. That would mean the acquisition of hundreds of hospitals and nursing care facilities by not-for-profit agencies or local governments, but Young and other PNHP members say there is no way to fix health care without getting the profit motive out of the system.

"You could have single payer," says Cook County's McDermott, "but if you don't get the for-profits out, it won't make any difference. Costs will just go up even higher than they are now--to 20 or 22 percent of the GDP."

Without those for-profits, though, middle-class America may face sacrifices it is not willing to make, the AAHP's Mohit Ghose counters. He remains confident that the current system can be fixed--costs brought under control and services and access improved--with incremental steps that don't require a large-scale social reconstruction project. According to Ghose, for instance, 7 to 10 million uninsured people are eligible for federal coverage through Medicaid and the Children's Health Insurance Program but aren't enrolled.

"Let's just try to tackle each component [of the overall problem] rather than go for big, blanket changes that could hurt the middle class," he says. Though critics charge the system is overloaded with "trivial" drugs designed more with an eye to profit than to cure and too-costly technology deployed on too-often unnecessary procedures, to Ghose, the current market system offers the best of all possible worlds to American consumers. He argues that U.S. health providers innovate and improve services at a rate that no single-payer system could match, without sacrificing the choices many have come to expect.

But that "I want what I want when I want it" attitude is precisely what Americans may have to change to include everyone in a redesigned system, says the CHA's Father Place.

"Single payer is not a panacea; it does not solve all the ills of our system," says Dr. Fegan. "It's a financial conduit that puts everybody on the same line for health care; it levels the playing field. It's step one." When everybody is on the same line, she reasons, each of us will have a vested interest in improving health care for all. Yes, universal coverage may entail some creative redistribution of services, Fegan admits: in short, the dreaded rationing.

"But what have we got now if not rationing?" Fegan asks. "We've got rationing based on the ability to pay, not on need for services or the effectiveness of treatment."

The moral call
Though the U.S. Conference of Catholic Bishops does not endorse a specific reform remedy, the U.S. bishops have consistently argued that health care is a basic human right and that extending dependable care to all citizens is a moral imperative of a just society. For his part, Place is content to be ambiguous about the kind of reform the CHA might support. He doesn't want the discussion to be short-circuited by loaded terminology at this fragile moment in the nation's nascent rediscovery of its health care woes.

"Our challenge in the United States is that we do not have a coherent national policy with regard to the provision of health care or access to health care." The resulting fragmentation is ruining primary care, he says. Establishing such a policy will require a more mature debate on the moral call of health care, says Place, something the nation, seemingly bogged down in bipartisan bickering each time the agenda turns to health care, has been unable to do.

Place is eager to get a new and comprehensive discussion going--one that will include business, labor, government, and last but not least the people who will actually be served by the health care industry. He thinks the church's respect for life, vision of the common good, and commitment to human dignity make a good place for that discussion to begin. The CHA has a reform plan of its own that includes a goal of universal coverage by 2008.

Hurting 'people who matter'
The impact of the continuing health care crisis can be measured according to its effect on the American economy, on personal income growth, even industrial competitiveness. Where the impact will be harder to measure is its long-term effect on the American family, the strains and fissures it generates, the troubled marriages it topples, the people it pushes over the edge.

"Single payer is going to happen," says Quentin Young. "It's going to happen not because of its social justice appeal, not, like the civil rights movement, because of the best traditions of our country. It's going to happen because the system is crashing and it's beginning to hurt the 'people who matter.' It's been hurting poor people all along."

Chris and Lisa Wilson have both found jobs now, but "with the two of us working we're just making what it takes to get through a month. [Family coverage] is just not possible now." Though her husband has acquired individual coverage through his temp agency, Lisa and her son remain uninsured--and vulnerable. Lisa lives in a constant state of low-level anxiety, heightened by events such as an outbreak of pneumonia that swept through Max's school in November. "We just keep going, and we hope nothing major happens.

"I really didn't think that much about health insurance before," she says. Now it's a daily worry. "I mean, if I were to get pregnant now, I have no idea what I would do.

"You don't miss it until you don't have it," Wilson says. She still tries to get Max in to see a doctor as necessary, but now when she gets sick, "I just try to bull through it."

Wilson has been busy mining New York social service paperwork to find public coverage at least for Max. "This should be taken care of," she says in exasperation. "This should be a no-brainer.

"Nobody should have to live like this."

Kevin Clarke is a senior editor at U.S. Catholic and managing editor of online products at Claretian Publications. This article appeared in the March 2004 (Volume 69, Number 3: pages 12-18) issue of U.S. Catholic.

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