The future of U.S. health care
IU health policy experts discuss the possibility of universal health care in America
Health care reform tops the domestic agenda for the 2008 presidential elections, with rising costs and coverage for the uninsured remaining prime issues for policymakers. Michael Moore's popular documentary Sicko has also helped focus attention on the poor health record in the U.S. compared to other industrialized nations.
IU health policy experts Eric Wright, director of the Center on Health Policy at IUPUI; Eric Meslin, director of the IU Center for Bioethics; and Nicole Quon, assistant professor in Bloomington's School of Public and Environmental Affairs, discuss the possibilities for health care reform in the near future. Change is drastically needed, they say, but fixing the problem will require everyone to sacrifice -- which few Americans are prepared to do.
Nicole Quon: I think Sicko was really right on about the sense of frustration people have. At the beginning of the film, Moore talked about sending out a request for health insurance horror stories and received 10,000 emails within 24 hours.
Eric Meslin: The United States ranks number 42 among all nations for health care outcomes. That's shameful. It's absolutely shameful. There is no good reason why we are 42. We're in a hole, and yet we still keep digging.
NQ: But the health sector is doing really well. Certain segments of the industry are making way, way more money than they should.
Eric Wright: Health insurers, and health device and pharmaceutical manufacturers have been among the most consistently profitable sectors since the 1970s. Many people are asking if it is in the public's best interest to have an industry that makes significant profits from something that everyone will need at some point in their lives. In Indiana, experts estimate that 27 percent of our health care dollar goes toward administrative overhead costs and profit.
NQ: I don't see the health insurance industry going down without a fight. I don't think it's realistic to expect to knock out a private industry and replace it with a huge government program.
EW: That's probably accurate -- I think now many are asking how to include the insurance industry as a player in a universal health care system. It may be a new role. In the old days, they were taking a risk in insuring people, betting against catastrophic illness. But their role in the new system seems to be more of a claims processors function.
EM: I don't know that it will ever be possible in the United States to not think of health care as a good to be bought and sold. This is not simply a choice about health care, it's a fundamental part of how Americans think. Don't forget the trio of virtues in the United States are life, liberty and the pursuit of happiness -- in Canada they are peace, order and good government. It's a very different idea about the minimal and maximal roles of government. But a lot of this is just language games, because in reality more than half of health care expenditures in the U.S. are paid for by the government already.
EW: The good news is that these Medicare programs are very efficient, in the sense that only 2 to 3 percent of costs go towards administration. In the private sector, as much as 30 percent of the cost of health care is paying for the paperwork. There are whole sectors of employment devoted to negotiating payment between payers and providers. This is the major reason many doctors are now demanding a national health program. Just like patients, they're tired of having to fight to get insurers to pay.
NQ: The providers are so frustrated with the situation that for many of them, the financial trade-off would be worth it. Especially the new generation of physicians coming up, who haven't necessarily known the world of autonomy that used to belong to doctors. But certainly there are many doctors who don't want to lose that autonomy, and a single payer system would have more restrictions.
EM: I think one of the "aha" moments for the public comes when they realize that doctors don't always make decisions based on solid evidence, that they are likely to recommend a course of action rather than inaction even if there is no solid evidence that it will help. We won't necessarily see worse outcomes if there is more waiting. But many people are afraid of that tradeoff of opportunity and choice for cost.
EW: The reality is, though, the difference between us and other industrialized nations is that we've been unwilling to think about or talk about cost-control mechanisms explicitly. We rely on our health insurers and government payers to do this. This is particularly problematic in the area of end-of-life care. We can't keep developing new and more expensive life-saving technologies and expect to give everyone access.
EM: I agree, we cannot continue to extend resources as if they are inexhaustible. We cannot continue to have a technology arms race that disproportionately allocates health care dollars on intensive care rather than producing really efficient primary care. That's not sustainable.
NQ: I think it's really hard for people to recognize that there are tradeoffs -- people get really scared of the idea of rationing. We could also cut costs by implementing more preventive care, but is there any way to change the attitude that says, 'It's my right to be a smoker and be overweight?" People really hold onto these positions.
EW: We need take a lesson from California's Secretary of Health and Human Services and realize that meaningful health care reform will invariably anger everyone. The system is broken, and to fix it, everyone is going to have to feel the pain. Providers, consumers, hospitals, employers, insurers -- everybody.
EM: There needs to be a dramatic and profound rethink of the value of health care in society. Clearly, health is an important value for the world of sickness and disease, but with nearly 20 percent of our gross domestic product being spent on health care, it's obvious that a sick country is not an economically vibrant country. I am optimistic because I think the country is prepared to do something. But we have to act fast because all it takes is a couple of wars and a hurricane to occupy our minds with other things.
