- The Washington Times - Wednesday, November 26, 2003

The most glaring shortcoming of our health-care system has just been highlighted by a report from the U.S. Census Bureau: 43.6 million Americans, 15.2 percent of our population, were uninsured for health care last year. These figures further reflect the double standard of health care that has evolved in our country.

The majority of Americans have adequate medical insurance and ready access to a health-care system that has almost doubled life expectancy in the past century and immeasurably improved its quality. It has been well-documented, however, that the millions of medically uninsured pay a heavy price for their limited access to the system. They get less screening and preventive care; their diagnoses are delayed; and they are sicker and die earlier than the insured.

Clearly, medical socioeconomics have not kept pace with the brilliant advances of medical science and technology.

Aside from the issues of access and quality, health-care costs are skyrocketing and will inexorably increase in the future. The reasons: The Baby Boomers soon will reach the age when they can be expected to have the highest medical expenses, and there has been a staggering growth of medical technology. Fully 50 percent of the knowledge needed to practice modern medicine did not even exist 50 years ago.

In grappling with the daunting challenges of health-care access, quality and costs in the 21st century, perhaps we can benefit from an analysis of the Canadian health-care system and our own experience with Medicare — both examples of national health insurance with a single-payer method of health-care provider reimbursement.

The foundation of an optimum system is mandatory universal health insurance (UHI) to ensure that the richest and most powerful nation on the planet provides what the populations of other Western industrialized societies have enjoyed for decades — the assurance that economic considerations are not paramount at the time of illness or accident.

The mandatory aspect of UHI is essential. For a small business insuring its employees for health care cannot compete with a rival electing not to adopt such insurance. The playing field is only leveled when a deli raising the price of a salami sandwich to cover the added overhead of insurance is assured that its competitor down the street mandatorily assumes the same insurance obligation.

It is axiomatic that improving the access and quality of health care will increase costs, and the question arises where the money will come from at a time when our Treasury is running up huge deficits.

The economic waters are somewhat muddied by advocating repeal of the Bush administration tax cuts to pay for UHI. Attempts to eliminate the tax cuts would in themselves arouse a storm of prolonged partisan debate in Congress and appreciably delay any action on health-care reform.

The least upsetting, most efficient and cheapest way of instituting UHI can probably best be realized by the incremental expansion of Medicare, over a period of years, to cover all age groups. The cost of adopting this single-payer system will not be as costly as commonly assumed:

(1) The uninsured are not dying in the streets. They obviously are receiving care somewhere — emergency rooms, public hospitals and clinics, or uncompensated care at private facilities with a “cost shift” to the privately insured through higher premiums. We are thus already largely paying for the health care of the uninsured.

(2) The high cost of Medicare cannot be extrapolated to the under-65 population. The elderly are plagued with costly chronic diseases that result in some 4 times higher health-care expenditures than those of the younger age groups.

(3) According to a study by Harvard University and the Canadian Institute for Health Information, administrative waste in our current system would be more than enough to provide care for the millions of uninsured Americans. The study found that the overhead costs of private insurance companies eat up 11.7 cents of every health care dollar compared with 3.6 cents for Medicare.

In addition to monetary savings, there are other factors favoring an expansion of Medicare as the method of choice in developing UHI: We have had a 38-year experience with Medicare and the kinks have largely been ironed out. An overwhelming majority of Medicare patients are more satisfied with their medical care than they were prior to Medicare’s inception. Seventy percent of Medicare subscribers also carry “Medigap” insurance to defray out-of-pocket expense — an expense ($1,500 to $3,000 per year) that could be greatly reduced with a beefed-up Medicare program that would make Medigap unnecessary.

Should further study indicate that adopting UHI would indeed make some dent in our federal budget, we must come to grips with the important question of our priorities. Are we satisfied to be only a military superpower, playing the role of a celestial policeman looking down upon a disorderly world and deciding who are the saints and who are the sinners? Or should we rise to the level of the other Western industrialized societies and also become a health-care superpower that provides our citizenry with UHI?

What is needed now is a comprehensive UHI plan that is not commercially oriented and spending millions marketing its product, that does not deny health insurance to patients because of pre-existing medical conditions and does not “cherry-pick” its subscribers to winnow out the unhealthiest.

In short, health insurers are less interested in the health of their insured than in the health of their stockholders. Medicare, however, does no marketing, cannot discriminate against patients by law and has no stockholders. The private insurance industry cannot make the same claims.

A single-payer health-care system would work out better in the U.S. than in Canada, whose health care has been underfunded, and shortages of medical personnel, hospital beds and advanced diagnostic techniques have created long waits for medical services. These problems are not germane in the U.S. where medical personnel are plentiful, there is a plethora of hospital beds and we rank among the world’s leaders in medical technology.

Of course, a switch to a single-payer system is not the cure for all of our health-care problems. Indeed, steeply rising health-care costs have forced Medicare to slate a 131/2 percent increase in premiums for next year, mirroring the yearly double-digit increases in premiums of private insurance plans. The basic economic rules of supply and demand simply cannot be overturned by changes in our health-care systems.

Paradoxically, we already have UHI in the U.S. It is called workers’ compensation — mandatory in all 50 states.

Will someone explain why it is important to medically insure a worker injured on the job but not if the same injury is sustained in a car crash while driving home from work? Why should a 5 o’clock whistle determine the rationale of UHI?

Alex Gerber, M.D., a University of Southern California clinical professor of surgery, emeritus, is a former health-care consultant to the White House and the U.S. Department of Health and Human Services.

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