Justice Withheld:
A Comment on the Threshold of Health Care Reform
by Guy L. Clifton, M.D.
Professor of Neurosurgery, University of Texas
For a downloadable version of this article in PDF format click here.
Over the course of the last year I have talked with and listened to a number of people with uncompromising opinions about the shape of health care reform. Their views varied but they all had one characteristic in common—they enjoy secure health coverage. Eighty-percent of the 47 million uninsured in America are too poor to buy insurance and their employers don’t provide it. These people are too busy making ends meet and too hidden from view to have a voice in this debate. The result is a high level ideological fight whose hallmark on both sides tends toward “If it can’t be my way, then not at all.”
Three factors could yet kill health reform—the failure to include a government managed insurance option like Medicare; failure of the legislation to reduce the cost growth of health care; and inclusion of an option for individuals whose premiums are subsidized with federal money to purchase a policy that offers abortion services. The uninsured have not thought about and do not care about these disputes. Their concerns are more immediate. Twenty-two thousand of their ranks die each year and legions of others face bankruptcy and misery when they develop chronic illnesses that are detected and treated too late. The poor are used to others deciding their fate—their lives are largely controlled by business and policy decisions made by the well-off and educated who are personally unaffected by the outcome. It is not just the poor, however, who have a stake in the outcome of health insurance reform.
There are only three ways to expand insurance coverage in America. One is to put everyone in something like Medicare—a single payer system. Another is to disconnect health insurance from employment. People would pick their own policy and write their own checks for insurance, which they could do if we redirected the $200 billion a year in federal tax advantages that sustain the employer-based health care system. The third method of expanding coverage is to patch up the existing system. This option is the only one of the three that is politically feasible.
The defining political reality of achieving health insurance reform in America is that new legislation must not affect those who are happy with their coverage. Barack Obama ran on this platform and has been faithful to it. Large firms like Exxon Mobil, the Catholic Church, and my employer, the University of Texas System, almost all subsidize the health insurance of their employees and self insure, directly bearing the cost of the health care services provided to their employees. Insurers only act to process claims and execute contracts with providers. Under the federal laws that govern self-insured firms, our employers cannot exclude a pre-existing condition or charge us higher rates because we are sicker or older, or exclude us from coverage.
However, another 90 million Americans who are self employed or are employees of small firms that must buy policies from health insurers have real problems. Insurance in these markets is regulated by 50 different sets of state laws that mostly permit insurers to exclude pre-existing conditions, charge high rates for anyone who is old or ill, or not offer insurance at all to applicants that are high risk.
Eighty million employees of large firms and about 100 million people covered by the two public programs, Medicare and Medicaid, don’t want any changes in their insurance. About 130 million Americans, who must buy their own insurance; who work for small firms that may not be able to reliably provide coverage; or who are uninsured do want some changes. So over half the country insists that their health care be left alone and the others desperately want something to change.
The insurance reform bills now before Congress require insurers to offer coverage to anyone who applies; prohibit them from excluding pre-existing conditions; and require them to charge the ill and the healthy the same rates. For these reforms to be enacted without breaking insurers, individuals must be mandated to have insurance--so that those who are healthy and don’t presently need coverage subsidize those who do. That is the definition of insurance. The cost of insurance reform is the cost of the federal premium subsidies for those who cannot afford the full cost of insurance, a subsidy amounting to less than 1 percent of annual US healthcare spending.
While these insurance reforms are imperfect, they are politically feasible and they redress the uniquely American injustice of disenfranchising about 40 million citizens who cannot afford to purchase health care from acceptable health care. If this opportunity is lost, matters will not return to the way we found them. In 1987 12 percent of the country was uninsured; today it is 16 percent. Most of the increase in the percentage uninsured in the past decade has been in the middle class. The number one issue for small businesses in the country is health care--the percentage of small businesses that do not offer coverage has declined steadily since 2003. In large American cities the emergency services system for the entire community began to fail in 2001 because of the rising number of uninsured. The public health care systems erected by communities for those without other options have long since been overwhelmed.
This is no time for litmus tests—the consequences are far too serious. Progressives must accept that there are ways to create insurance industry competition other than creation of a new public program. Fiscal conservatives must understand that coverage expansion and cost control cannot come in the same legislation. The last time health reform was attempted in 1993 the medical industry spent hundreds of millions of dollars to kill it. This time the American Medical Association, the American Hospital Association, the Pharmaceutical Research and Manufacturers of America and Americas Health Insurance Plans all support insurance reform--they see 47 million new customers. The cost of health care must be reduced or the expansion of coverage that the country is attempting will be dismantled, but that will be for the next round of reform. Abortion is repugnant—no one wants it or wants to have it. But the political reality is that a healthcare bill that is anything but neutral on the frequency of its performance cannot become law in the United States. Proponents of unrestricted access to abortion and proponents of no access to abortion that choose to use health care reform as a platform for their objectives risk the unintended consequence of denying coverage to the uninsured. Choices come with consequences and the consequences of continuing to withhold justice from the poor, the near poor, and a sizeable segment of the middle class are too great for the country to bear.
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Guy L. Clifton, M.D. is Professor of Neurosurgery at The University of Texas Medical School at Houston where he was founding chairman and holds the Runnells Distinguished Chair in Neurosurgery. Dr. Clifton was a 2006-2007 Robert Wood Johnson Foundation Health Policy Fellow where he completed a one-year stint in the office of Senator Orrin Hatch (Republican, Utah).
During the years of his practice in Houston he was frequently listed among America’s top doctors. Internationally recognized for clinical research in the treatment of severe brain injury, he has published over one hundred scientific articles in peer-reviewed medical journals and has been principal investigator of two NIH/NINDS-funded multi-center clinical trials of hypothermia treatment for severe brain injury, a treatment he developed and is testing.
Dr. Clifton recently authored a major book on the U.S. health care system. More information about the book, Flatlined: Resuscitating American Medicine, can be found on Dr. Clifton's website, http://flatlined.org
January 7, 2010 |