Tuesday 10 December 2019

America stands at the crossroads on healthcare

Barack Obama's health reform plans are modest but critically important, writes John Crown

America should learn today whether President Barack Obama has succeeded in his efforts to persuade the US Congress to pass a modest but critically important reform of the US healthcare system.

The majority of Americans have good access to outstanding healthcare, probably the finest in the world. Most are covered by occupationally based private insurance, which allows them to attend hospitals and doctors of their choice.

What is often forgotten by external commentators who fixate on the private-for-profit aspects of American healthcare, is that the United States is also the largest provider of socialised medicine in the world, via its Medicare programs for the elderly, and Medicaid for the poor. The problem is that the principle of "universality of access", based on need and not on ability to pay, has not been enshrined as a national belief in the American collective psyche, or in its laws.

As a result, a large minority of Americans are either uninsured, or very poorly insured. Many of the unemployed or poorly paid cannot afford insurance, or work for companies that do not provide it. To qualify for Medicaid, one must be virtually bankrupt; thus the working poor can lose out badly. Not all of the uninsured are denied healthcare. Some well-off citizens opt not to pay for insurance, preferring to play the odds and pay out of pocket. Tragically, others simply cannot afford it and go without, with sometimes disastrous consequences.

Even those with insurance can encounter problems. For example, US citizens, who change their job and thus their insurance company while they are on treatment for existing illnesses, may find that they have lost their old cover, while the new insurers will refuse to take them on. In addition, loss of job can mean loss of health cover, something which can cause huge anxiety at a time of rising unemployment.

What is Obama proposing? While he is broadly maintaining the existing system as it stands, he is introducing reforms in four key areas.

Firstly, insurance companies will no longer be able to discriminate against citizens with pre-existing illnesses. Secondly, tax breaks and an innovative insurance 'exchange' will make traditional insurance more affordable. Thirdly, and controversially, there will be a 'public option' insurance plan aimed specifically at the uninsured. It is hoped that this measure will also help to drive private insurance premiums down by force of competition. Finally, and somewhat vaguely, a commission of healthcare experts will be set up to try and eliminate waste and fraud. This latter aspect has fuelled some possibly paranoid speculation that it is a stealth rationing mechanism. The moose-shootin' fringe of the Republican Party has, for instance, coined the term "death panels" for the putative bureaucrat committees who would decide if granny should or should not get that expensive cancer drug.

Hillary Clinton famously and unsuccessfully attempted to reform the system during her husband's first presidential term. While powerful lobbying and public advertisements by the insurance industry and a degree of high-handed imperiousness on her part are generally blamed for the failure of her reforms, I believe that the principal reason that they did not succeed was that she failed to tap the public zeitgeist, which was that most Americans did, and still do, feel that their own healthcare is great, doesn't need reforming and might decline in quality with greater government interference. Even this weekend, as the Obama reforms seem just about likely to squeak through, polls show that a majority of Americans are opposed to them. Sadly, many Americans regard poverty as an exclusive consequence of poor life choices, and wonder why they should pay more to subsidise the healthcare of others.

We will have our healthcare reform debate soon, by the spring of 2012 at the latest. It will occur in the context of our general election. Our health problems are different to America's. While we do have guaranteed access to hospital care, and many have free GP care, the system is mediocre in quality, terribly inequitable and highly inefficient. The current Health Minister and her officials talk about reform and transformation but what actually happened during Mary Harney's tenure was a series of management exercises that all had the common goal of reining in costs for the taxpayer, while simultaneously incentivising patients to leave the public system.

Sadly, the only as yet non-extinct political parties in the Coalition, Fianna Fail and the Yel. . ., sorry, Greens, are currently following the Pontius Pilate school of health policy -- washing their hands of all responsibility.

Fine Gael and Labour, on the other hand, have both proposed well thought out, mutually compatible health reform plans, reforms based on successful European models. We will discuss these over the next weeks.

Meanwhile, fingers crossed that the Obama reform will pass Congress.

Professor John Crown is a consultant oncologist

Sunday Independent

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