By Samir N. Banoob, M.D, Ph.D.*
“ The administration inherited a basket of bad apples from its predecessor: the budget deficit, the recession, a week economy and unemployment to mention a few. Among the problems, the health care crisis is the worst by far”
This quote is not recent since I published it on February 7, 1993 in the St Pete Times, an article titled “Health Care: Painful Remedies are needed”
I was referring to the Clinton administration and the President’s promise to produce his Health Security act within the first administration 100 days. As a reminder, at that time Republicans raised the issues of big government, increasing the deficit, government taking over health care, eliminating choices, more taxation, hurting the private sector and the rest of the same old story. Moreover, they introduced 6 more health plan proposals to the Congress until the whole reform issue faded away and was dropped. This was paralleled with an aggressive heavily funded campaign lead by the Republican Party, insurance companies, the pharmaceutical industry and others. Since then, and until 2008, every Democratic presidential candidate, learning the lesson the hard way, dropped the health insurance and universal coverage from his agenda.
In 1994, I published an article in the Florida Journal of Public Health (vol VI, no1) on “Reforming Health Care in the US and Europe: Why we Fail and They Succeed? “ It said: “Why health reforms succeed in all western countries? They established concrete health policies of universal access and user-friendly systems in the 30s and the 40s, guided by a solid commitment to national welfare and social solidarity. Second, the voice of interest groups is not so loud, and if it becomes so, its impact on policy-making is minimal since policy makers’ behaviors are put under stringent scrutiny of their well-informed voters. Third, the government and the elected representatives, who are elected by the watchful voters, are more trusted, and the government is allowed to govern, and elected representatives make decisions in the public interest”
– * Samir Banoob, M.D, D.M, DPH, Ph.D. is a professor of international health policy and management and consultant to WHO, World Bank and international agencies who consulted with 76 countries.
After 16 years, while our health care “ non-system” deteriorated more than ever, we are facing the same tactics and the same allegations lead by the same campaign funding agencies. This time, and as desperate as they are, they added allegations such as “killing grandparents”, and some behaving disrespectfully during discussions in the Congress or in town hall meetings. During these 16 years, we were only scratching the surface of the problem by incremental acts such as the children insurance plan, Medicare D drug plan and some modest state plans that benefited insurance companies and drug companies most while the major problems remain the same or become worse. Our health system, as compared to the western world, is
- The only system that do not provide HEALTH SECURITY to its citizens, meaning that, no one except the elderly, feels secure at receiving continued medical care when needed, and no one, even the elderly, is safe from severe financial hardship when getting seriously ill. The uninsured population reached 46.3 millions in 2008 as compared to 36 millions in 1993 and is steadily increasing. Last year alone, with the rising unemployment, 600,000 lost their coverage. If the status quo continues, it is expected to reach 75 millions in 2019
- The highest expensive system in the world that cost us 17 per cent of our gross national Income compared to an average of 9 percent in Europe. The cost per individual reached $ 7, 290 in 2007 as compared to $ 4,704 in 2000. This is almost double the price in any country of comparable national income. The reasons have been well diagnosed: commercialization, fragmentation, extensive administrative cost, the cost of the uninsured reaching the system through the emergency rooms of hospitals when it is too late and too expensive, and defensive medicine of physicians to guard against litigation. In this respect, we probably have almost ten times more medical liability cases per physician more than European countries. This is natural since we have money- hungry insurance companies in order to pay the multi-million dollar annual salaries for its executives, and rich dividends for The Wall Street and the stockholders. We are the most lawyerly country in the world since we have one attorney per 265 citizen as compared to 1: 1000 or more in most Europe, and non of these attorneys in Europe can declare publicly that he/she is injury specialized nor can advertise aggressively and publicly to promote and solicit medical malpractice suits. This is strictly prohibited by professional ethics and standards.
- One of the lowest western systems with medical providers per thousand population especially physicians and nurses, and the highest with administrators (8 administrators per 10 health providers). The administrative cost of private health insurance agencies is 30 percent as compared to 2- 4 percent in Medicare and governmental agencies.
- One of the lowest western systems in terms hospital beds and inpatient care, the lowest hospital admission rate and the lowest length of hospital stay if admitted to the hospital. We probably are the only western country that forces the patient scheduled for major surgery including open heart surgery, to arrive at 4:00 A.M the day of surgery, and the only country that has an established unit in each hospital named “ Early discharge planning” whose job is planning from day one for kicking the patient out the soonest Similarly, while each European citizen uses 7-8 outpatient doctor visits per year, we use 3.8 visits per year.
These are just few features of our system that some falsely call it “the best system in the world” By technical and scientific standards; this system is rated as number 37 among the 190 countries in the world, and the lowest among industrial countries. Health systems are also measured by its impact on health. The life expectancy at birth, 78 years in the US is among the lowest of industrial countries. It is 81-83 years in Japan, Scandinavian countries, Switzerland, South Korea and Singapore. The healthy life expectancy, measuring the years of healthy living is equally low. Seven of each 1000 American children die before their first birthday. This is similar to Thailand and Lithuania, while it is only 2-3 in Japan and most of west Europe. We should not be proud of our rate of high tech surgical procedures that exceeded most western countries since the research proved that about 20% of these procedures are unnecessary and are financially driven or performed to avoid litigation. Some refer to the Canadians crossing the border to have surgery to avoid the delay in their country, but no one counted how many does that. It is probably a minute fraction of rich nervous patients that may be comparable to those who go to India or China seeking traditional medical care and treatment with herbs. In western countries, no one is denied care in emergencies or serious conditions. The scientific measures of quality of care indicate that the US system in general is comparable with most western countries.
The notion that the public option will increase bureaucracy is equally false. Almost half the Americans (about 45%) now are covered by governmental programs, including Medicare, Medicaid, Veterans health services, federal, state and local government employees and retirees plans, military health services and other governmental programs. In the State of Florida, and after several years of repeated hurricanes, insurance companies quadrupled our home insurance cost, and many of them denied new policies or dropped existing ones. The only solution that saved Floridians was introducing a state funded home insurance entity that covered this gap.
Another allegation is the cost and the deficit. The president responded to that in his speech to the Congress joint session last week. But even if it costs more in the beginning, no body estimated the savings to individuals and families from lowering the out-of pocket that is about 25 % of the total expenditure on health and is increasing every single year by 7-8%, and the cost to employers who either lower the health benefits or shift the cost to the employees. And often do both.
So what is next? The interest groups are proceeding with “ business as usual”, and do what was done to the Clinton plan, organizing scare campaigns spending $ 1.5 million a day, six paid lobbyists per legislator and submitting parallel plans for the purpose of distraction and liquidation of the whole reform move. But it will not work this time for two reasons: one is that we have a persistent president, and second is that Americans have had enough. We cannot wait until the system of health care collapses like the financial system. Congressmen who are dancing between the two sides from both parties should know that it is different this time. The voter now is more informed and will not forgive those who will vote in favor of the interest groups against the public interest.
It is essential at this time to focus the debate on the health system alone, Many opponents to the reform plan are purposively confusing the debate by inserting side issues such as immigration, government, political ideology, the presidency and even race. This will hurt all Americans in the future. Those who are satisfied with their current insurance coverage (except the elderly) should know that it is temporary, and changes in cost and coverage are unpredictable under the current system.
Here are some suggestions to finish the reform:
- Public education and information should aggressively continue, objectively and simply to gain support and confront the scare tactics. The President should weekly address the nation until the law passes. Summaries of the plan should be prepared and widely distributed, ranging from 10-100 pages.
- No new plans should be discussed in the Congress until the President’s plan is voted on. Changes or amendments can be introduced.
- The deadline of the end of 2009 is not a sacred cow and can be extended if compromise is the alternative. And no compromise should be allowed since the president’s plan is technically the minimal.
- The public option can be implemented to be a state program and not a federal one, where each state will form a public not-for-profit entity as an insurance body that will be managed by elected board members. It is natural that the state and the Federal governments can fund this state program as Medicaid is funded. In fact, combining it with Medicaid in one entity is even preferred to avoid creating a new entity and to maximize the golden rule of insurance- the rule of large numbers.
- The essential factor is that citizens should exercise their active role. Whether republican or democrat, this is a non-partisan issue that is vital for their families, and they should not be distracted. Our representatives should know that re-election is tied to their vote and honest performance on health security of the Americans. They should rest assured that there will be no killing for the health reform plan this time