What ails America’s health system depends on the diagnostician

By Leigh E. Rich

When it comes to health care, we can have our cake and eat it, too, third-party presidential candidates Ralph Nader and David Cobb claim.

But, they say, we need different bakers.

Both Nader and Cobb, running on the Reform and the Green tickets, respectively, call for a whole new recipe to mend America’s ailing health care system—but, to a lesser extent, so do Democratic contender John Kerry and Republican incumbent George W. Bush.

Whether it’s the ever-rising number of uninsured Americans, the cost of prescription drugs, the state of medical malpractice insurance or the impact the current health care crisis has on job creation and the economy, all of these presidential hopefuls agree that something must be done or else such issues, in the words of former Hungarian Ambassador Nancy Brinker, “will plague generations to come if we don’t fix them now.”

While each of the candidates believes he has the best vision and none quite see eye-to-eye with each other, all four know that health care, as Brinker pointed out when she stumped in Denver for the GOP last Tuesday, “is going to be the (dominant) subject … in the next decade.”

Already a reigning theme on the campaign trail, recent statistics depict a health care system that is decrepit and, if left alone, could eventually collapse from its infirmity.

America’s medical results are nothing if not alarming.

According to a U.S. Census Bureau report released in August, the number of Americans without health coverage increased from 43.6 million in 2002 to nearly 45 million—or 15.6 percent of the population—in 2003. These figures have been steadily growing since 1987, the report states, when the uninsured rate was 12.9 percent. With the exception of a slight dip between 1998 and 2000, the number of uninsured Americans has increased or remained unchanged from year to year since the late 1980s.

And the numbers are worse for the nation’s minority populations. Compared to an 11.1 percent uninsured rate among non-Hispanic whites, 19.5 percent of Blacks, 18.7 percent of Asians, 23.8 percent of American Indians and Alaskan Natives, and 32.7 percent of Hispanics did not have health insurance in 2003.

Pitting the United States toe-to-toe with other industrialized nations, and the status of America’s system looks even frailer. According to the World Health Organization’s World Health Report 2004, the United States in 2001 spent 13.9 percent of its gross domestic product (GDP) and $4,887 per capita on health care expenditures—compared with Switzerland at 11.0 percent and $3,779; France at 9.6 percent and $2,109; Canada at 9.5 percent and $2,163; Japan at 8.0 percent and $2,627; and the United Kingdom at 7.6 percent and $1,835.

Figures used by the presidential campaigns are even more daunting. According to a policy paper on Nader’s Web site, for example, health care spending could increase to 18.4 percent of the GDP by 2013.

And it’s not only the cost of health care that concerns Americans, politicians and citizens alike. According to the Kerry campaign: “Small businesses cannot expand because they cannot afford to provide health coverage for their employees. Bigger businesses have trouble competing in the global economy because of the high cost of health care. Raises that workers need and deserve are swallowed by rising insurance premiums,” and the uninsured are more likely to file for bankruptcy and less like to engage in preventive care.

So the question in the current election is not whether something should be done but, rather, what.

Not surprisingly, with four different head chefs clamoring to be in the kitchen, the winning recipe remains untested and no one knows which flavor will prove to be the best.

Potato, potahto

Despite having gone head-to-head for four months now, there are a few things on which President Bush and Sen. Kerry do agree when it comes to health care.

There is no doubt, both say, that we must reform health care in America.

And despite this fact, both have claimed on the campaign trial and in their campaign books, that America’s health care system is still number one.

“We’ve got the best health care system in the world,” President Bush told onlookers when he signed the Medicare Prescription Drug, Improvement and Modernization Act last December and again this January when he publicly discussed “quality, affordable health care” in Washington, D.C.

Kerry concurs, almost word for word. According to his campaign book, Our Plan for America: Stronger at Home, Respected in the World, “America has the best health care system in the world”—but with one caveat—“for those who can afford it.”

Both also want to “curb the rising cost of medical malpractice insurance” and both think increased technology in the day-to-day practice of medicine will decrease medical and billing errors that add to the costs of our already pricy system.

And that’s where the congruities seem to end.

In the Republican camp, according to campaign textbook Record of Accomplishment: Building a Safer and a More Hopeful America, the Bush plan promotes the use of tax-free health savings accounts (HSAs) and Medicare-approved prescription discount cards; the establishment of association health plans that allow small businesses to pool their risks; the “adoption of proven minimum standards that make the medical liability system more fair,” such as the capping of non-economic damages; the creation of new and the expansion of current community health centers in underserved populations; and the strengthening of Medicaid and SCHIP programs.

In the Democrats’ corner, the Kerry plan would “pay the full costs for the 20 million children in the Medicaid program,” as long as states expand coverage for “children in families with higher incomes than are currently eligible”; guarantee Americans access to the Congressional Health Plan that is offered to U.S. senators and representatives; establish various tax credits for low- and moderate-income adults as well as small businesses that provide coverage for low- and moderate-income employees; and allow the “re-importation of safe, FDA-approved prescription drugs” and remove barriers to generic availability and price negotiations.

Bush has called his proposal, particularly HSAs, “something inherently American” that allows individuals and employers to control their “own destiny, as well as an answer to the current “philosophical struggle” in Washington about who should be the decision-makers in health care.

But medical liability reform seems to have become the cornerstone issue in the Bush plan, even though the president himself admits this wasn’t so in the beginning.

“When I first came up from the governor, I said, we’ll just let the states deal with the medical liability reform,” Bush told the U.S. Chamber of Commerce in March. “And then I saw what the practice of defensive medicine does to our budget. … See, everybody is getting sued. It’s like a giant lottery. I’m just going to sue, and sue, and sue, and maybe I’ll get lucky and win one of those settlements, where I get 40 percent of the take.”

On the other side, Kerry has claimed that, under this plan, “we will make sure that 95 percent of Americans, including all children, have health coverage. Our plan will provide health coverage for 27 million people who are currently uninsured.”

And both have denigrated the other’s strategy.

During the third presidential debate earlier this month at Arizona State University, Kerry argued that “this administration has stood in the way of commonsense efforts that would have reduced the costs” of health care, such as drug importation and bulk purchasing.

According to the Kerry campaign book, moreover, “the Bush administration has put drug companies and HMO profits above family health and small business costs. … The few proposals he has offered would actually make the health care crisis worse by further dividing the system between one that is affordable for the healthy and wealthy, and one that is unaffordable for the elderly, the sick, and increasingly, for America’s broad middle class.”

Bush characterized Kerry’s proposal in the third debate as one that will “cost $1.2 trillion” with more than “20 million people added to government-controlled health care. It would be the largest increase in government health care ever. … We have a fundamental difference of opinion,” Bush added. “I think government-run health will lead to poor-quality health, will lead to rationing, will lead to less choice.

“Once a health care program ends up in a line item in the federal government, it leads to more controls.”

Covering America

Extremely unpopular with the two major parties, Nader and Cobb’s proposals for a national health insurance are practically identical—though not necessarily because Nader was the Green’s front man in the previous two presidential elections. Both third-party contenders base their health care plans on a single-payer model put forth by the nonprofit group Physicians for a National Health Program (PNHP) in a 1989 New England Journal of Medicine article.

According to the abstract of that article, the PNHP proposition calls for, inter alia, “a national health program that would … fully cover everyone under a single, comprehensive public insurance program” and “contain costs through savings on billing and bureaucracy, improved health planning, and the ability of the national health program, as the single payer for services, to establish overall spending limits.”

Though some Americans, Bush and Kerry included, cringe at what sounds like a form of socialized medicine, health policy advisers for the Cobb and Nader campaigns emphasize a difference.

“If you want to call it ‘socialized,’ it’s socialized insurance, but it’s not socialized medicine,” says Dr. John Battista, a psychiatrist and a radio talk show host who is a member of the Connecticut Coalition for Universal Health Care and a consultant to the Cobb campaign.

“The important thing” to note, Battista says, is that “it’s not the government making health care decisions … (and health care providers) are not employees of the government.”

Such depictions have been heard often on the Bush campaign trail, though the president’s criticisms against supposed government involvement in health care have typically been lobbed in Kerry’s direction, not Cobb’s or Nader’s.

“That’s what liberals do. They create government-sponsored health care,” Bush said at the second presidential debate at Washington University. “Maybe you think that makes sense. I don’t.”

Kerry has defended his proposal against such accusations, reiterating time and again that his health care plan “is not what the president described. It is not a government takeover,” he responded during the second debate. “You have choice. Choose your doctor, choose your plan. The government has nothing to do with it.”

Similarly, at the third presidential debate, he repeated that “it’s not a government plan. The government doesn’t require you to do anything. … If you don’t want to take the offer of the plan that I want to put forward, you don’t have to. You can keep what you have today. Keep a high deductible, keep high premiums, keep a high co-pay, keep low benefits.”

Though the Kerry and the PNHP-based plans differ significantly, a similar defense is used by national health program proponents against what they believe is a knee-jerk reaction.

“The fear of socialized medicine,” says Kevin Zeese, the Nader campaign’s spokesman and press secretary, “is a false fear. … You can have private doctors and private hospitals (and) a range of health care providers” under a national health program.

Similarly, it’s never been “the Green Party’s intention to have the government administer the health care system,” Battista says, unlike the Democrats’ plan under Kerry. Instead, the Green Party advocates a not-for-profit trust “under the control of a board which represents all interests—tax payers, health care advocates, public officials, business. … That’s the ‘by the people’ side” of America’s foundational mantra.

Moreover, the trust would be “administered as locally as possible,” with each state having its own board. The board—or “Consumer Health Vigilance Association” as Nader tentatively deems it—also would serve to protect patients’ rights and be a watchdog against fraud.

According to a Nader policy paper, a national program would replace “our fragmented, market-based system with a single-payer health plan—where the government finances health care, but keeps the delivery of health care to private non-profits.”

PNHP, founded by Harvard Medical School doctors David Himmelstein and Steffie Woolhandler, proposes a publicly-financed, universal health care system in which, as stated on the Nader campaign Web site, everyone “would be included in a single, comprehensive public plan covering all medically necessary services, including acute, rehabilitative and long-term care, mental health services, dental care, prescription drugs and medical supplies.”

In addition, everyone “would have … free choice of doctors and hospitals at all times”; “medical decisions would be left to patients and doctors, not to insurance companies or the government”; physicians and other health care “sellers would stay private, and the health plan would provide for different payment schemes … to prevent profit motives from unduly influencing physicians”; and a “transition fund would be established for insurance-company employees whose jobs would be eliminated due to the simplicity of a single-payer system.”

Zeese says the successful implementation of such a program, however, requires a paradigm shift in America’s thinking. “This is all a major challenge” and one that “takes away corporate power over our government.”

But it’s doable, he emphasizes. Under the PNHP model, a universal program would be financed by a roughly 7 percent payroll tax on employers and a tentative 2 percent income tax on individuals. Currently, according to the PNHP, small businesses spend 25 percent or more of their payroll to cover insurance premiums, while large businesses spend about 8.5 percent.

And Zeese claims, under the Nader plan, that the 2 percent individual income tax may not even be necessary, especially if we “tax wealth more and labor less.”

“We tax buying food but not buying stock,” for example, Zeese says. “(If you) tax stock transfers at a quarter of a penny each, you would raise $300 billion a year.”

Other health care funds could be raised by taxing so-called “detrimental activities,” particularly industries that create public health risks. But with well-funded lobbying groups in Washington, Zeese admits that such a paradigm shift could be an uphill challenge.

“That will definitely be the battle. Anyone who takes this on has to be a strong advocate and a strong organizer.”

Waiting for a solution

Other roadblocks also exist.

One common refrain issued by opponents is that a universal system would adversely affect access to care, portraying images of long waiting lines.

Not so, says Battista.

Though he admits there will at first be greater demand once a national program is implemented, “a lot of people’s uptightness” about this is “unwarranted.” Even now, waiting for medical services in Canada and the United States, for example, is comparable, he says, “but the kind of waiting is different.”

In Canada, there is a longer wait for non-emergency surgical procedures, such as a hip or knee replacement, but in the United States, there is a longer wait for emergency services.

And America would fare better under a national program than our northern neighbors, Battista adds, because “the United States has the most unused beds per capita. This is part of the inefficiency of the U.S. health care system. In the end, you won’t have waiting lines in the United States because we have an oversupply of medical infrastructure” in the form of unused medical and surgical beds and other medical equipment.

Fears that a revamping of America’s system would affect access to care are also illogical when the uninsured and the poor are taken into account, Battista explains. The United States currently ranks poorly compared to other industrialized nations on several health care indices—such as longevity and infant mortality—because of distribution disparities between the wealthy and the poor and the insured and the uninsured.

“It’s very important … to differentiate between health care available and health care in the population,” Battista says. “No matter how you look at it, (a national plan) is a better system.”

Other criticisms focus on how it would affect the doctor-patient relationship and the quality of medical services available.

Both Bush and Kerry have emphasized throughout the election that America’s system must put health care decisions back into the hands of practitioners and individuals, rather than HMOs and insurance companies.

At an Oct. 11 appearance at Red Rocks, for instance, President Bush told the crowd that he is “standing with the doctors and the patients” and, under his plan, patients will be able to “base their medical decisions on advice from a doctor, not somebody in an HMO” and “not by government officials in Washington, D.C.”

Kerry and running mate John Edwards have pushed for a patients’ bill of rights that would, among other things, allow patients to appeal HMO decisions.

But proponents of a universal program argue that it’s not only better for patients but also doctors.

According to a 1995 paper by Himmelstein and Woolhandler used in Nader’s position paper, “Physicians in the U.S. face massive bureaucratic costs. The average office-based American doctor employs 1.5 clerical and managerial staff, spends 44% of gross income on overhead, and devotes 134 hours of his/her own time annually to billing. Canadian physicians employ 0.7 clerical/administrative staff, spend 34% of their gross income for overhead, and trivial amounts of time on billing (there’s a single half page form for all patients, or a simple electronic system).”

And, with everyone covered, rates of malpractice, liability, worker’s compensation and automobile insurance will decrease, Battista says. “For example, the malpractice rates in Canada … are less than 10 percent. … You don’t have to sue for your medical costs.”

Regarding quality of care, Bush claimed during the second presidential debate that “government-sponsored health care would lead to rationing. It would ruin the quality of health care in America.”

Again, Battista and other supporters disagree.

“We actually would expect it to improve,” Battista says.

With an increased focus on preventive, or primary, care instead of tertiary care, “it’s really a win-win-win all around,” says Zeese. “The only person that doesn’t win is the health insurance industry. … The consumers need to have a choice. People need to feel like they have control over their health care.” 

Rich, L. E. (2004, October 22). Search for a cure: What ails America’s health system depends on the diagnostician. The Colorado Statesman, pp. 2, 12, 14–15.