In healthcare, when a cure is available its unethical to prescribe a placebo instead. Politicians apparently face no such constraint.
At least 18,000 American adults die each year from not getting proper care because they dont have insurance. Experience in dozens of countries shows that not-for-profit national health insurance is an effective cure. Yet, save for Dennis Kucinich, the presidential contenders offer variations on Richard Nixons old recipe: a concoction that has already failed in several statewide trials.
In 1971 and again in 1974, Nixon proposed a National Health Insurance Partnership to achieve universal coverage. His plan called for:
- An employer mandate requiring employers to cover their workers. A new government program offering insurance to those not covered by Medicare or an employer (i.e., the self-employed and the unemployed). This coverage would be free for low-income families (i.e., those making less than $22,000 in todays dollars), while others would pay premiums based on a sliding scale pegged to income.
- Improved preventive care and disease managementhealth maintenance in Nixons parlance.
- Preserving consumers cost consciousness.
Todays Republicans offer only the last of Nixons ingredients: a call for consumers to (in Mike Huckabees words) have some skin in the game. Their proposals barely nod at the need to expand coverage. Mitt Romney has even renounced the full-Nixon approach he championed while pushing through Massachusetts health reform; now thats socialized medicine.
On the Democratic side, Hillary Rodham Clinton, John Edwards, Barack Obama and Bill Richardson have proposed plans that include the first three of these elements. All but Obama add a coercive twist. Theyd criminalize the uninsuredforce middle-income families to buy coverage, not merely offer them the option. Presumably big fines would await those who dont comply with this individual mandate. (Massachusetts is set to impose bigger fines for being uninsured than for domestic assault or drunken driving.)
Nixon never passed his employer mandate plan. But a wave of state health reforms starting in 1988Michael Dukakis Massachusetts legislation as well as bills passed in Oregon and Washingtonincorporated Nixons employer mandate idea. The Massachusetts and Washington plans also required the self-employed to purchase insurance, prefiguring the individual mandates in the 2006 Massachusetts bill and those proposed by todays Democrats.
The Dukakis plan and its cousins in other states were all loudly hailed by politicians and the media for reaching the goal of universal coverage. All foundered as rising costs made expanded coverage unaffordable, and died quiet deaths. More are uninsured today in those states than at the time the reforms were passed.
Romneys 2006 Massachusetts law, which combines a tepid employer mandate with an individual mandate and an expanded Medicaid-like program, looks set to run a similar course. Only 2% of the middle-income, uninsured families required to purchase coverage as of July 1 had signed up. Under the plan, an uninsured couple has to lay out $8,638 annually for a policy with no drug coverage at all and a $2,000 deductible per person before insurance even kicks in. Few can afford it.
The Nixon/Dukakis/Clinton/Edwards/Obama/Romney approach rests on impeccable political logic, avoiding any challenge to the stranglehold that insurance and drug firms have on the healthcare system. But its economic nonsense. Absent effective cost controls, expanding coverage is simply unaffordablefor government, employers and middle-income families.
All of these candidates tacked on a laundry list of cost-saving measuresmore computers, more care management, more prevention. Whatever their value for quality improvement, none are credible cost-containment strategies. Even as most billing has been computerized over the past two decades, both total and administrative costs have continued to rise. The oft-cited RAND Corp. estimate of impending savings through computerization (funded by computer vendors and based entirely on unsubstantiated projections) reprises the forecasts of savings made repeatedly by expert panels over the past 40 years.
As for disease management, the Congressional Budget Office recently concluded it sometimes improves quality but found no good evidence of cost savings. Already, vendors are abandoning Medicares much-touted disease-management demonstration programs, convinced that no cost savings (and hence profits) will accrue.
Prevention saves lives. But years ago economist Louise Russell convincingly demonstrated that virtually everything but cheap immunizations adds costs.
Except for Kucinich, all of the presidential hopefuls sidestep an inconvenient truth: Private insurers are the cause of our healthcare mess, and failure to evict them will doom reform. Only not-for-profit, single-payer national health insurance can resolve the cost/access conflict.
Americans provide ample funds for their carenearly twice per capita the amount spent in other wealthy nations. But by the time it reaches the bedside, the torrent of money that flows to insurers has shrunk to a modest stream, insufficient to provide for the 47 million uninsured and the tens of millions more who are underinsured.
Three hundred billion dollars is diverted each year to useless insurance bureaucracy, the unnecessary paperwork insurers inflict on healthcare providers, and the seven-, eight-, even nine-figure incomes they pay themselves. Tens of billions more go for profitable but unnecessary procedures. And drug firms siphon off far more than their fair share through price gouging and research too often focused on profitable me too drugs rather than real innovation. Only the single-payer approach can redirect these wasted resources to the care our patients need.
Assuring quality care in a hospital, nursing home or outpatient facility is complicated. Paying for it should be simple.
Steffie Woolhandler and David Himmelstein are primary-care physicians at Cambridge (Mass.) Hospital, associate professors at Harvard Medical School and co-founders of Physicians for a National Health Program.