Journal of Health Services Research & Policy >
Volume 13, Number 3 >
Pp. 131-132
Editorials |
Yet, none of the leading candidates for President has put forward a proposal that will achieve affordable, good quality health care for all. All of the plans, both Democratic and Republican, fall short in that they fail to provide universal access to care, add additional funds to an already too costly system, and none offers a realistic way of containing the rising cost of health care.
Only single payer national health insurance can achieve affordable, workable access to health care for everyone.2
John McCain, the Republican candidate, puts the responsibility on the individual. He proposes eliminating the tax deduction that employers gain when they contribute to the cost of health insurance for their employees and giving it to individuals who purchase private health insurance. The most likely impact of such a change would be to accelerate the exodus of employers from employer-sponsored coverage. In 2000, 69% of firms offered health insurance; in 2005 only 60% did.3 Although McCain suggests subsidies for the poor to buy their own health insurance policies, he has not specified the amount. Since he also advocates making consumers more cost-conscious, it is likely that these subsidies (in the form of tax credits) will not be substantial. The McCain approach has been characterized as the YoYo (You're On Your Own) approach. It is nothing new. In fact, it harks back to the 1920s, the period before insurance was available through employer groups.
The Democratic candidates for President, Hillary Clinton and Barack Obama, have put health care reform higher in their domestic policy priorities. Although a lot of newsprint has been spent highlighting the differences between the Clinton and Obama proposals, both fundamentally advocate a Mandate Model. Their proposals share a set of common elements:4,5
All candidates suggest that what they are proposing is providing the rest of the country with access to the kind of plans that members of Congress have. While this is attractive rhetoric, all it means is access to the same, frequently inadequate private health insurance plans that are the major problem for all those who are under-insured.
The most intriguing Democratic proposal, initially championed by John Edwards, is to establish a public plan, like Medicare, to compete with existing private health insurance plans.7 The logic behind such proposals goes something like this: if Medicare's overhead is approximately 3% and the average commercial carrier's overhead and profit is 19%,8 then Medicare will be able to offer employers attractive prices that are lower than private plans are willing to offer, and employers will drop their private coverage in favor of the new public program. The problem with this presumption is that there is no assurance of a level playing field between the public insurance plan and the private ones. Insurance company advertising and targeted marketing will still be used to promote private plans over the public plan and to avoid the poor and the sick. Over time, sick patients will be dumped into the public program, and its premiums will rise faster and higher than those of the private companies. At the same time, private insurers will surely insist on the additional subsidies that they already enjoy in the Medicare Advantage program (on average 12% above Medicare rates).9
The usual argument against a single payer plan is that it is not politically feasible. But, are these Democratic mandate plans politically realistic? They are focused on expanding coverage to the uninsured but do little to help the under-insured. The public is not clamoring for a mandate to buy private health insurance. Rather, they want guaranteed access to the doctor or hospital of their choice. On the other hand, the forces of opposition are formidable: the insurance companies will fight tooth and nail against guaranteed issue and community rating, as well as other requirements for benefit coverage. Businesses will resist a mandate that they purchase insurance. In Massachusetts, they were unwilling to pay more than $295 per employee, and even objected to that small fee. The proposed subsidies, amounting to about $2000 per uninsured individual, are about half the cost of purchasing group insurance today.10 Millions will continue to find insurance unaffordable. The attempt to impose an individual mandate in Massachusetts is already showing that, as long as the program continues to rely on private insurers, very large subsidies will be needed if coverage is to be both affordable and comprehensive; without such subsidies, coverage will either be limited or unaffordable.11 These mandate plans will add to the US' overall spending on health care, already the highest in the world, with much of the additional spending going to insurance company administrative costs and profits rather than additional health care.
In conclusion, none of the Presidential candidates' proposals will work in practice. None proposes automatic enrollment and true universal access to care. They do not overcome the very significant deficiencies of private insurance. None offers a realistic way of containing the rising cost of health care, and all would add additional expenditure to an already too-costly system. They are, at best, a diversion from the direction we should be going, toward the creation of a single, national, publicly funded insurance pool that can provide comprehensive, continuous, cost-effective coverage along with the budgetary tools needed to begin containing costs. Numerous studies conducted over nearly two decades have shown that a single payer program can provide full coverage for everyone without requiring that we spend any more on health care than we do now.12 Savings achieved through reduced administrative and billing costs can provide the funds needed to provide care for the uninsured and the underinsured. Polls show that close to two-thirds of the American public support such a plan.13 The only thing lacking is the political drive by our Presidential candidates to make it happen!
Professor of Clinical Medicine and Public Health Weill Cornell Medical College 425 East 61st Street, Suite 321 New York, NY 10065 Email: ofein{at}med.cornell.edu
Professor and Chair of Urban Studies Department Queens College City University of New York
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