Our health care discussion, for all its political content an social consequences, has essentially been about managing the expense of providing insurance, rather than about investing in the appropriate elements of a health care safety net and affecting the outcomes of a comprehensive strategy. John Maurice Clark, a prominent social economists during the mid 20th century, agreed that our national health should be considered a paramount resource. Well before these issues surfaced during our current debate, he wrote: "It is clear that health is a national asset, and it is worth conserving, more or less regardless of whether it can be done on purely commercial principles." ("Economic means - to what ends?," American Economic Review, 1950). Many of us know that, as a country, we spend much more on health care than any other country in the world. Few of us realize that the health of Americans, by many different measures, is actually worse than the health of citizens in other wealthy countries.
Our health care system is expensive. In 1960 we spent 5.2% of GDP on health care. In 2009 this number had shot up to 17.6%. (Kaiser Foundation, "National Health Expenditures, 1960-2009," published April 6, 2012). While the increase in expenditure did help us improve our overall life expectancy, as well as our "healthy" life expectancy, our improvement has been considerably slower than what most other wealthy countries experienced. The Journal of the American Medical Association, in "The State of U.S. Health, 1990-2010," documented trends in mortality and morbidity (the rate of disease in a population) across 34 OECD countries. It concluded that life expectancy in the U.S. dropped from #20 to #27 , while our healthy life expectancy ranking dropped from #14 to #26. Another study, conducted by the National Research Council and Institute of Medicine, produced a report by a panel of experts examining health indicators in 17 high-income countries. It discovered that American men ranked dead last, while women did only slightly better, ranking second lowest.
The World Health Organization produced a chart showing life expectancy by country across the globe. The U.S. ranked # 31. A list produced by our own C.I.A. ranked us even lower, #43. This is well below countries like Japan, Switzerland, Singapore, Australia or Spain. The contrast between our significant health care expenditure and our disappointingly low healthy outcomes result, especially when compared to much of the developed world, seems paradoxical, and begs for an explanation. Fortunately, studies explaining why we rank as we do are readily available. Unfortunately, our representatives appear less interested in digging below the surface of complex challenges when they are not easily translated into simplistic sound bites.
Kristen Beckman, a senior editor on LifeHealthPro.com, serving the insurance industry, compiled a list of nine factors affecting longevity. A number of these suggest answers that could help us solve our paradox. "Gender," "genetics" and "marital status" are considered important factors. However, they won't help explain the discrepancy. "Pre-natal and childhood conditions" is significant, however. The U.S. has the highest rate of infant mortality among high-income countries. Children born in the U.S. have a lower chance of surviving to the age of five than children born in any other wealthy nation. "Socio-economic status" contributes to life expectancy as well. Poverty has an adverse affect on access to medical care and participation in healthier lifestyle habits. In the U.S. 17% of the population lives in poverty. The median for OECD countries is almost half that, 9%. (Steven Schroeder, past president of Robert Wood Johnson Foundation). "Education" also contributes. According to the Center for Disease Control, a 25 year old man without a high school diploma has a life expectancy 9.3 years less than a man with a bachelor's or higher degree. (A study published in the Washington Post in 2008 concluded that life expectancy in the U.S. was on the increase, but only among people with more than 12 years of education.} Ms. Beckman completes her list with "ethnicity," "lifestyle," and "medical technology." Not all of these explain why our outcomes are lower than those in other countries. Other researchers observed that we invest less than other wealthy countries in social programs like parental leave and early-childhood education. While we rank 1st among OECD countries in heath care expenditures, we are 25th in spending on social services. And, perhaps consequentially, among 17 wealthy democracies included in another report, the U.S. has the highest rate of adolescent pregnancy and sexual disease.
The research suggests that pouring money into health care is not the only answer. Experts estimate that, during the last century, modern medical care treatment delivered to individual patients, thru physician and hospital treatment covered by health insurance, has only been responsible for 10-25% of the improvements in life expectancy. The remainder came from changes in the social determinants of health, especially in early childhood. While other countries use governments to improve health, including, but not limited to, the development of universal health insurance, the U.S. has consistently invested less than other wealthy countries in social programs. Medical care can prolong survival and improve prognosis after some serious diseases. However, the social and economic conditions that make people ill and in need of medical care in the first place appear more important. Perhaps we should re-focus our health care discussion on the overall objective and rethink where our investments will do the most good. There are healthy outcomes in many countries that can serve as examples of how to do this.
Saturday, August 12, 2017
Tuesday, August 1, 2017
CONSEQUENCES OF REPEALING OBAMACARE
Ever since last year's election results became known, the congressional majority has labored to repeal and replace the Affordable Care Act, a.k.a. Obamacare, President Obama's signature legislation which went into effect in January of 2010. Aside from attempting to fulfill a political promise seven years in the making, the most significant reasons behind the desire to repeal the law have been "government overreach," budget impact, and the additional taxes levied on high income earners. Moreover, legislators want to use the potential savings realized from repeal to fund another policy objective, tax reform.
Obamacare's major accomplishment was that it pushed the nation's health insurance uninsured rate to a record low 8.6 percent, composed of about 27.3 million people. Those numbers were 16 percent and 48.6 million in 2010. The law helped provide insurance for an additional 21.3 million people. This result was achieved by mandating that nearly all Americans have some form of health insurance or pay a tax penalty, barring insurance companies from declining coverage to people with pre-existing conditions, and authorizing an expansion of Medicaid to nearly all poor adults. (Thirty-one states expanded Medicaid programs with the federal government picking up most of the costs of providing coverage to the newly eligible.)
The most recent analysis by the Congressional Budget Office (CBO), which focused on the current proposal considered by the Senate, to "repeal without replacement," estimates that, when enacted, this legislation would increase the number of uninsured by 17 million in 2018, and 32 million by 2026. The CBO estimate also projected that insurance premiums in the individual market would double, and it suggested that by 2026 most of the country would no longer have an insurer selling individual plans. Its projections assumed that a total repeal would include the end of mandatory insurance requirements, an end to subsidies to help low- and middle-income people purchase individual plans, and, by 2020, the end of federal funding for the expansion of Medicaid to poor adults. It would decrease federal deficits. Most of the savings would be generated by repealing the Medicaid expansion. ("H.R. 1628, Obamacare Repeal Reconciliation Act of 2017," CBO, July 19, 2017.)
While many of the proposed policy nuances may appear convoluted and unnecessarily complex, the elements affecting our personal lives are simple: 1. How will policy changes affect our premiums? 2. How many more of us will end up uninsured? 3. What effect will this condition have on our lives, individually, cumulatively, and on the viability of our support network?
Simply put, the uninsured have very limited access to healthcare Their care will generally come too late. They will be sicker and die sooner One in five uninsured adults will go entirely without medical care due to cost. They won't receive preventive care and services for major health conditions and chronic diseases. ("Key Facts about the Uninsured Population," Kaiser Foundation.)
A 2003 study published by the National Academic Press, entitled "Social and Economic Costs of Uninsurance in Context," provides even greater detail. Its findings show that 18,000 will die prematurely, 8 million uninsured with chronic illnesses will receive fewer services and have increased morbidity, 41 million adults and children will be less likely to receive preventive and screening services, and people living in communities with higher than average uninsured rates will be at risk for reduced availability of health service and overtaxed resources.
Other analyses of Obamacare repeal suggest that repeal of tax credits and Medicaid expansion could lead to a loss of 2.6 million jobs in 2019, and cuts in federal spending for health reform would likely cause serious economic distress for states. "If replacement policies are not in place, there will be a cumulative $1.5 trillion loss in gross state products, and $2.6 trillion reduction in business output from 2019 thru 2023. ("Repealing Federal Health Reform: Economic and Employment Consequences for States." This study was financed by the Commonwealth Fund.)
We should also consider the plight of hospitals. The "Emergency Medical Treatment and Labor Act," passed in 1985, requires that hospitals treat all individuals in need of emergency care regardless of their insurance status. When people are uninsured hospitals effectively serve as insurers of last resort by providing care to uninsured patients who cannot afford to pay for their medical bills. The estimate is that each additional uninsured person costs local hospitals $900 per year. In 2013 alone the cost of uncompensated care was $84 billion. ("Who bears the cost of the uninsured? Non-profit hospitals." Kellog Insight, North-Western University, June 22, 2015.)
This all boils down to a question of priorities. How important is it to us, as a society, to protect those who can least afford it? Do we really think that politically flaunting "access" to health care equates with actually making care available and affordable for all? Shouldn't we consider the consequences simplistic political calculations impose on our personal lives and on the deteriorating health care support structures surrounding us? Do we really want our representatives to ignore these consequences because they promised they would repeal a law that has been on the books for seven-plus years, or because they need to realize a savings so they can squander it on tax reductions for some who don't need it?
The answer appears obvious. This can't just be about economics and politics, this is a moral issue as well.
Obamacare's major accomplishment was that it pushed the nation's health insurance uninsured rate to a record low 8.6 percent, composed of about 27.3 million people. Those numbers were 16 percent and 48.6 million in 2010. The law helped provide insurance for an additional 21.3 million people. This result was achieved by mandating that nearly all Americans have some form of health insurance or pay a tax penalty, barring insurance companies from declining coverage to people with pre-existing conditions, and authorizing an expansion of Medicaid to nearly all poor adults. (Thirty-one states expanded Medicaid programs with the federal government picking up most of the costs of providing coverage to the newly eligible.)
The most recent analysis by the Congressional Budget Office (CBO), which focused on the current proposal considered by the Senate, to "repeal without replacement," estimates that, when enacted, this legislation would increase the number of uninsured by 17 million in 2018, and 32 million by 2026. The CBO estimate also projected that insurance premiums in the individual market would double, and it suggested that by 2026 most of the country would no longer have an insurer selling individual plans. Its projections assumed that a total repeal would include the end of mandatory insurance requirements, an end to subsidies to help low- and middle-income people purchase individual plans, and, by 2020, the end of federal funding for the expansion of Medicaid to poor adults. It would decrease federal deficits. Most of the savings would be generated by repealing the Medicaid expansion. ("H.R. 1628, Obamacare Repeal Reconciliation Act of 2017," CBO, July 19, 2017.)
While many of the proposed policy nuances may appear convoluted and unnecessarily complex, the elements affecting our personal lives are simple: 1. How will policy changes affect our premiums? 2. How many more of us will end up uninsured? 3. What effect will this condition have on our lives, individually, cumulatively, and on the viability of our support network?
Simply put, the uninsured have very limited access to healthcare Their care will generally come too late. They will be sicker and die sooner One in five uninsured adults will go entirely without medical care due to cost. They won't receive preventive care and services for major health conditions and chronic diseases. ("Key Facts about the Uninsured Population," Kaiser Foundation.)
A 2003 study published by the National Academic Press, entitled "Social and Economic Costs of Uninsurance in Context," provides even greater detail. Its findings show that 18,000 will die prematurely, 8 million uninsured with chronic illnesses will receive fewer services and have increased morbidity, 41 million adults and children will be less likely to receive preventive and screening services, and people living in communities with higher than average uninsured rates will be at risk for reduced availability of health service and overtaxed resources.
Other analyses of Obamacare repeal suggest that repeal of tax credits and Medicaid expansion could lead to a loss of 2.6 million jobs in 2019, and cuts in federal spending for health reform would likely cause serious economic distress for states. "If replacement policies are not in place, there will be a cumulative $1.5 trillion loss in gross state products, and $2.6 trillion reduction in business output from 2019 thru 2023. ("Repealing Federal Health Reform: Economic and Employment Consequences for States." This study was financed by the Commonwealth Fund.)
We should also consider the plight of hospitals. The "Emergency Medical Treatment and Labor Act," passed in 1985, requires that hospitals treat all individuals in need of emergency care regardless of their insurance status. When people are uninsured hospitals effectively serve as insurers of last resort by providing care to uninsured patients who cannot afford to pay for their medical bills. The estimate is that each additional uninsured person costs local hospitals $900 per year. In 2013 alone the cost of uncompensated care was $84 billion. ("Who bears the cost of the uninsured? Non-profit hospitals." Kellog Insight, North-Western University, June 22, 2015.)
This all boils down to a question of priorities. How important is it to us, as a society, to protect those who can least afford it? Do we really think that politically flaunting "access" to health care equates with actually making care available and affordable for all? Shouldn't we consider the consequences simplistic political calculations impose on our personal lives and on the deteriorating health care support structures surrounding us? Do we really want our representatives to ignore these consequences because they promised they would repeal a law that has been on the books for seven-plus years, or because they need to realize a savings so they can squander it on tax reductions for some who don't need it?
The answer appears obvious. This can't just be about economics and politics, this is a moral issue as well.
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