More Marketplace Medicine
By David Moberg
This year's Democratic primaries looked like an opportunity for an illuminating and timely debate on health care. After all, the system is unraveling into crisis, with the numbers of uninsured and dissatisfaction among those who are insured both growing--despite the longest period of economic growth in the nation's history. Health care is a top voter concern, and voter sentiment on health issues clearly favors the Democrats.
Yet for all their lofty proclamations about the need for universal care, neither Bill Bradley nor Al Gore is offering a plan that will fix what ails the system--and, in some ways, they could make things worse. It's a sad commentary on American politics that the presumably more liberal candidate in the race, Bradley--who has said he wants to revive the Democratic Party with a plan guaranteeing health care for all--is offering a variant of proposals from the right-wing Heritage Foundation and has won support from the insurance lobby.
Here's the heart of the issue: The most serious problems of the health care system stem from relying on the private marketplace and for-profit corporations. But the Democratic proposals attempt to tinker around the edges while preserving the basic system and increasing public subsidies to the for-profit insurers and providers. While Republicans want to privatize the system even more, most Democrats--even as they offer tepid defenses of Medicare--are seduced by the misguided idea that private companies and competition can cut costs and increase consumer choice. That approach only produces fragmentation, high bureaucratic costs and poor care.
The framework for the current debate was set by the failure of Clinton's comprehensive health care reform plan in 1993. Clinton thought he could avoid a fight by shunning advocacy of a national health insurance program--like Canada's "single-payer" system--and instead incorporating the big insurance companies and HMOs. But Clinton failed to launch a strong grassroots political campaign for his plan. And the plan was so complex and flawed that it left many citizens confused, worried and vulnerable to the counterattack unleashed by industry.
Democrats learned the wrong lesson from this experience. In elite Beltway circles, the prevailing belief is that dramatic reforms can't be passed and don't have public support. This is reflected in Gore's strategy: Though he wants to move toward access to universal health care, he says, "we have all learned that we cannot overhaul the system in one fell swoop." Thus the only alternative is incremental reform. "The current wisdom, when you've got two-party politics, is that you better think practically and do so in a way that doesn't incur the wrath of large stakeholders in the health care system," says Ron Pollack, executive director of Families USA, a health care reform think tank.
Yet it is essential, if the United States is ever going to get good, reasonably priced, universal health care, to take on those large stakeholders--especially the insurance and pharmaceutical industries. In 1993, Clinton hoped his compromise would help him avoid right-wing attacks on "big government." But by now one thing should be perfectly clear: Any government health care proposal, unless it is a no-strings-attached subsidy of private health industry businesses, will be attacked as "big government," no matter how modest it is. (Witness the latest television ad campaign against the highly popular idea of Medicare prescription drug coverage as a threat of "big government in your medicine cabinet.") So would-be health care reformers might as well be prepared from the beginning to defend government and attack the profiteers. It isn't really that hard to do.
According to an October Kellogg Foundation survey, 80 percent of Americans, including large majorities of Republicans, already think that health care should be everyone's right. The survey also found overwhelming public support--around 90 percent--for the idea that everyone should be guaranteed prenatal care, childhood immunizations, routine check-ups, emergency room visits, mental health care, eye care, dental care and prescription drugs. Only 15 percent of respondents said the health care system itself was "in good health," while 35 percent characterized it as in "critical condition" or "terminally ill."
The public also profoundly distrusts insurance companies: By 2 to 1, those surveyed said managed care decreased the quality of health care. By wide margins, they denounced the insurance industry as having too much control over health care and complained of companies restricting patient choice and inadequately reimbursing patients. Fully 85 percent agreed that "much of the expense of health care in this country is created by insurance bureaucracy."
These opinions about the shortcomings of profit-oriented, market-driven medicine are supported by recent research. Despite steady economic growth, the number of Americans without insurance grew by 1 million people every year in the last decade, up to more than 44 million in 1998. Yet contrary to conventional wisdom, private insurers and hospitals are not more effective at holding down costs. Over the past two fiscal years, Medicare costs rose 0.5 percent, but private insurance premiums increased more than 15 percent. (This has led to new projections that Medicare will be solvent at current rates for another two decades.)
Profit-oriented HMOs, the darling of privatizers, have proven to be a source of one-time cost savings and long-term problems. A Harvard University study published in the Journal of the American Medical Association last year concluded that investor-owned HMOs scored worse on all quality measures than non-profit HMOs. Studies have found that HMOs cost Medicare about 6 percent more for each beneficiary than conventional fee-for-service plans, even though HMOs selectively enrolled healthier older people, and, more recently, began cutting back benefits or dumping Medicare patients altogether. In recent years, there also have been revelations of massive fraud and overcharging by managed care companies and investor-owned hospitals.
Meanwhile, Americans are paying hugely inflated prices for prescription drugs. Because its national health service bargains with companies to win reduced prices, Canadians paid roughly one-third less for the same drugs as Americans, according to a study released last summer. If the United States struck the same deal, Americans would save more than $16 billion a year. While HMOs often bargain to reduce prices, their savings are far less than what the Veterans Administration wins, and the drug companies charge the highest prices of all to the one-fourth of Americans without prescription drug insurance.
Bradley knows the system is wasteful. In announcing his health care plan, he noted that administrative costs add up to $300 billion a year. But his proposal would rely on that system even more heavily. He would require parents to enroll children in private insurance plans (if they are not covered through an employer plan) and provide subsidies according to income. He would eliminate Medicaid and offer adults an opportunity to enroll with private insurers offered through the Federal Employee Health Benefits Plan, providing a refundable tax credit scaled to their incomes and tax deductions for all insurance premiums.
Trying to inform and enroll individuals in this fashion would incur huge administrative and outreach costs--possibly eating up 40 percent of premium costs, compared to 5 percent of premiums under big corporate plans, according to Economic Policy Institute health economist Edie Rassell. The reimbursements are likely to be inadequate, leaving many families to pay more out of pocket or unable to afford insurance. Also, many employers will be tempted to drop insurance for their workers, pushing them into Bradley's plan and pocketing the money they now spend on employee insurance.
Gore's plan, while less ambitious, relies on many of the same inefficient, ineffective mechanisms. It would expand the Children's Health Insurance Plan, a Clinton/Gore initiative to provide health insurance to poor kids--even though during CHIP's first two years the number of uninsured children increased dramatically, partly as a result of welfare reform. Both Gore and Bradley hope to offer prescription drugs through Medicare, but the program would be optional and rely on private insurers--the least effective method, but one designed to avoid political confrontation with the drug companies.
The candidates' caution reflects not only the typical clinging to the supposed political center, but the absence of strong, coherent popular movement for national health insurance. However, after a period of retrenchment, the movement for a single-payer insurance system is growing, and support among health care professionals for national health insurance is expanding. But the key ingredient--support from organized labor--is still missing. There also are several state initiatives, including a solid multiyear campaign to enact a statewide single-payer system in Maryland.
One of the most promising notions is to build on the appeal of Medicare by improving it--adding prescriptions and reducing patient out-of-pocket payments, for example--and expanding it to include everyone. "Medicare for all" is an idea that is easily understood and familiarly American. As numerous studies have demonstrated, it is possible to pay for both the improvements and the expansion largely through savings-by eliminating administrative overhead and bargaining for lower drug prices, for example. If "Medicare for all" seems too ambitious, then a "Medicare for kids," automatically enrolling every child under 18, might be more politically appealing. This would be one of the few incremental reforms that could help break the grip of the marketplace and be a stepping stone to Medicare for everyone.
Regardless of the research data and opinion surveys, most politicians will not embrace real reform. There will be no significant progress until there is a massive popular movement expressing the already well-established belief that the government should guarantee everyone decent health care and directly confronting the corporate powers and market ideology that are the real obstacles to this goal.
David Moberg is a senior editor of In These Times.