FIGURE
I remember the days when health care providers intently debated whether 'health care for all' should be a right or a privilege. Current realities make the option of debating that question sound luxurious. Today, we ration health care depending on age, type of illness, employment status, geographic residence, and income. The number of uninsured Americans has risen to 44 million people, not including the millions who are intermittently covered as they change employment. The poor are often unable to access care even when they have been accepted for government supported programs, due to a paucity of available providers. States have cut back eligibility, slashed benefits, and hiked co-payments for Medicaid.
Soaring Costs
Health care costs are soaring. The question of how much insured Americans will pay for out-of-pocket expenses has become a major one for companies, labor negotiators, and politicians. Managed care has cut reimbursement and limited covered expenses. The insurance premium is rising close to 20% per year for many companies. Employers today are passing increased deductibles, co-pays and premium contributions onto employees. American workers are spending more for their share in health care costs (in many cases up to 50% in the last 3 years).
Meanwhile, the Medicare payment system has huge loopholes that provide disincentives to improving care. 1 Specialty hospital growth has soared (e.g. with $20,000 profit for each coronary bypass) while generalist hospitals lose money on treating simple pneumonias. 2 The new landmark Medicare legislation opens up new questions. Will the Medicare premium rise precipitously? Will insurers be lured into the Medicare market? Will private plans cost more than traditional Medicare? Will employers scale back retirees' health benefits knowing they can get a basic drug benefit from Medicare?
Why Not a Change?
If we continue our market-driven system, America's health care will continue to be complex, chaotic and rationed. Insurers will continue to avoid unprofitable patients and shift costs back to patients or other payers. Administrative costs will continue to soar, taking resources away from clinical services and depositing them in the hands of consulting businesses, administrative companies, and marketing firms. 3
Why not a fundamental change in how the United States delivers health care? A recent article in JAMA4 proposes an expanded and improved version of traditional Medicare, which would cover every American for all necessary medical care. The impressive list of drafters propose that this single payer system would get rid of the private health insurance industry, abolish Medicaid, and eliminate co-pays and deductibles for both drugs and medical visits. With a single payer system, we could save $209 billion a year by eliminating the high overhead and profits of the private insurance industry (rates that are likely to rise even higher with the new Medicare legislation). Critics complain that similar models in Canada cause long waits for patients. But we have long waits here in the U.S. already 5, and the Canadian system is under-funded, not structurally wrong.
APNs must remain vigilant and critically evaluate each proposal to avoid plans that merely perpetuate the current health care power and money brokers. APNs must ensure that they support only those plans offering fair competition in the medical marketplace by guaranteeing a patient's right to choose among all qualified health care professionals, not just participating physicians. Upon initial perusal, however, the single-payer national health insurance plan appears to have strengths. What do you think?
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