During this campaign season, there will be many more cursory calls to make health care accessible to every American. Unlike a lot of political promises, this one is actually attainable - now, perhaps more than ever. But it will only happen if we implement a model of essential health care for the uninsured and get tough with clinicians and patients alike.
The ranks of the uninsured have grown steadily in recent years. Figures released in August by the U.S. Census Bureau showed slight improvements in 2007, prior to the downturn in the economy. This reflects transfers to Medicaid as the poor become poorer, and transfers to Medicare as the population ages. The federal/state safety net is becoming overburdened, and the uninsured remain at over 15% of the U.S. population - one in six of us. Many of the uninsured are young people whose families cannot afford coverage; some are "free riders" who eschew the high costs of premiums, figuring they are healthy enough to get by without insurance, hoping for a governmental safety net if they have an emergency.
Access to affordable health care remains a national crisis. The nearly 46 million people in this country who aren't covered - either by choice or circumstance -- typically delay care until their health problems become acute, resulting in otherwise unnecessary hospitalizations and expensive treatments.
The uninsured cost society upwards of $200 billion dollars a year when factoring in both the direct cost of providing them with medical care and the indirect costs of disability and lost productivity.
Every day, we are tantalized by news of potential medical breakthroughs and incredible new technological advancements, but good health still starts with the basics - early care that prevents chronic illnesses from escalating into crises, and promotes a healthy lifestyle that makes those chronic illnesses less likely to develop in the first place.
We need a system in which everyone has access to these essential services.
Universal coverage will reduce the cost to all of us.
So how do we go about achieving this lofty goal? My practitioner colleagues at the Columbia University School of Nursing and I have outlined a plan that we believe is workable and affordable. This is an essential benefit plan, providing cost-effective services required by the majority of the enrollees, with reasonable premiums due to the benefit design, broad enrollment and evidence-based decision-making.
This plan would be privately administered and community-based. It would offer affordable cost for a group of enrollees that mirrors the risk in the general population of their region. It would be a strictly in-network plan.
The price tag, in 2008 dollars, would be a low premium (with the understanding that "low" is a relative term in the world of health care) of around $2,500 per year and a similarly priced cap on out-of-pocket expenses, including prescription drugs.
A few key features: The plan would charge a high co-pay -- upwards of $100 - for an emergency room visit that did not result in hospitalization in an effort to discourage patients from seeking costly, nonessential care in the ER. Conversely, a low co-pay of approximately $20 for preventative care services - including screening, immunizations, etc. - would encourage patients to seek care that has long-term health and financial benefits. Among the uncovered services would be transplants, which are extremely costly and only benefit a very small percentage of enrollees. Those who need these services would have to seek additional coverage, Medicare disability coverage or Medicaid, if they're eligible.
A fundamental change in clinician and patient behavior will make this idea work. Doctors and nurse practitioners must start saying no to patients' demands for any care, medication, testing or therapy that is not needed or proven to be effective. Care has to be based on scientific outcomes, not patient demands or clinician preferences.
If we want to insure 100% of the population, we will need to require everyone to have at least basic coverage, just as we require drivers to carry car insurance. This mandate is not without its implications, but it is essential to making universal insurance affordable by making sure that even the healthiest people are included in the pool.
States and the federal government now subsidize much of the care of the uninsured; those same dollars could provide premium subsidies for those who are least able to afford the cost.
For those who are already insured, the savings benefits for enrolling the uninsured in essential health plans would be substantial. Hidden in all insurance premiums is the cost of treating the uninsured. Take away that cost, and suddenly premiums are far less daunting.
Our health care system is broken, and we can no longer afford the financial or human toll of inaction. Will we finally take this issue head on and implement a pragmatic plan to cover the uninsured, or just pay it more lip service for another four years?