Why is Health Care Reform so Hard?

Harold M. Koenig, MD

Vice Admiral, Medical Corps, United States Navy, Retired

America has been struggling with how to reform its health care system for several decades now.  The principal arguments made for why we need reform are:

·       Costs, we spend more on health care per capita than any other nation

·       The uninsured, 15% of our population historically has had no health insurance coverage

·       Shorter life expectancy than many other highly developed nations that spend much less per capita on health care than we do

Since the end of WW II health care inflation has exceeded the general cost of inflation and in recent decades has exceeded it by 2.5 - 3 times.  Soon it will consume 20% of our Gross Domestic Product.  Many believe this is not sustainable. 

Before WWII and during the Great Depression people paid cash, or bartered, for their health care.  If they couldn’t pay or barter for it, they usually went without.  During WW II there was a wage/price freeze. Employers could provide better benefits to attract and retain workers, so health care and pension benefits were offered. 

After the war employers continued to provide health care benefits.  Soon nearly two-thirds of Americans had employer provided health insurance.

Those who weren’t in the work force either paid for health care out-of-pocket, they got “charity” care or they just didn’t get it.  Amongst this latter group were many of the nation’s elderly. As part of the Great Society program of the Kennedy-Johnson administration, a program to pay for hospital care for those over 65, Medicare, was started in 1965.  Since then Medicare has been expanded with a cost-shared program to help pay for doctor bills (Medicare B), a managed care option (Medicare C) and most recently, a prescription drug benefit (Medicare D).  Today there are 40 million people over 65 enrolled in Medicare and another 8 million enrolled in another addition to the program for the disabled.  Between 1946 and 1964, 76 million Americans were born, known as the baby-boomers,  and they are beginning to retire.  Medicare costs will soon increase dramatically and with it the nation’s total health care bill.

Medicare coverage, employer provided coverage and those who pay for their own health insurance still leaves the nation with many without coverage.  Medicaid is a federal-state program for low-income individuals that meet certain criteria.  The State Children's Health Insurance Program (SCHIP) – more commonly known as the Children's Health Insurance Program (CHIP) – is a program administered by the United States Department of Health and Human Services that provides matching funds to states for health insurance to families with children. The program was designed with the intent to cover uninsured children in families with incomes that are modest but too high to qualify for Medicaid.

Even with all these programs we still have ~ 15% of people without coverage.  How to cover them is another major part of the financing problem.

That Americans have a shorter life expectancy than people living in over 40 other nations and that we pay more per capita for health care is often used as a reason why we need health care reform.  But a better understanding of these statistics is necessary before relying on them.  According to the US Census Bureau there are 308 million of us living in America now.  That’s over 100 million more than were here when the Great Society program got underway less than fifty years ago – meaning we’ve been adding about two million people a year.  Much of that population growth has not been from our indigenous birth rate; it is from people immigrating here.  Our fertility rate has been barely, and is probably now, insufficient to maintain our population numbers.  Today one of every eight of us living in this country was not born here – that’s forty million people.  Most of those people came here for the same reasons our ancestors did, they are looking for a better life for themselves and their families, and most of them hopefully will find it.  They carry with them the burden of disease brought from their homeland, and that takes a toll.  Most of them don’t live as long as we who were fortunate enough to be born here do.  They count in our life-expectancy statistics.  Over a million of them come here every year, and most stay.  No other nation has immigration like this, in fact, many have the opposite, emigration and a lot of their emigrates are heading here.

We also have regional differences in life expectancy, which we have a fair degree of understanding about, as we do gender and ethnicity differences.  Most of the explanation for these differences is because of cultural and educational differences rather than health care availability.  Better access to health care is not going to increase life expectancy near as much as are improvements in education.

One short comment about physicians.  When I graduated from medical school I did so along without about 8,000 others.  When the Great Society program was being built one of the elements in it was to double the output of physicians because the designers knew that it was going to take a lot more doctors to take care of all the elderly – older people need a lot more medical care.  So, over the next decade the number of medical school graduates doubled – to 16,000 a year.  Today we graduate about 17,000, not near enough.  We need another massive increase in physician output to take care of the 40 million people who don’t have health care insurance today and all the others heading our way.

So, this is why it’s so hard to do health care reform.  It is going to cost a whole lot of money, and we haven’t figured out how to convince the population of this great nation that we have to do this.  We need to educate people about why this is important and what it is going to take to do it.  That is the task before us.