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Universal health insurance: Private or government?
Health care reform will be widely debated in ever-greater detail as the new presidential campaign progresses. A central issue, particularly in the democratic primary, will be the question of whether every citizen will be guaranteed medical care coverage, regardless of ability to pay.
Besides the question of how our nation might finance the potential unlimited costs of universal health insurance, what are the ethical and moral issues surrounding this “entitlement?” Will health care become “a given right?”
Needs vs. ability to pay
As physicians, we have traditionally favored medical care based on need and not ability to pay. We also have supported the idea that children, in particular, should not be denied care because of their economic situation or insurance status.
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But as medical care costs continue to climb, the question of whether it is possible to provide one level of health care for all becomes more pressing. Oregon and other states have tried this, which some might view as appropriate, others as a form of rationing.
What seems clear is that the method of financing a new comprehensive health care plan would go a long way towards deciding the shape of any reform.
The tough questions
In coming to grips with universal coverage, key ideas that must be thrashed out in this presidential campaign will include the following:
- Will the program that eventually is adopted be government financed and regulated? If so, what can we learn from government-run programs outside the United States?
- Will Americans believe an entrenched governmental bureaucracy can run an efficient health care system?
- Is there a place for deregulation — a private system without “mandates?”
- Will Americans believe health insurance companies will evolve without overzealous greed? Will these private companies continue to want higher profits?
- Can supply and demand in a capitalistic system create an equitable and profitable system for treating the sick and dying for the entire population?
- How should we finance universal coverage for programs such as drug and alcohol addiction, obesity surgery, mental illness, transplants, unlimited chiropractic and acupuncture treatments?
- Will underinsured individuals voluntarily budget for their health care needs or will they dismiss the risk of illness and accident for themselves and their family, and choose to spend the funds that could go to insurance in other areas? Only disciplined individuals will voluntarily obtain and provide for their own and families medical care.
- Should those who do not prepare or make long-term decisions in a voluntary system get a safety net? Does a health care safety net for everyone mean more government rules, subsidization and risk pooling of large groups? Will it involve means testing rather than personal responsibility for medical payments? What additional taxes will be needed to finance it?
Health care reform is far overdue, but where are we headed? Does anyone have confidence that our politicians and political system will solve our health care coverage dilemma?
Elusive answers
Whatever happens, as physicians, we will provide the care under whichever system evolves.
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We will buy medical care ourselves and try to run our small businesses (medical practices) with increasing overhead in the face of likely diminishing reimbursements. And we will most likely be taxed more to pay for whatever evolves. Unfortunately, I do not think there is a chance of any real and meaningful solutions for our current health care crisis during the remaining years I have in practice.
I am reminded of a quote from Alexander Tyler, a Scottish history professor at the University of Edinburgh, speaking about the fall of the Athenian Republic. I hope that one of his statements, taken a bit out of context, does not apply to us. “A democracy will continue to exist up until the time that voters discover they can vote themselves generous gifts from the public treasury.”
How much is enough?
Having one level of unlimited medical care for everyone will challenge our ability to finance it. We can agree that we need a better system for many of our citizens.
But I feel we must decide how much of our resources will go for health care and then develop a system that works within some defined constraints, and offers individual involvement, accountability and risk sharing.
Douglas W. Jackson, MD
Chief Medical Editor