When Insurance Isn't Enough: What is "Universal"?
by The Opportunity Agenda, Wed Jul 29, 2009 at 08:17:53 AM EDT
If you've been following my occasional blogs arguing for a more robust vision for health care reform, often titled "When Insurance Isn't Enough," you know that I start from a values-based framework, the idea that the opportunity to reach our highest attainable standard of health is a right inherent to our dignity as human beings. And then I usually go on to highlight an aspect of health care that isn't getting the sort of coverage or discussion that it should be, given the almost myopic focus on cost-cutting and insurance coverage; in the past, I've highlighted preventative care, healthy infrastructure like walkable communities, care coordination, and enabling services. Today, I'd like to take a step back and think about one of the keystones of the current push for reform: the idea of "universal" health care.
Literally, "universal" means "applicable everywhere or in all cases." The question is, what do the various actors in the health care reform debate mean when they use the word "universal"? President Obama has said that "universal" health care is one of his primary goals for any reform, as have many Congressional leaders and public interest advocates. Do they actually mean "universal," or is this an appropriate time to reference that oft-quoted scene from the Princess Bride, where after having dealt with Vizzini calling every occurence "inconceivable" all night long, Inigo Montoya remarks, "You keep using that word. I do not think it means what you think it means."
The idea of "universal health care," or "health care in all cases" can be thought of as satisfying a two simple propositions:
1. Health care is provided when needed in all cases, regardless of who needs the care.
2. Health care is provided when needed in all cases, regardless of what type of care is needed.
Each proposition has corollaries. Health care regardless of who needs care means that everyone living in the United States should receive necessary care and be free from discrimination based on race, gender, language, national origin, disability or other demographic characteristic. Health care regardless of what type of care is needed means that a "universal" health care system provides comprehensive coverage, including but not limited to primary, preventative, wellness, reproductive, mental health, and dental care.
So back to whether folks are using the word "universal" in a literal sense. Even in the current, narrow frame of the health care reform debate, which focuses simply on insurance coverage, it is doubtful that any of the current reforms being proposed would lead to insurance coverage "in all cases." Certainly, as a baseline, we know from state reform efforts that a mandate on all employers to provide insurance coverage can still leave up to 8% of the population uninsured (Hawai'i), and even a mandate on individuals can leave up to 3% uninsured (Massachusetts). Undoubtedly better than the 15% nationwide, or 45 million Americans who are uninsured, but we'd still have anywhere from 9 to 24 million uninsured Americans at 2009 levels.
Staying within the narrow frame of insurance for just another moment, the treatment of immigrants in the current reform proposals is another major barrier to providing insurance coverage "in all cases." There are approximately one million new legal immigrants coming to the United States each year, and some current proposals would restrict the ability of legal immigrants to benefit from the same health care insurance system that citizens do. This is, in fact, already the case; since 1996, legal immigrants have been subject to a 5-year waiting period for public insurance options, including Medicaid. Until this past year's reauthorization of the Child Health Insurance Program, even legal immigrant children were uneligible for CHIP (or S-CHIP) for their first five years. The Senate Finance Committee is currently considering not only maintaining the five-year "waiting period" for legal immigrants to benefit from Medicaid, but excluding them from any subsidies in a new insurance exchange that will be essential to making health care affordable.
And of course, current insurance reform legislation does not envision enabling coverage for the 12 million undocumented immigrants liviing in the United States.
Of course, having an insurance card in your pocket doesn't mean that you'll get health care. So when we talk about "universal" health care, or the ability to receive health care "in all cases," insurance reform is insufficient if it perpetuates the status quo of underinsurance and unmanagable out-of-pocket costs, and if it only treats cases reactively and doesn't provide preventative and wellness care. It is a stretch to call a health care system "universal" when it is substantially limited in the types of care provided; current proposals that don't include dental care, mental health care, or reproductive health care won't provide health care "in all cases." Let's take these one at a time.
In addition to the 45 million uninsured, there are 25 million underinsured Americans (though that number is from a year ago, and likely higher now). Underinsurance is, in many ways, the core example of why insurance isn't enough: you can have an insurance card, sure, but it's no guarantee that if and when you need health care, the insurance will pay for the care you need. High deductibles, co-pays, and lifetime benefit caps mean that too many Americans facing chronic illnesses or tragic injuries find their pain magnified in by medical bills that would be unbelievable if they weren't so common. President Obama and others have said that solving the health care crisis is key to solving the current economic crisis, and this isn't an understatement, as in many ways the health care crisis caused the current economic downturn. Medical crises and the ensuing bills are responsible or partly responsible for 7 out of 10 home foreclosures. Amidst all the recent focus on "cutting costs," early talk of making health care more "affordable" seems to have evaporated, a dangerous development for those hoping to see health care reform succeed. The study which found that medical crises are one of the causes of 70% of foreclosures looked at middle-class families, with a median income of $52,000 among survey respondents. Considering that the out-of-pocket medical costs that led to foreclosure (for more than a third because of diversion from mortgage payments to medical bill payments) was a median of $1,250, and a median of $5,200 for those who stated that medical bills were the specific cause of the foreclosure, it is disturbing that current Congressional proposals appear to support this type of underinsurance, with the House proposal creating an annual cap on "cost-sharing" (i.e., total out-of-pocket costs) at $5,000 per individual, or $10,000 per family.
One area in which the House bill looks more expansively at health care reform and promotes the concept of comprehensive care is around preventative and wellness care. I've commented before on some positive House provisions that would invest in healthy community infrastructure. The bill also takes steps to reduce bureacratic and insurance company barriers to receiving preventative care by expanding the capacity of the U.S. Preventative Services Task Force and including their recommended preventative services in public insurance plans and private insurance plan on the proposed Health Insurance Exchange, as well as by eliminating co-pays for preventative care. There is, undoubtedly, more that can be done to improve preventative care, including mainstreaming the medical home model (the House bill proposes a pilot program) and supporting care coordination. Care coordination has been highlighted recently in the successes of Vermont's health care reform, where coordination between primary care physicians, mental health counselors, nutritionists, and social workers has led to a 30% decrease in emergency room admissions. It will be important for advocates of "universal" health care to keep an eye on these provisions when the reconcilation of House and Senate proposals occurs.
In addition to making sure that everyone can get the health care they need without losing their house, and before a condition worsens and requires an emergency room, "universal" health care means that everyone can get needed health care regardless of the type of health care. Two major types of care have been excluded or soft-pedaled in the current proposals: dental and reproductive health care. Dental care may be the victim of the current obsessive discussion concerning cost-cutting, but regardless of the reason for its exclusion, ignoring the need for dental care is a mistake: 26 million American children lack dental care insurance, as do 82 million adults. Dental care is both primary and preventative care; as the Mayo Clinic notes, "your mouth is a window to your body's health," gum disease can make your body more vulnerable to bacterial infection, lead to premature births, and even possibly be related to cardiovascular diseases such as heart attacks and strokes. While the Senate Health, Education, Labor and Pensions (HELP) Committee's bill included dental care for children, it did not for adults. The summary of the House bill's benefits does not appear to include dental care among its guaranteed benefits.
Reproductive health care is a type of care that current proposals dance around. The House bill includes "maternity care" as a guaranteed benefit, alongside preventative care, but it is not clear whether reproductive health care, both preventative, primary, and specialized, is or will be covered in the eventual package of guaranteed services. The approach by those drafting the bill seems, at the moment, to be to claim that they are deferring the details of services to the Secretary of Health and Human Services as a regulatory matter, and to avoid discussing abortion as a guaranteed service. Anti-abortion advocates want explicit provisions that exclude, at the least, abortion services. The Guttmacher Institute estimates that 82% of private employer-based health care insurance plans cover abortions, meaning that if such an explicit provision were included banning abortion services through the Health Insurance Exchange, many would lose the benefit. Reproductive health care is, of course, broader than just maternity care (obstetrics) or abortion; it includes gynecology; education, prevention, and treatment of sexually-transmitted infections; contraception and family planning; and sex and sexuality education. A health care system that excludes reproductive health care, dental care, or specific types of mental health care will, by definition, fail to provide necessary care "universally."
I began this post by mentioning a values-based framework. Talking about the values that are important to us in a health care system leads us to expand the conversation beyond the current consumer-based, cost-cutting discussion of health care and toward a discussion of how we can make Americans healthier. My interest in what "universal" actually means isn't academic; universality is very much a value, encompassing Americans' belief in equality, both bodily and economic security, and community. A major part of our health care crisis is that, somewhere along the way, Americans began talking about health care as a commodity, like a car or washer/dryer, rather than as a right and a public good. As the recent, much-discussed Atul Gawande article on physician culture in McAllen, Texas underscores, how we think about our relationship with the health care system, the health of others in our community, and the health of all Americans has very real impacts on the health care we'll end up with.
*Amnesty International USA, National Economic and Social Rights Initiative, National Health Law Program, The Opportunity Agenda: Health Care is a Human Right Coalition
*The Opportunity Agenda: Public Opinion Research-How to Discuss Health Care Within a Human Rights Framework
*The Opportunity Agenda: Talking Points-Health as a Human Right (2008)
Read more at The Opportunity Agenda website.