Debate #2: To provide an effective and just health care system and to forestall societal strains caused by the aging Baby Boomers, a Canadian-style government-sponsored, one-payer universal health insurance system should be instituted

I am pleased to report to Canadians that the often-overheated rhetoric about Medicare’s costs, effectiveness and viability does not stand up to scrutiny. Our health outcomes, with a few exceptions, are among the best in the world, and a strong majority of Canadians who use the system are highly satisfied with the quality and standard of care they receive. Medicare has consistently delivered affordable, timely, accessible and high quality care to the overwhelming majority of Canadians on the basis of need, not income. It has contributed to our international competitiveness, to the extraordinary standard of living we enjoy, and to the quality and productivity of our work force.

This sentiment is also shared by many Canadian patients.  When asked, 80% of Canadians would not want to go to a medical system like the one provided in the United States, which shows Canadian’s satisfaction with the healthcare system overall.  

        As many look to the north for ideas for a new healthcare program, an equal number in the United States do not feel large changes need to be made.  Proponents of the United States system site Medicare and Medicaid as success stories, and believe the current health plan should remain in tact with little or no changes.  The healthcare system of the United States contains three major subsystems, Medicare, Medicaid and employer-sponsored programs.  Each program has its strong and weak points.

The federal government runs Medicare, which provides healthcare assistance to those over 65 years of age and people with permanent disabilities.  Medicare is separated into two parts, part A and part B.  Part A is mainly financed by payroll taxes, and covers inpatient hospital stays.  Part B covers physicians visits and outpatient care, as well as in-home care, (which requires a small premium and co-payment, and is voluntary).  Part B of Medicare also includes preventative medicine such as mammographies and other cancer screenings.  Medicare succeeds in providing the minimal necessary assistance to the elderly residents of the United States.

Opponents and critics of Medicare cite the huge expense as a major downfall.  Medicare is one of the government’s largest expenditures.  In 1970, the government consumed approximately 3.75% of the federal budged, and in 1995 consumed 10.5% of the budget.  In 2000, the federal government spent 250 billion dollars on Medicare.  These costs are also predicted to rise in the future.  Critics of the program question the consistently rising costs, and wonder when they will level off.  The allocation of Medicare funds is also a frequent point of debate.  “Some claim that more resources should be freed up for children, others that too much public money is spent on the elderly…Critics argue that the program inadequately meets the needs of the aged and disabled”.  

Excessive rationing of healthcare for the elderly has been a rising trend in the United States. This has spurred legal battles across the country over legal responsibility of the HMOs to provide adequate care for their patients.  Recently, the Supreme Court ruled that Medicare patients could sue HMOs that deny patients necessary but expensive care that they refuse to pay for.  This ruling is in response to the excessive amount of healthcare rationing that has been taking place by the HMOs.

 Other downfalls of the Medicare program include the lack of prescription drug coverage.  Patients who are covered by Medicare do not typically have prescription drug coverage, unless a separate Medigap coverage is purchased.  As the population-percentage of the elderly continues to increase, prescription drug coverage (or at least partial prescription drug coverage) is an essential component that has been left out of the equation.  It is expected that prescription drug spending will double during the next five years, with the 65-79 age group paying approximately $1,400 per year on drugs.  If this trend progresses as predicted, the elderly will not have the means to pay out of pocket for essential lifesaving drugs.  In addition to the elderly, the Baby-Boomer generation accounts for an extremely large portion of the prescription drug markets.  Policy makers must look toward the future elderly populations and adjust current healthcare policies so they will accommodate the needs of the elderly today, as well as the elderly population of future generations as well.  Medicare must be adjusted so at least partial coverage of prescription drugs is included.

Two other large problems arise with Medicare.  When Medicare was first established, it initially focused on providing for hospital expenses that are now supplemented by outpatient treatment and prescription drugs.  However, adjustments for these factors have not been made (i.e. covering a portion of prescription drugs and paying for outpatient services).  In addition to this, Medicare is a government program that was imposed on a private, decentralized healthcare system, which is often cited as a source of the excessive costs, and somewhat disorganization of the program.

Another subsystem of the United States healthcare system is the Medicaid program; a state/federal program that supports low-income Americans.  Medicaid assists low income families with children who meet specific requirements, disabled and the elderly, children under six years old, women who are pregnant and whose family income is below 133% of the federal poverty level, and children under 19 years old who have a family income level below the poverty line.  Medicaid provides the poorest people in the United States with basic health care, which is an essential component for a country such as the United States that embraces a large number of immigrants, to help people in economic hardships with basic services such as healthcare.  However, the Medicaid program is often criticized for charging the most to patients who have the least.  Also, many who are eligible for Medicaid and other government-funded assistance do not participate, with reduces the efficacy of the program.

The last subsystem of the United States healthcare system is the employer-sponsored branch, which is a partnership between employers (typically large and medium businesses) and their employees.  The employer sponsored branch typically covers middle aged Americans who work in fairly large corporations, as small businesses often down have the means to assist their employees with a large portion of their healthcare coverage.

The uninsured population who do not fall into coverage from either Medicare or Medicaid are extreme problems for the United States healthcare system. Major problems arise in this system when the unemployed (and people who are moving from job to job) get stuck in-between jobs, and then get sick.  This leaves people uninsured and needing healthcare but not having the resources to pay for it out of pocket. In the year 2000, approximately 38.7 million Americans lack private health insurance, and were not enrolled in government health care programs.  

Many people gain or lose insurance for part of a year, and these gaps in coverage have an impact as well.  In 1997, one-third of working-age adults reported they had some period of time in the past two years when they were uninsured, and most of these people were without health insurance for more than a year.

The self-employed and the entrepreneurs also are another downfall to the healthcare system in the United States.  This leaves the person to provide complete coverage for their own insurance costs, and that of their families, which is extremely expensive, and often an unreasonable goal.  “The majority of the uninsured are neither poor by official standards nor unemployed. They are accountants like Mr. Thornton, employees of small businesses, civil servants, single working mothers and those working part time or on contract.”

        The last group of uninsured is those who are non-poor and working.  However, many are not offered insurance at work.  More than eight out of ten uninsured Americans are workers and dependents of workers, and approximately 74% of uninsured are in families with at least one part time worker.  Recent studies in California show that many are not offered health insurance at work.  The majority of people who fall into this group are single, white, and under the age of 40.  A staggering 81% of the uninsured in California are employed, and still do not have health insurance .  These large populations groups of uninsured in the United States are huge gaps in the healthcare program.  Studies show that “employer-sponsored health plans are paying 48 percent more out of their own pockets for care than they did three years ago.”  

Not only are costs increasing, but the choices of a health provider are decreasing.  Employees who once participated in the PPO programs are now being forced to sign on with HMOs because their employers are making the PPO too expensive, and not covering enough of the costs.  In this way, PPOs are essentially being phased out in exchange for more frequent HMO usage.

Besides cost, one of the main reasons that many choose not to subscribe to healthcare is because they feel that the availability of emergency room and free charity care is abundant, and can be utilized if necessary.  However, by not having insurance, and waiting until an emergency situation to see a doctor (such as not going to the doctor for lower abdominal pains but instead waiting until they are unbearable, and then going to the emergency room and finding out one needs hernia surgery), drives up costs, as emergency rooms are extremely expensive to utilize.

        By far the largest criticism of the American healthcare system is that of the HMOs.  HMOs have started to ration care in an attempt to try and lower their costs, and in turn have caused disputes over who should get healthcare.  “HMOs that are serving the lowest-income population on the state’s dime are making huge profits.  It’s a great time to be an HMO investor but a bad time to be a patient,” said Jerry Flanagan, who is a director with the non-profit Foundation for Taxpayer and Consumer Rights.  All HMOs require ‘preauthorization’ for specialty procedures to ensure that reimbursement will occur, and that the procedure is indeed necessary and recommended by a doctor.  HMOs have also been criticized for limiting patient’s access to emergency rooms, access to specialists, and access to new and experimental treatments by paying for none or virtually none of these services.  Because HMOs have started to ration health care, Americans began to demand the right to sue their HMOs for not providing adequate and speedy treatment, which often times leads to the death of loved ones who don’t receive proper healthcare in a timely manner.

        Another criticism of HMO overage is the widespread lack of prescription drug coverage.  Prescription drug costs and coverage is often a main debating point.  As prices continue to soar for these sought after drugs, patients are searching for other cheaper retailers, such as online drug wholesalers and other countries.  This has led to the creation of a ‘prescription drug black market’.  Horror stories of diluted drugs, fake prescriptions and contaminated drugs that have been available on the market, are the new reality of prescription drugs in the United States.  These black market drugs are mostly unbeknownst to patients who, in an attempt to save money, are blind to the fact that it could cost them their lives.  

        Health care in the United States is based on four major pillars, often referred to as “the diamond”.  The diamond includes: high quality care, freedom of choice, efficiency and cost control, and equity and access. As Americans, we want to have all of these four categories when it comes to our healthcare, and are not willing to sacrifice one in exchange for the other.  Every individual would love to choose an extremely certified and highly educated doctor, while paying an affordable amount, at any hospital in the United States.  However, being realistic, experiencing these four points to the fullest extent is not a feasible reality.  We must decide which qualities are the most important to us, and from there devise a healthcare system that attempts to provide the majority of the components in a cost efficient and effective manner.

        The Canadian system emphasizes the equity and access point, by providing undeniable basic care for all residents, however the United States does not.  Canada also manages all costs so the patients are not burdened with excess bills and fees, whereas the United States almost always requires the patient to intervene financially, and pay at least a small fee for all services if not a larger percentage.  Both Canada and the United States provide high quality primary care for most patients, but the United States greatly outweighs Canada when it comes to the quality of specialized procedures and treatments.  Not only does the United States provide more widespread access to elective and other surgeries, but also the wait to have an operation performed is often times much shorter than the wait that is experienced in Canada.  Another downside to the Canadian system is its impact on immigration laws.  If a person attempts to move to Canada after the age of 50, they are often not granted access because the government views the person as a loss of economic funds, since the person did not contribute to the healthcare system economically like other Canadian residents, but will undoubtedly utilize the resources as they age.

 In both countries, primary care physicians are often the gatekeepers to seeing a specialist, as a referral is almost always needed in Canada, and is usually needed in the United States unless one pays extra for a selective health coverage plan.  However, Canadians are allowed to choose their primary care physicians, whereas most insurance plans in the United States have designated/contracted partners with which a patient can be treated.  In a study done by the Center for Studying Health System Change, HMOs and non-HMOs were compared in relation to the four goals.  They found that HMOs lowered the financial barriers to care, but they raised administrative barriers to specialized care (i.e. a patient must go through the HMO gatekeeper and have their specialized treatments ‘preauthorized’ in order for it to be covered, but once the treatment is approved, the wait is usually minimal).

While Americans are segregated about selecting a new health policy for the citizens, most agree that major changes need to be made to the system for it to function adequately in this new millennium.  Managed care has far too many flaws for the program to continue for much longer, especially as more and more HMOs are being held accountable for the quality and timeliness of the healthcare they provide, which will cost them millions.

  A new proposal, Medical Savings Accounts (MSA’s) could be in the future for United States healthcare.  Proponents think that MSA’s will work because they employ opposite ideas than those of managed care.  MSA’s lower the participation of a third-party payer system and allow patients to pay more out of pocket to see a more qualified doctor.  This is appealing to most upper middle class and upper class families, who believe that it is their right to contract higher quality healthcare if they can afford it.  They also lessen the administrative burden, and attempt to put the patient in a position of power.  MSA’s also encourage the patient/physician relationship, and believe in innovative medicine.  They encourage not only treating the specific problem, but the whole body and person.  MSA’s also allow patients to play a larger role in their own healthcare, which HMOs do not.  

Milton Friedman, a proponent of the MSA program, believes it holds the key to solving many of the current problems with healthcare in the United States.  He states:

“Yet it seems clear from private experience that a program along these lines would be less expensive and bureaucratic than the current system, and more satisfactory to the participants. In effect, it would be a way to voucherize Medicare and Medicaid. It would enable participants to spend their own money on themselves for routine medical care and medical problems, rather than having to go through HMOs and insurance companies, while at the same time providing protection against medical catastrophes…This reform would solve the problem of the currently medically uninsured, eliminate most of the bureaucratic structure, free medical practitioners from an increasingly heavy burden of paperwork and regulation.”

Friedman is convinced that implementing the MSA program would help both families and the government, as well as the future of healthcare in general, because patients would receive treatment for their health, without worries of insurance reimbursement and coverage.

As with all healthcare plans, downfalls with the MSA also exist.  First, skeptics are worried that the program will create an even further gap between the rich and the poor; the rich will be able to afford cutting edge technology and can hire best providers, whereas the poor might not be able to afford basic healthcare.  In addition to this, people are worried that a distinction between the healthy and the sick will be made, and cherry picking will occur (i.e. some companies will only insure the healthy, not the ill in order to save money).  People who are sick will use all of their funds that are in their MSA account, whereas people who are healthy will be able to accumulate their health savings and save up in case of an illness later in life (such as cancer therapy or cardiac surgery)  This makes MSAs a poor health choice for those who get severely ill at a young age, and those who have chronic syndromes. These two factors make establishing a socioeconomic and health blind insurance system difficult, even with the idea of MSAs.

Many Americans look at the Canadian-style healthcare system and cannot fathom establishing such system in America.  However, the MSA is not as large of a change in policy as is the Canadian-style government, but it does propose ways to provide healthcare in a more economical and medically sound approach as opposed to HMOs.  This is why the MSA program is being seriously considered as a viable healthcare option in the United States

Another threat to the current United States health system is aging of the Baby Boomer generation.  As people begin to live longer, there will become an increasing need for more geriatric care in the United States.  Because of the unusually large population of the Baby Boomers, the United States is experiencing changing demographics as the Boomer generation grows older.  Currently, the rate of elderly people is doubling, while all other age populations are remaining virtually the same.   As Ken Dychtwald, health and aging expert believes, the longevity of people is being extended tremendously as cutting edge research and technology is searching for the answer to human enhancement and life extension.  Dychtwald emphasizes the impact of science on life extension, and how new research about nutrition, hormone therapies, bionics and organ/gene cloning will essentially allow people to live until 100 or older, and then their body will fall apart due to usage.  He also poses the idea that if science can find a way to eliminate or cure Alzheimer’s disease, the population will have a chance at living an even longer life; as Alzheimer’s attacks the brain, which is the main control system of the body.

The elderly population is also gaining economic wealth, which is a large resource shift for this age group.  In addition to this, almost 50 percent of the Boomers in the United States already have a chronic disease, and 20 percent of adults that receive community based long term care are Boomers.  These numbers will only continue to increase as the Boomer population ages over the next few decades.  Stronger health plans must be established for the large population of aging and sick Boomers.

 The growing age of Boomers is a politically savvy group with the largest percentage of people who vote.  The group as a whole has a large influence on the medical situation in the United States because of their size.  Anyone over 50 can join the AARP (the second largest membership in the country), which is amassing a large population of followers, and continues to grow.  This group advocates healthcare for the aging population, and has one of the most influential voices in healthcare policy making due to its size.  As the Boomers continue to age, they will have an extremely influential role on deciding the future of healthcare.

However, there are experts who believe that the aging of the Boomers does not pose a threat to the future of healthcare in the United States.  Theodore R. Marmor addresses this issue in his 2001 article: How Not to Think About Medicare Reform.  Marmor states: “There is no correlation between the aging of the population and spending on medical care.”  Marmor urges Americans to disregard the hype that surrounds the aging of the Boomers, and instead look at the big picture; which he states does not show that the aging Boomers will put healthcare (especially Medicare) in jeopardy.

Financial surveys taken about the Boomers show trends that are not positive.  Data about the Boomers shows that social security is the principle retirement income for approximately 80% of all Boomers.  This does not provide a strong economic outlook, as social security was designed as a means to assist the elderly, but not be the entire means for financial support.  In addition to this, most Boomers’ have a net worth well under $50,000; which does not provide a vast amount of resources for necessary healthcare.  This means that as the Boomers age and need more frequent doctor visits, more prescription drugs, and surgical procedures, the government will need to find a way to subsidize their needs.  

An often-lobbied point among the Boomers is prescription drug coverage (as it is not covered under Medicare).  Data shows that baby Boomers’ have a higher drug trend, and are the group responsible for increasing the per-person drug spending, (not the elderly,) says a study done by Merck-Medco.  This means that the Boomers will strongly urge the government to pass prescription-subsidizing bills because the majority of Boomers will not be able to afford them without government assistance.

One of the main problems in adapting a Canadian system is the difference in societal values between the two countries. Not only are the healthcare systems opposite in Canada and United States, but so are some of the main societal values.  The United States takes part in the belief of “each man for his own,” insinuating that if one has the means to provide themselves and their family with top-notch healthcare, then they should be able to without problems. On the other hand, Canadians have a more equalitarian, and more caring approach toward the healthcare situation.  They acknowledge that not everyone will be employed at all times, or will have enough funds to provide themselves and their family with adequate healthcare.  Therefore, they provide the essentials for all Canadian citizens to access proper and basic healthcare.  Canadians care about the entire population, not just the rich, which allow them to justify their branch of healthcare systems, and which is why establishing a Canadian system in America might be a struggle.  Canadians also have more of a national community, and not as much distrust of the centralized government, as compared to the United States, where the citizens are often extremely critical of the government.  This makes people in the United States less likely to trust those who hold a political office; especially with important factors, such as their health.        

The current state of healthcare in the United States is in crisis.  As the population of Baby Boomers age, and more and more of the population demands healthcare coverage, is it necessary that appropriate changes are made.  HMOs continue to deny coverage, prescription drug costs are skyrocketing, and the United States is spending billions of dollars on healthcare more than virtually all other nations in the world.  However, coming to a consensus on what changes should be implemented will be a struggle in the United States because the values and expectations of the American population are extremely unique, and differ from the Canadian ideals.  If America wants to continue having a healthy nation, we must propose new ideas that will allow all citizens to receive payment-assisted healthcare.