On the Future of U.S. Health Care Financing

No matter how much we talk about global health issues like infectious disease, maternal health, and the role of education, at the heart of every problem we are facing is the question of financing health care initiatives. Perhaps the only other variable so crucial to population health is stewardship, and a large part of stewardship concerns judicious management of funding.

Two videos recommended for this week brought up provocative issues on the future of health care financing in the U.S.: Uwe Reinhardt's lecture and the California OneCare initiative. California OneCare lobbies for universal health insurance, calling for swift steps instead of small changes. The biggest issues we face are administrative costs and lack of access to care for a staggering chunk of the population. Also disturbing are inequities in the quality of care people receive, a measure closely linked to SES and race.

Many other countries use a single-payer system to control administrative costs. Canada and the UK are just two examples. Health care investigators in these countries would be quick to tell us that the single-payer system is no panacea...it has its own disadvantages, like everything else. However, at the heart of the current health care crisis is a civil rights issue that the single-payer system might address: unquestionable inequity in the ability to attain something that is, at least ideologically, universally considered to be a basic human right.

Even developing countries understand (and act on the understanding) that the way we do health care doesn't cover the most vulnerable people. In this country, over half of family bankruptcies filed are a direct result of medical expenses. 3/4 of these people have jobs. They are productive individuals of society crippled by a health care system that's supposed to increase their productivity. Instead, it's leeching it.

If that's not convincing enough, consider this: a 1% decline in income in the U.S. translates into an increase in mortality rate of 22 deaths per 1000. In Canada, no association is found between income inequality and mortality rates. Infant mortality rates show similar results, with the world superpower ranking in the 40's on the list of country-specific rates.

Fundamentally, health is more important than money. Anyone who's ever experienced a serious illness, even a bout of flu, can tell you that without your health, your money doesn't mean much.

Unfortunately, that piece of wisdom is no longer true, and it's least true in places like the U.S., where both health and money are available, but money is infinitely more important than health. Here, money buys health and happiness. What is wrong with this picture???

Back to that paradigm shift we talked about. Sure, we'll have to iron out some kinks in a single payer system to adapt to our needs as a country. But what we're doing right now--taking those kinks and calling them reasons not to act in the best interests of human beings--can't continue. We must first accept that inequality of some sort may always exist, and then go about decreasing it as surely as we can, as other nations--even less developed ones like Korea, Brazil, and India--have done.

And one more thing: an equality of opportunity, as the U.S. has historically been praised for having, is not the same thing as equality. There are several forces, some known and others unknown, working against equality. For instance, racism and SES interact additively to produce poorer health outcomes for certain groups of people. This holds true even when patient characteristics are held constant. What does this mean? It means that somewhere among health care providers and institutions, inequality is being perpetuated. It means that addressing individuals is not enough; the entire establishment must be examined. We must ask important questions: Are doctors giving every patient the same quality of care? Are there good hospitals in largely ethnic areas? Good schools? What are the differences? Our country likes to believe that racial segregation was so long ago that its effects are no longer profound. We have made great strides (remember, in the late 18th century an African-American slave was only roughly 3/5 of a human being). But vigorously addressing contemporary manifestations of these issues will greatly aid a successful reworking of health care financing in this country.

In order to treat some persons equally, we must treat them differently.
-Harry Blackmun