A Primer on Health Care

When you're dealing with a topic like universal health care, it begs a clear definition. Some hear the term and think it can only be applied to their favorite solution – say, single-payer – or their least favorite – socialized medicine. Others don’t know what to think. It sounds good in principle, but what does it mean?

For the purposes of the debate we'll have together on this blog, and the debate that will echo in the halls of Congress and in living rooms across the country this year, let's try this definition:

"Universal health care means giving coverage to every American, reducing the costs of our wasteful system to make care affordable for every American, and ensuring the care we receive has the best quality."

Think of it as a three-legged stool – if one of the legs isn't sturdy, the whole thing will topple over. You need all three to be truly universal.

Coverage for All

The single most pervasive number in our health care debate, and the most repugnant, is the over 46 million Americans who have no coverage at all. They make too much money or don't match the 50-state patchwork eligibility for Medicaid, they're too young for Medicare, they're not veterans or current service members, or they're left behind by our employer-based system.

The people who slip through the cracks are pretty much "normal" Americans. Eight out of ten come from families where one or more person works. One in nine are children (even with the success of SCHIP). Sixty-percent work for small businesses, and another quarter work in businesses with more than 500 employees.

And every year, over 20,000 of them die because of lack of access to health care. The injustice speaks for itself. We must find a way to achieve coverage for all Americans.

But too many progressives stop here. Coverage alone is not enough.

Cost That's Affordable for All

The mission of the 2006 Massachusetts health care plan was clear: every resident of the Commonwealth had to be covered. Democratic legislators worked with a Republican governor, businesses worked with the government, dogs worked with cats. Everyone was required to purchase insurance, the Health Connector was set up to match individuals to the right plan for them, subsidies were given to individuals who couldn't afford insurance, they played this commercial so much people started to see dorky bald guys with broken arms in my sleep, etc.

It's been a good start. Two years later, more than 439,000 more Bay Staters have insurance. So why aren't more states rushing to carbon copy their own Massachusetts plan?

Because extending coverage to the uninsured didn't help the major reason why health care is a crisis for everyone, whether you have insurance or not: cost.

At $2.3 billion per year, the United States pays twice as much in health care dollars per capita as any other nation, and it's dramatically on the rise. According to the Kaiser Family Foundation, insurance premiums have jumped 78% over the past 8 years while wages have barely budged above 15%.

It's not just families who feel the squeeze. It's businesses owners, who are faced with a Sophie's Choice of paying higher premiums in an economic downturn or stop providing coverage to their employees. It's hospitals administrators who, in a recession, get the double-whammy of more people using the emergency room for uncompensated care and budget cuts to Medicaid. It's primary care doctors and nurse-practitioners who are working harder for uncertain compensation. It's seniors who are paying through the roof for prescription drugs, even with Medicare Part D.

Cost is as much a limiting factor as coverage. This year Massachusetts is exempting 62,000 uninsured from its statewide mandate because they can't afford insurance, even with government subsidies. Even worse, 25 million Americans are underinsured, forgoing care because of high deductibles and living one medical catastrophe away from bankruptcy.

To really provide universal health care, regardless of ability to pay, we need to tackle costs head on. As health care writer and blogger Maggie Mahar asks about Massachusetts, "If 37 percent of insured families cannot afford to the deductible and co-pays, what good is the insurance?"

Quality That Increases Lifespan and Health for All

By the same token, what good is universal coverage if you're not getting the care you need?

We have the most expensive health care system in the world, in part because we spend $700 billion on unnecessary care. We've got the best equipment, the latest pharmaceuticals, the most diversified specialists, the most diagnostic tests, and machines that go "ping!" But we don't have better health outcomes than other nations. We rank 29th in infant mortality, 48th in life expectancy and 19th in preventable deaths. That's not money well-spent.

The American Health Insurance Plans' recent white paper on health care reform contains this eye-popping statement: "Spending more on health care does not necessarily equate to better quality; rather, the opposite has been shown." That's like Heidi Montag accusing you of being shallow – and being right!

But getting too much care is better than too little, right? It turns out we’re doing both. A RAND Corporation study on primary care discovered that Americans get the recommended care for their particular ailment only 55% of the time. Too much of what we don't need, too little of what we do -- we're the Bizarro World of health care.

The U.S. facing a physician shortage, especially when it comes to primary care. It's a huge factor. You can have great coverage at an affordable price, but if there's no doctor to provide your health care, you'll still be locked out.

Our health care system needs top-to-bottom reform. We can start by being evidence-based and refocusing on improving quality of life and life expectancy of patients. After all, isn't that the whole point? Without an emphasis on improving health, it's not health care, let alone universal health care.

Coverage, cost and quality are the three pillars necessary for health care reform. We need to work on all three – only then will we have guaranteed health care as a right for all Americans.