• AcademyHealth: How the argument for universal coverage changed

    In his inaugural editorial in Inquiry (2007), Alan Moneheit documented the shift in arguments over the last century for universal coverage. In my latest post on the AcademyHealth blog, I summarize the piece.



    • I’ve only read your summary and intend to read the entire piece, but I wanted to emphasize the point that the enormous increase in the number of illnesses that at one time were death sentences, but as the result of medical advancements are now treatable, chronic conditions, has shifted a lot of assumptions about health insurance and financial risk. It is the increase in chronic illnesses that is the big driver in the escalation of health care costs and in the incidence of financial catastrophe for many including those with health insurance, as out of pocket expenses for someone with, for example, chronic leukemia will quickly drain all of the person’s assets. While ACA will provide needed help for these people, it will not avoid financial catastrophe as out of pocket expenses will continue to drain the person’s assets. Health insurance is great for covering the risk of an injury or curable disease but not chronic illness.

    • Two anecdotes to make my point. My father was diagnosed with lung/esophageal cancer 47 years ago and survived only five months. He had health insurance and his medical expenses barely affected our family. My brother was diagnosed with chronic leukemia about 12 years ago and is alive today thanks to the advancements in the treatment of leukemia. But he has spent all of his financial resources on out of pocket expenses, been harassed for payment by hospitals and other providers,, and has at times been dependent on the good graces of the local public hospital for treatment when his spleen ruptured (common for leukemia patients) and has suffered from pneumonia (also common for leukemia patients). Earlier this year he lost his health insurance and, because he’s a veteran, registered with the VA. I can’t say enough good things about the VA. My brother’s disease had progressed to the point that he was at the acute stage and the magic cocktails weren’t working, as his swollen lymph nodes made him look like the Michelin Man. The physicians at the VA got him into a trial that, thank goodness, has kept him alive and significantly reduced the lymph nodes. Moreover, they they have convinced pharmaceutical companies to supply enormously expensive drugs without cost. There’s the difference between a deadly disease and a chronic illness.

    • Based on my sketchy reading of the history of health insurance (Paul Starr’s book and the story of Tommy Douglas), I think that the driving force behind universal health insurance is the fear of medical bankruptcy.

      The goal of many reformers has been to have the community pay the bills.

      Whether the public got first rate care is tremendously important to doctors, of course, but the driving emotion of Medicare in both Canada and the US was to get free care at the point of delivery.

      The feeling was (and is) that health care delivered without financial stress will be better for that reason alone. Both doctors and patients hate the idea that they might have to slow down and bargain over each procedure.

      This incidentally is why I did not pay a lot of attention to the Oregon study. I do not care if adults on Medicaid achieved lower blood sugars. I do care passionately that they not be hounded by medical bill collectors.

      Bob Hertz, The Health Care Crusade

    • If the subject is risk management, then I will go to the expert, Robert Schiller, an economics professor at Yale who teaches finance. As Schiller would say, in a perfect world all risk would be shared so that the per capita cost would be nominal. Health insurance, even with the ACA reforms, works opposite of Schiller’s perfect world, as it’s designed to limit not spread risk by, for example, having very large cost sharing by the insureds. Politically, ACA is at considerable risk, as the middle class, those with any assets, come to realize that ACA will not protect them against financial catastrophe in the event of a chronic illness.

    • The solution to the chronic illness dilemma is a Medicare buy-in for persons under 65.

      The buy-in could be triggered by a ratio of annual expenses to income….
      we could call it ‘Medicare for the Medically Needy.”

      The patient might have to pay $1000 a month for the Medicare, or 15% of their income if less. In exchange they would have a low deductible and none of the great evil we call coinsurance.

      We would need to limit the number of persons in such a program.
      MS, Parkinsons, leukemia, fibroyalgia……this needs more research.

      Thanks to Mr Alyward for a good contribution!