As the Obama administrations develops strategies to strengthen the economy, create jobs, and provide relief to middle-class Americans, it is imperative that health care reform be considered as an essential part of fixing the economy. 

There are several key reasons why economic strengthening and health care reform go hand in hand, including the alarming rate at which rising costs of premiums and high deductible plans are squeezing the middle class pocket books.  One reason providing low-cost quality care through a National Health Plan can help grow the ecomony is that workers who are trapped in jobs because of the insurance provided through employers will have more flexibility and ability to create their own small businesses or be self-eployed as entrepreneurs.  Women who want to work at home to help manage their family responsibilities and cut back on child care expenses will benefit from the ability to purchase low-cost quality health care through the National Health Plan. 

In addition, the stress of the uninsured on the health system has significant implications for rising costs and premiums.  The insured who continue to make premium payments regardless of the increases will see relief from this uncontrolled rise as more Americans care will be covered.  The lack of control or ability to know the extent of rising costs forces many insured Americans to accomodate rising costs without the ability to plan financially.  In a home budget, sticking to that budget is difficult when one expense that is necessary can increase significantly without much warning. 

The most important part of economic well being is the impact of providing preventive health services to all American workers.  A healthy population is a productive work force.  We must invest in the health of all Americans as part of our economic stiumulus plan in the coming months. 

Many members of the middle and upper classes feel that the creation of a National Health Plan uses their hard–earned money to redistribute wealth.  If the economic downturn is not addressed, middle class jobs will be lost and health insurance along with it.  We have a choice to support efforts to help others in ways that will ultimately benefit us.   Supporting health care reform that improves access to low cost insurance is one aspect of ensuring the economic well-being of the middle class. 

For more information please read the following articles:

“Make Health Care Costs Part of the Economic Cure” from the Detroit Free Press

“Record Share of Economy Spent on Health Care” from the Washington Post

Which Comes First, Health Care Cost Containment or Access:

Comparing the Health Plan Policies of John McCain and Barack Obama

Either John McCain or Barack Obama will become the next president of the United States in January 2009. According to a recent poll by the Kaiser Family Foundation, “one in four Americans cite paying for health care as a serious problem.” (Kaiser Family Foundation, 2008) Beyond the challenges of American individuals struggling to manage rising health care costs, insurance companies, hospitals, and employers continue to adapt their policies to attempt to decrease the economic burdens of health care. As these stakeholders have responded to rising costs by attempting to shift the cost burden to other stakeholders, the burden that is shifted back on the individual has contributed to increases in the number of uninsured Americans. The recent economic downturn and associated rise in the unemployment rate is associated with an increase in the number of uninsured individuals by a factor of 1.1 million new uninsured for every 1% rise in the unemployment rate. (Kaiser Family Foundation, 2008) The presidential candidates have both articulated health care plans and policies that address health care reform in terms of cost, quality, and access to varying degrees.

Barack Obama and John McCain’s foundational philosophies about health care reform are vastly different. Where Barack Obama aims to reform health care and create affordable, quality health insurance accessible to all Americans, John McCain’s approach is to reform health care by focusing on cost containment measures that will be market driven. While Obama does not articulate his plan as a plan for universal health care, the idea that health care is a human right appears to be the foundation of his plan. Obama’s rhetoric focuses on increasing access through increasing the role of the government in providing insurance along with investments in research, technology, and public health. McCain articulates a philosophy of change that emphasizes shifting control of the system to the individual consumer. In McCain’s health care reform paradigm, shifting control and cost burden to the individual consumer will optimize cost containment. According to McCain’s plan, the notion of moral hazard in our current health care system, where the consumer is shielded from the cost and therefore has no incentive to be cautious in their utilization of services, is a contributor to rising healthcare costs. In comparing the underlying principles without reference to the specifics, one must evaluate whether reform of health care is best accomplished by increasing access or containing costs first. Where Obama’s plan lacks clarity on cost containment, McCain’s plan does not significantly address the issue of access. In terms of the many details of their plans for increasing quality, the candidates are in agreement.

Access

The road to increasing access to insurance for all people is clearly defined in Barack Obama’s plan. Obama’s plan will create a national health plan that people who do not have access to insurance through their employer, cannot afford private insurance, or have not been eligible for coverage can purchase. Obama’s outline indicates that all premiums, co-pays, and deductibles will be “affordable.” According to the outline, those individuals who do not qualify for Medicaid or SCHIP but cannot afford the premiums of the national plan will be eligible for subsidies to offset individual costs. Other aspects of Obama’s plan that are designed to increase access include expansion of eligibility for Medicaid and SCHIP, mandatory coverage for children, creation of the National Health Insurance Exchange as a means of regulating the private insurance market, and inclusion of portability as a component of the national health plan.

While Obama’s plan does not mandate coverage for adults, it does appear that more Americans would have access to insurance through the creation of the national health insurance plan. One area that seems unclear is how well the subsidies would offset costs for families that would qualify. Obama does not dismantle the private insurance system, but would require employers to either provide insurance or contribute towards the costs of the national health insurance plan. The integration of public and private insurance under Obama’s plan makes it appealing, and less likely to evoke strong resistance on the part of big business than a true universal health care plan. In terms of access, Obama’s plan appears to be a true reform, but the implications of this plan for cost control in health care are problematic.

McCain contrasts sharply with Obama over the issue of increasing access to healthcare for Americans, though he has never articulated commitment to universal health care. McCain’s plan does state that they will make insurance more available to individual Americans by lowering costs and increasing portability. According to his outline, he will use tax credits to make insurance more affordable. He will eliminate the employer tax exemption on health care and provide families with direct tax credits they can use to pay for insurance. The idea here is that families will search for the lowest cost plans and this will drive competition in the industry. Employer-based plans are still an option, though. Bob Lazewski has analyzed McCain’s plan and notes, “With the average cost of employer-provided family health insurance at $12,000 a year, a $5,000 tax credit will often come up way short—especially for higher age people and those who don’t have the benefit of an employer contribution.” (Lazewski, 2008) In addition, if an employer pays a portion of the costs, families would now pay taxes on that benefit. In this sense, McCain’s tenet is that he will make health insurance more affordable, which will give more people access. The challenge here is that it is not clear who will benefit from this plan. It depends on how much one earns and the ability to find coverage. (Kaiser Family Foundation, 2008) In addition, there is no requirement of coverage. The McCain plan also emphasizes the use of Heath Savings Accounts, national plans that are portable, and a Guaranteed Access Plan for people who are otherwise ineligible for insurance. The mechanism of the GAP is not well-defined.

McCain’s plan may make health insurance more affordable for some, but the shift from the employer-based system to an individual purchaser system will undoubtedly be a bumpy road. The plan does not address how the uninsured poor will have more access to insurance, especially since the degree to which the costs will be driven down is unknown.

Cost

McCain’s plan is rooted in cost containment. In this sense, his plan does not require significant new expenditures that need to be funded by tax increases. His tax credit will essentially be funded by ending the tax exemption on health insurance benefits. Looking at how his plan impacts stakeholders, it appears as though his plan to drive down costs through competition would decrease costs for some stakeholders to some extent. By placing the burden on individuals, there would be some relief of cost burden for employers who may stop providing insurance and subsidize their employees’ individual purchases. At the same time, McCain’s plan does not articulate a clear mechanism to deal with the impact of the uninsured on hospitals and providers, who then pass the cost of providing care of the uninsured to private insurers. Unless there is flow of new capital into the system by way of more purchasers of insurance or some other means, the cost burden on the private insurers may increase, and then increase costs to individuals whose salaries do not rise at an equal rate. McCain does articulate other cost containment strategies such as: lowering drug prices through reimportation and increased generic availability, emphasizing preventive care and disease management strategies, greater use of information technology as a cost-saving measure, increased use of walk-in clinics in retail outlets, tort reform, and Medicaid and Medicare payment reform. In terms of cost containment, McCain’s plan does have a cost benefit in so far as the implementation of the plan will not produce significant new government expenditure; however, it does not clearly articulate who will have lower heath care costs and to what extent the costs will be lower. The extent to which low-income uninsured will benefit from tax credits depends on several specific details about tax credits that are not stated in McCain’s Plan. (Kaiser Network, 2001) McCain’s plan also does not demonstrate that the cost containment strategies he will implement will be equal or greater to the cost burden of 47 million uninsured on the system.

With respect to cost, Obama’s plan requires extensive government spending to be implemented, estimated at 50 to 65 billion dollars per year according to his campaign website. This cost will be passed on to individuals through the repealing of Bush’s tax cuts. In all fairness, those tax cuts have been noted to primarily benefit the wealthiest Americans. Essentially his plan will infuse cash into the system that will cover many uninsured and increase the number of insured. On the other hand, his other cost containment strategies are not well-defined and are similar to the McCain plan. Obama’s plan also emphasizes cost control through use of information technology and lower drug costs, though he does briefly discuss regulation of unjustified price increases by big business. Ultimately, if the cost of health care itself cannot be reduced through decreased utilization of the system and reduction of administrative costs, covering the uninsured will not be feasible in the long run with tax increases. The bottom line is that Obama’s plan will cover the uninsured which will help reduce the cost burden on hospitals, providers, private insurance companies, and the privately insured, but does not provide well-articulated strategies for controlling costs within the system.

Quality

There are few significant differences between Obama and McCain’s ideas about improving the quality of health care aside from the implications of access or as quality indicators. Both support initiative for preventive care, public health, research, increased use of information technology, and federally supported outcome measurement initiatives. Obama provides more specific examples of the types of quality initiatives he supports, but they are really not espousing vastly different quality improvement strategies other than the ways they relate reform of access and cost issues to issues of quality in health care.

Nurse Practitioners and the McCain and Obama Plans

McCain is the only candidate that gives some reference to utilization of nurse practitioners as a mechanism of improving access and quality when he discusses the use of walk-in and retail clinics, though he does not explicitly state that nurse practitioners constitute a component of the approach. The physician lobby is fairly powerful and both candidates are most likely aware that if they want support of their plans, they will need the blessing of the physician lobby. Even though increased use of nurse practitioners as providers has the potential to decrease costs for Medicare, Medicaid, and the insurance companies, McCain and Obama are not likely to state this in their plans.

Obama’s plan has potential to impact Nurse Practitioners favorably by virtue of increasing the flow of revenue into the system in the form of more insured patients. If nurse practitioners can position themselves as lower cost yet effective providers, they have the opportunity to create jobs for more nurse practitioners and have more money flowing into their pockets. Many nurse practitioners feel that the health of the population is adversely affected by the number of uninsured individuals.

Conclusion

While the lack of cost containment policies in Barack Obama’s plan is a concern, the expanded access that it will provide to uninsured Americans makes it a better plan than John McCain’s plan. I do not think the shift towards a consumer driven insurance market is going to aid the uninsured or be a real cost containment measure unless the shift is coupled to heavy regulation of the insurance industry. Given John McCain’s principles, it is unlikely that he would support increased regulation. Even though Obama’s plan is more costly, I support the repeal of the Bush tax cuts to pay for it and also believe that decreasing the numbers of uninsured will serve as a cost containment measure. Once access is expended, efforts to contain costs can be more focused and refined with the removal of the financial cost of caring for the uninsured. Without expanding access, I do not believe costs will be contained. While expanding access has a cost, it is a cost that also serves the health of the population, which is important. I also happen to support the idea that health care is a human right. Given the current state of the economy, I fear that McCain’s plan will only increase the numbers of uninsured as individuals struggling to make ends meet will be forced to use any tax credits to offset other necessary costs. If that were to happen, the cost burden could continue to be shifted back on the insured anyway. In do not believe the net cost effect on the average insured American differs that greatly between the two candidate health plans. While we may pay in the form of taxes for Obama’s plan, I believe McCain’s plan will probably cost us some employer-provided benefits that will not be made up by increased wages as well us cause increases in hospital costs to cover the uninsured. By failing to address the access issue for uninsured Americans, I believe hospitals and private insurance companies will continue to deflect the cost of care to the uninsured onto the privately insured. The costs associated with either plan are essentially equal in that I believe any health reform will cost me. But my belief that health care is a human right leads me to support Obama’s plan.

References

1. Bodenheimer, T. S. & Grumbach. (2005). Understanding health policy: A clinical approach. Stanford, CT: Appleton& Lange.

2. Kaiser Family Foundation (2008) New Analysis Shows Effect of Rising Unemployment on Health Coverage, Medicaid and SCHIP Spending and Enrollment. Retrieved on 7/13/08 from http://www.kff.org/medicaid/kcmu042808pkg.cfm

3. Kaiser Family Foundation (2008) Tax Subsidies for Health Insurance: An Issue Brief. Retrieved on 7/16/08 from http://www.kff.org/insurance/upload/7779.pdf

4. Kaiser Network. (2001) Presentation Transcript from 4/6/2001: A Briefing on Extending Health Coverage- Tax Credits, Public Program Expansion and Combination Approaches. Retrieved on 7/17/08 from http://www.kaisernetwork.org/health_cast/uploaded_files/kff040601.pdf

5. Lazewski, Bob. (2008) A Detailed Analysis of Senator John McCains’s Health Care Reform Plan. Retrived on 7/12/08 from http://healthpolicyandmarket.blogspot.com/search/label/McCain%20Health%20Plan%20Analysis

6. McCain, John. (2008) Straight talk on health Care System Reform. Retrieved on 7/10/08 from http://www.johnmccain.com/Informing/Issues/19BA2F1C-C03F-4AC2-8CD5-5CF2EDB527CF.htm

7. Obama, Barack. (2008) Plan for a healthy America. Retrieved on 7/10/08 from http://www.barackobama.com/issues/healthcare/

This essay originally written for my advanced practice nursing class on Health Policy and Finance July 23, 2008 at Emory University.

Have you ever heard the saying by Ghandi, “Be the change you want to see in the world”? If we apply this idea to the need for change in our country’s healthcare system as it relates to how people who work in the healthcare industry are insured, we have an interesting set of issues that are readily visible. Many healthcare institutions bemoan the effects of uninsured or under insured patients that flow through their doors because of the money they lose. There is an opportunity for these institutions to examine the effect of their insurance plans on their employees to understand how their policies may contribute to the numbers of uninsured, under insured, and insured but still in debt.

The following examples are food for thought.

When I worked for a nonprofit children’s hospital in New Orleans, our health insurance covered no well visits. Most children only see their pediatricians for well visits which include immunizations. These visits were not covered by insurance. Can you believe that a hospital whose mission is to serve the health needs of children did not provide a health insurance policy to its employees that covered well visits? Imagine how the employees who worked there and did not earn a living wage fared with this insurance policy. For immunizations, employees were encouraged to visit a free immunization bus that traveled around the city. While this would allow everyone to have their children immunized, it did not provide for well visits with a pediatrician to screen children and provide anticipatory guidance to parents.

Many businesses are now encouraging their employees to open Health Savings Accounts for their health insurance. I understand the idea behind such accounts, but I think they are a potential disaster for people with lower incomes. I am concerned about how employers are encouraging people to enroll in these plans as if they are less expensive for everyone. The system is complicated enough that we all need to carefully weigh the costs and benefits associated with various plans, the propaganda about these plans is misleading, in my opinion. If I were to change to this type of plan, I would not have sufficient cash to start the account such that if I had a catastrophic illness before I had put several thousand dollars in the account, I would have a serious financial problem.

Similar problems can occur with PPO plans. These were also touted as better than HMO plans because they have lower premiums and you have more choices. You also have a much higher deductible. I had this type of plan at one time. When I needed a minor surgical procedure, I ended up paying about $800 between my deductible and some other fees not covered by the plan. It was very difficult for me to pay this much cash, even though I have a very good income. Imagine what happens to people who make less than I do.

I do not believe that it is fair for the housekeepers upon whom we depend to keep our facilities clean pay the same premiums for healthcare that we do when those premiums will constitute a significantly higher proportion of their incomes. If I made minimum wage, I do not believe that I would enroll in the health insurance plan my employer provides because it would be financially implausible for me to have health insurance and pay my bills. This phenomenon has been noticed by forward thinking living wage advocates who have advocated for a living wage ordinance in Los Angeles. This is a description of the rationale for their efforts to include health insurance premiums in their living wage calculations.

If we want more Americans to have the befit of health insurance, we may look to the practices of our own employers and start the dialogue about how we are insured. Contact your Human Resources Department and ask them to investigate how many of their employees are uninsured and why. Also ask them to investigate what proportion of their employees require public assistance to be insured. Remind them if we want to change the flood of uninsured that come into our facilities, we need to look at how their own practices contribute to the numbers of uninsured in their area. I would advocate researching the costs and benefits of instituting a sliding scale of insurance premiums for employees that would set the cost of the premium at a proportion of your income.

In the meantime I devoutly enroll in my HMO plan during benefits renewal every year, until my employer or the insurance company decides that it costs them too much money. I may need a referral or a PCP, but I choose not to pay 10% of my hospital bill.

When I first went to Nursing School 6 years ago, I remember meeting so many idealistic nurses to be with dreams of taking their education and going to work overseas to make a difference in countries less fortunate than our own. Their experiences as Peace Corp Volunteers and NGO employees sounded so noble and exotic to me and I felt somehow inferior for having chosen to become a nurse without consideration for how my knowledge could benefit those living in areas without access to care at a fundamental level.

We undoubtedly have an incredible wealth of resources within our health care system from beautiful hospitals and clinics with multi million dollar architectural features to state of the art medical equipment, computer services, and highly educated medical personnel compared to health care systems in other countries. For example, it is unheard of in this country for a medical facility to have such a shortage of supplies that medical personnel would have no gloves available to wear when handling blood and body fluids or have to wash out the same pair of gloves repeatedly in between patients. When one considers how vastly privileged we are in this country, it is hard not to feel alternatively grateful for our own fortune and disgusted that we have so much when others have so little.

After 5 years of working as a Registered Nurse in pediatric and adult emergency rooms in New Orleans as well as in Pediatric Hematology Oncology at a nationally ranked pediatric hospital, I have come to understand how social, economic and cultural factors interact with one another in our health care environments that illustrate vast inequalities among patients within our own systems of health care.

The divide between the experience of the wealthy and the poor in this country is well documented. If you asked any medical professional if they treat all their patients the same regardless of their race, class, gender, or cultural background most would answer with conviction that they provide the same care to everyone. As individuals caring for patients, I know how deeply we believe that we treat patient equally. At the same time, if we acknowledge and examine all the ways in which the health care system is designed from corporate insurance policies to how our implementation of particular policies in hospitals and clinics may exclude patients who speak languages other than English, we would be forced to admit how our systems are defined to produce and affirm inequality that is defined by differences in race, class, and cultural background.
Too often we understand the concept equality to mean that everyone is treated exactly the same. This construct itself is what produces and supports inquality. Treating people the same way for the same conditions adheres to this notion of equality but in essence illustrates a failure to understand and address how differences in socio-economic and socio-cultural identities change the way people interface with social institutions such as health care. Imagine a pediatrician who sees two children on the same day in the same office, each wih a complaint of fever. Upon examination, the provider finds that both children have bilateral ear infections. Amoxil is prescribed. Two weeks later, one family returns with the same complaint and the provider examines the chil to find that his ear infections have not improved. The provider is concerned. It would seem that the second family spoke Spanish. The provider used an interpreter to explain the prescription the first time and cannot understand why they did not treat their child as he instructed. As it turns out, this family spoke only a little Spanish, they first language is a tribal Guatemalan dialect. In addition, they could not afford the prescription because they do not have insurance and are not eligible for Medicaid because they are in this country illegally. They did not tell the provider because they feared deportation. Finally, neither parent in this family completed education beyond 6th grade level in their home country.

Of course many providers address these issues successfully on a daily basis, however, there are numerous examples of how our awareness of these issues is not heightened until our attempt to treat patients the same fails. This is a process of trial and error in many provider experiences. If a situation is urgent enough or for cases of complicated management of chronic conditions, however, we may not have the luxury of trial and error. Also the difference economically for a family with access to insurance and without is crucial. Most providers have few options to provide the same treatment to families living below the poverty line who must bear the financial burden of treatment themselves. In effect, the differences between how these families and their upper middle class counterparts with insurance and large disposable incomes access medical care and treatment are astounding. Our health care system is designed to provide them the same treatment in theory, but not in practice.

In my own practice as a nurse, I have come to understand that even my best efforts to provide all children with the same care is severely limited within the health care system at times due in part to my own lac of understanding of the social, cultural or economic realities of my patients. I do believe that our resources are vast enough to decrease many inequalities, though complete elimination of inequality is perhaps unrealistic.

I propose that medical professionals must first define the scope of the problem through research. Let us begin to expand our studies of disease outcomes to include data about insurance status, primary language, family income, and cultural background.

Once such data is collected, we can begin to design interventions that will address the specific needs of families with different backgrounds. No doubt the need for health care policy change will be a highlight of such efforts, but we must also focus our interventions to find the most effective ways to treat, teach, and monitor families on the most basic level of how each provider interacts with each patient. We may find that shifting our thought processes away from notions of equal treatment and towards different treatments for different basic human needs is a philosophical shift that produces profound results.