As a new dawn embraces the United States of America, President Barack Obama and the 111th Congress face several seemingly insurmountable challenges. The armed forces are divided between two wars, the economy is in shambles, and the health care system is at the brink of failure. Every thrity seconds, an American goes bankrupt because of medical calamity. Regrettably, seventy-five percent of these people are insured. The American health care system is on life support; with this in mind, we offer this series of seven policy prescriptions for 2009.
Our children are the first item on next year’s health care agenda. The State Children’s Health Insurance Program (SCHIP), a federal-state partnership designed to provide health insurance to the near-poor, expires on March 30, 2009. Although President Bush twice vetoed reauthorization of SCHIP in 2008, Congress must act swiftly to not only renew but to make permanent this critical program.
President-elect Obama should demand that Congress expand eligibility for SCHIP to children from all income ranges. In order to do this reasonably, SCHIP should be valued actuarially and all parents will have the right to purchase coverage for their children. Additionally, subsidies must be provided to ensure that those with financial need can purchase this coverage. Insurance companies must be mandated to guarantee enrollment to any child who applies; and in fairness, parents must be held responsible to cover their children with either public or private insurance.
Our second prescription for health care reform comprises several intelligent and important fixes to the Medicare program. The “doughnut hole” – a coverage gap in the Medicare prescription drug plan which has exposed over 3 million seniors to extremely high out-of-pocket spending for prescription drugs – must be eliminated. This can be accomplished by eliminating Medicare Advantage subsidies. These payments to private insurance companies provide additional money to offer Medicare managed care plans. Another way to reduce costs in Medicare is to reverse the current restrictions preventing the Medicare program from directly bargaining with pharmaceutical companies.
Our third prescription recommends eliminating the provider payment disparity between Medicaid and Medicare. Data have born out that access to care among Medicaid patients is more difficult than for Medicare patients, largely as a function of inequitable payment differentials. This merely amounts to government sanctioned segregation in health care; the government unethically pays a physician different amounts for the same work simply because one patient is poor and the other is not.
Our fourth prescription urges President-elect Obama to establish two commissions early during his first 100 days in office. The first commission should be tasked to decide what kind of health benefits should be provided by a future national health program. The second commission would objectively and scientifically determine the clinical and cost effectiveness of new drugs and medical devices, similar to the United Kingdom’s National Institute of Clinical Effectiveness. Upon hearing the preliminary reports of these two commissions, President Obama must work quickly with the leaders of Congress in order to advocate to create a multi-payer, universal health care system in the United States. The backbone of this system would be traditional employer-sponsored health care. However, new regulations – outlined by our final prescription – will be necessary in order to convert a dysfunctional health insurance marketplace into a valued public good.
Our fifth policy prescription addresses health care provider shortages. If we fail to expand the pool of health care providers, efforts to insure every American will only result in greater delays for patients who seek care. America currently has a nursing shortage; a physician shortage is looming. Through increased availability of student loan programs and loan repayment programs, such as the National Health Service Corps, Congress and President Obama should foster an environment where a new generation of primary care providers (specifically, internists, pediatricians, obstetrician/gynecologists, family practitioners, and general surgeons) can flourish.
Our sixth prescription exposes the lack of diversity within the medical profession. If America is serious about eliminating racial and ethnic disparities in health care, there must be more Black, Hispanic, and Native American health care professionals. Creating a diverse healthcare workforce requires health professions schools to become more proactive and more creative in attracting, enrolling, and retaining minority applicants. Without such an investment in the human capital comprising our health care system, providing equitable health care will remain a challenge.
Our final prescription asks Congressional leaders and the President-elect to craft legislation and regulations which will lead to a multi-payer universal health care system. All Americans must possess health insurance. An individual mandate, much akin to similar mandates for car insurance, would help to increase the size of the health insurance risk pool. As a trade-off, insurance companies must offer guaranteed enrollment without restrictions for pre-existing conditions. And as advocated for children’s care above, subsidies will be needed to help the less fortunate afford private insurance coverage if ineligible for Medicaid. Likewise, similar to our thought of offering SCHIP to anyone who would wish to purchase it, every American adult ought to have the freedom to purchase a nationally available, publicly operated, not-for-profit health insurance plan.
Although President-elect Barack Obama and the new Congress face immense challenges not seen since the days of Franklin D. Roosevelt, health care reform must remain a priority in 2009. Our policy prescriptions for the upcoming year would (1) provide universal care to our children, (2) make some simple fixes the Medicare program, (3) provide equal payment to providers for Medicare and Medicaid, (4) establish commissions to craft a national health care plan and to evaluate the clinical and cost effectiveness of new medical developments, (5) expand the pool of primary care providers, (6) ensure a diverse health care work force, and (7) put America on the path to universal health care for all Americans.
by Cedric K. Dark, MD, MPH
with contributions by Stanley Frencher, Jr., MD, MPH and Kameron L. Matthews, MD, Esq.