The hazards of sickness, accident, invalidism, involuntary employement, and old age should be provided for through insurance. (Theodore Roosevelt, 1912)
Running as a third-party candidate, and seeking to pull progressive voters from both the Republican and Democrat parties, Theordore Roosevelt argued for a form of sickness insurance similar to that established in Germany in 1883. The United States, with the passage of the Patient Protection and Affordable Care Act (“the Act”, “PL111-148”), has taken its most recent step towards this goal of insuring all Americans. The Act expands medical care for the poor through Medicaid, fosters the growth of the private health insurance market with subsidies and tax credits, demands personal responsibility through a controversial individual mandate, and promotes continuity of coverage with robust patient protections. While older generations celebrate today’s success after bitter memories of the failure Clinton Health Plan, the young generation of health care advocates must remind itself that the Act will not cover everyone, nor will the issues of affordability, quality, and access to care be fully satisfied during the implementation this new law.
The Institute of Medicine states that the most important goal of our health insurance system should be universal coverage. This conclusion is reached after examining the exidence that uninsurance promotes problems for individuals, families, and society as a whole. The post-reform era of the next several years must keep this primary goal in mind.
Health insurance ought to be something that individuals can trust to cover them regardless if they choose to change jobs or lose a job. The COBRA law allows for continuity of insurance only with job loss and for a limited period of time. The health reform law just passed prevents insurance companies from cancelling someone’s policy, thereby also fostering improved continuity of coverage. Even more creative solutions to the lack of continuity in coverage must be found so that individuals can keep whichever insurance policy they like regardless of their work status, employer, or place of residence.
Many opponents of the Act refer to the health reforms in Massahusetts as a demonstration that costs will increase under the new national health reform law. Some describe double digit increases in health insurance premiums in Massachusetts while nationwide increases ran 3 to 5 percent this past year. Health care costs are unlikely to be adequately controlled until people know how much health care really costs.
Americans need to be aware not only of the share of the health insurance premium they pay, but also the amount contributed by employers.
Quality and Access
Recent reforms have often focused on coverage. However, coverage is only worthwhile when patients can be assured they can actually see a doctor. And doctors are only as good as the quality of care they can provide. Our healthcare system must be re-structured to encourage doctors to deliver effective, efficient, equitable, safe, and timely care centered around the patient. Our system must guarantee that a patient can see their personal doctor whenever the need arises.
The Next Generation
Therefore, while many will pause to celebrate and others will focus on implementation, there is still much work to be done to arrive at the vision conceived nearly one hundred years ago.
But first, in the coming months the executive branch will be attempting to define two critical concepts: (1) “quality” as it applies to health care delivered in federal programs and (2) the “minimum creditable coverage” that all Americans must obtain until full implementation of the Act. For the next generation of health care advocates, this is your opportunity to begin to assert your voice.
Then, as the Act’s provisions interweave with the fabric of American life, time will again call for a movement to focus on truly covering all in the United States and streamlining the many silos under which health care is currently delivered. Those challenges await the next generation of health care advocates and policy makers.
Cedric K. Dark, MD, MPH