WHAT ASPECT OF HEALTH CARE DELIVERY IS MOST IN NEED OF REFORM? By Arnold Rosoff, Professor of Health Care Management and Legal Studies

Most Americans agree that Health Care Reform (HCR) is necessary. This apparent consensus evaporates, though, when you ask what aspect of our healthcare system is most in need of reform. It’s difficult, some say impossible, to balance the three essential elements of that system: Quality, Access and Cost (the “three-legged stool,” as it has been called). Many believe that achieving adequate access for all citizens, Universal Health Care (UHC), is the top priority. Approximately 16% of the U.S. population, some 46 million people, are uninsured or underinsured, a situation hard to understand or justify when most other major nations on the planet have universal coverage. However, not all Americans see UHC as the top priority. Many who have health insurance coverage for themselves and their families think the main issue is the constantly rising cost of care. Still others bemoan the variable, uncertain quality of U.S. health care. The high rate of medical error and the increasingly apparent instances of health disparities undermine the claim some make that the U.S. healthcare system is the best in the world.

In my view, although controlling cost and maintaining quality are essential, assuring all U.S. citizens access to an adequate level of health care (UHC) should be the primary goal of healthcare reform. For a nation that values equality of opportunity it is intolerable for a large segment of the population to not have reliable access to basic health services, an essential component of equal opportunity. Why have we tolerated this inequity for so long? A lack of solidarity is perhaps the key factor setting the U.S. apart from the rest of the world – in this regard, at least. Americans don’t seem to believe what most of the world’s other peoples take for granted, that we’re all in the same boat when it comes to health and we must have a healthcare system that serves all with fair, although perhaps not absolute, equality. Why is that? There’s no simple answer. The American position reflects our national history all the way back to colonial times: our deep-seated distrust of government control, our frontier values of self-sufficiency and individual initiative, our leadership in the development of free enterprise and industrial capitalism, and our role throughout the years of the Cold War, when the U.S., as the world’s principal counter-force to the spread of Communism, exalted individual responsibility. Can we now rise above these formative influences and embrace health care as a right of all our citizens?

The U.S. can’t lay claim to having a world-leading healthcare system when so many of our citizens are not regular players in the game. This isn’t just a question of philosophy and political orientation, in other words of how tightly the social fabric is woven and citizens bear responsibility for their fellows. It’s also a practical question. The uninsured and underinsured in our country are entitled to receive health services when they’re urgently needed. EMTALA, the Emergency Medical Treatment and Active Labor Act of 1986, requires most U.S. hospitals to provide emergency care; and the cost of such acute, episodic care is borne by all of us through a complex, only partly transparent, web of cost-shifting and cross-subsidizations. But discontinuous, uncoordinated care is inefficient and wasteful in many ways. A properly designed healthcare system could assure adequate care for all Americans at little or no greater cost than what we now pay. This last, though, is a statement of personal belief, not of proven fact. People can, and do, disagree widely on what “properly designed,” “adequate care,” and “little or no greater cost” mean. As with other issues in complex social systems, the devil lies in the details.

The notion that all citizens should have access to basic services and coverage to pay for them goes to the core structure of the healthcare system. It affects whether there should be mandated coverage, in other words whether all who can afford health insurance should be required to have it and pay for it. It also affects whether health insurers should be allowed to exclude people from coverage, or impose exclusions, limitations or surcharges, based on their health status – a practice known as “medical underwriting,” long a tenet of our free-enterprise private health insurance system. As we ponder whether the U.S. should continue to have basically a private or a governmental system, the questions of whether coverage should be mandated and whether medical underwriting should be allowed are “inextricably intertwined.” As Princeton health economist Uwe Reinhardt so aptly puts it:

“Many Americans oppose such a mandate as an infringement of their personal rights, all the while believing that they have a perfect right to highly expensive, critically needed health care, even when they cannot pay for it. This immature, asocial mentality is rare in the rest of the world. An insurance sector that must insure all comers at premiums that are not contingent on the insured’s health status — a feature President Obama has promised — cannot function for long if people can go without insurance when they are healthy, but are entitled to premiums unrelated to their health status when they fall ill.”

To summarize, the fate of healthcare reform in the U.S. at this critical juncture turns on how we, as a people, perceive the role and responsibility of individual Americans and of our government. That statement is, at the same time, both profound and obvious. How we approach and deal with healthcare reform will show the wisdom and character of our leaders, the strength and flexibility of cherished institutions and, above all, our mettle as a people and a nation. At this time of great moment and challenge, hope and change must be more than political slogans; we must embrace them as national ideals.

Related posts:

1. Cultural Competency, Community-Based Organizations, and a Resilient Community Landscape-Important Elements of Philadelphia’s Health Care System By Raymond Lum, Professor of Health Management and Policy
2. Changing Healthcare Delivery in America By Corbett Brown, Chair, Graduate and Professional Students Assembly
3. Barriers to Health Care Access in Philadelphia By Marla Gold, Dean, Drexel School of Public Health

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