LAUNCHING UNIVERSAL HEALTH CARE IN THE UNITED STATES - Global Perspective

PREAMBLE:  We delayed this month’s issue due to the uncertain outcome of a political confrontation in the United States of America over raising its debt ceiling, which would have resulted in a US default on its budgetary commitments. The confrontation was resolved meekly at the “eleventh hour”, late on October 16, when a majority of elected officials came off their soapboxes and voted for sanity.

The standoff came about, as anyone who watches the news knows, due to an abortive attempt by an ultra-right wing Republican faction to block the US from finally aligning itself with other developed countries in providing universal health care.  This faction was lead by Senator Ted Cruz from Texas, the state with the greatest proportion of persons not covered by health insurance: about 1 person in four – an underclass of people that it seems this faction would like to keep that way on a permanent basis.

Many Americans see their country as ”exceptional”, and exceptional this certainly was: a startling display of grand-standing as the world watched in dismay as the United States was pushed to the precipice of a default that would certainly cause irreparable damage to its own and the global economy.

During this crisis, many individuals from a political lunatic fringe (dubbed the Tea Party) made deliberately false statements about the new health care provisions, using the opportunity to sow confusion in the minds of Americans at large.  Despite all this, the new health system was launched ahead of time on October 1^st, 2013. Core provisions are supposed to be in place by 2014. Although with its early launching, and perhaps largely because of this, operational glitches were widespread e.g., registration webpages not fully functional, but no major amendments were made as a result of the simultaneous carnival of political opportunists.

Watching on, it was difficult to accept that the USA – a nation often projected as the leader of the free world – was being subjected to what can only be viewed as a form of sedition by self-proclaimed defenders of political freedom, all the while attempting an end-run to deny Americans a measure of universal health protection that citizens of all other developed countries have enjoyed for decades.

It is with this background in mind, including the importance of US global leadership, that we devote this issue to the core elements of the Patient Protection and Affordable Care Act, so that readers may appreciate what it was that the Tea Party sought to overturn by using the threat of default as political blackmail.

UNIVERSAL HEALTH CARE AS THE EVENTUAL OUTCOME OF THE PATIENT PROTECTION AND AFFORDABLE CARE ACT – As viewed by a Non-American

In the United States, the private sector has long dominated the health care system, yet has failed to meet the health care needs of some 50 million non-insured people, about 20% of the population. The Patient Protection and Affordable Care Act (modeled after a system now in place in Massachusetts, brought in under a state Republican administration under former Governor George Romney, but dubbed “Obamacare” by political opponents of the federal Democratic administration which designed the legislation), intends that everyone has access.

Dramatic changes are now taking place: under this new legislation (to be fully phased in by 2020), the US will begin to close the gap on universality and other deficiencies will be addressed. The legislation was upheld by the Supreme Court on June 28, 2012, against challenges by numerous states and individuals and the National Federation of Independent Businesses. Nonetheless, even with this policy shift, the US will remain the only developed nation that depends predominantly on a private insurer, private provider entrepreneurial model.This acknowledged, the US system also contains substantial public sector elements that will continue to grow: Medicare for the elderly (a universal single payer system where providers are not directly employed by government); a program called Medicaid to address essential health care for low-income families based on eligibility criteria, financed jointly by state and federal governments; Veteran’s Affairs health care (a single payer system whose providers are employed by the Department of Veterans Affairs, although not applied to persons in active service who are covered by private insurers under “Tricare” - an employer based insurance scheme).

The Patient Protection and Affordable Care Act (passed in 2010) is too complex to address in its entirety in this blog. People of developed countries with more equitable systems will find the barriers to health care access and/or affordability in the US to be instructive, e.g., the ability of insurance companies to deny coverage for pre-existing conditions – this practice is to cease in 2014.

Obamacare will take many years to fully implement, but does have the prospect of bringing the US into line with the principle of universal coverage that has been in observed for decades in all other developed countries, and increasing numbers of developing ones.  Access to essential health care is also addressed under the Universal Declaration on Human Rights (Article 25:  http://www.un.org/en/documents/udhr/ )

Readers interested in further information on the Patient Protection and Affordable Care Act in the U.S., as upheld by their Supreme Court, a summary of its key features is available at the following site:  Senate Democrats  http://dpc.senate.gov/healthreformbill/healthbill04.pdf

Wikipedia has also been updated on this topic although their full article is much longer and history more detailed   http://en.wikipedia.org/wiki/Patient_Protection_and_Affordable_Care_Act

Our Opinion:

"Obamacare" is a major step forward to a more equitable health system in the USA. Issues of effectiveness and efficiency will be tested, studied and addressed as it attempts to provide quality care for all citizens under the new legislation. This process should not be treated as a political football by Republican extremists although no doubt there will be legitimate policy challenges as it makes its way forward to the goal of universality.  If the Tea Party continues to engage in obstructionist antics, primarily for local constituency gains, and risk default once again, the reputation of the US for sober global leadership will only be further damaged.  


Background References

American College of Physicians. Position Paper: Achieving a High-Performance Health Care System with Universal Access: What the United States Can Learn from Other Countries. Ann Intern Med 2008;148:55-75. http://www.annals.org/content/148/1/55.full#T1  Accessed October 17, 2013.

White F, Nanan D. A Conversation on Health in Canada: revisiting universality and the centrality of primary health care. J Ambul Care Manage 2009; 32,2:141-9. http://journals.lww.com/ambulatorycaremanagement/Abstract/2009/04000/A_Conversation_on_Health_in_Canada__Revisiting.9.aspx Accessed October 17, 2013.

Guyatt GH, Devereaux PJ, Lexchin J, et al. A systematic review of studies comparing health outcomes in Canada and the United States. Open Medicine 2007;1,1:E27-36. http://www.pnhp.org/PDF_files/ReviewUSCanadaOpenMedicine.pdf  Accessed September 15, 2012.

The World Health Report 2000 – Health systems: improving performance. Geneva, 2000 http://www.who.int/whr/2000/en/whr00_en.pdf  Accessed October 17, 2013.

Supreme Court of the United States. National Federation of Independent Business et al vs Sebelius, Secretary. Health and Human Services et al. Certiorari to the United States Court of Appeals to the Eleventh Circuit. No 11-393. Decided June 28, 2012. As cited in the Washington Post: Full text of the Supreme Court health-care decision. June 28, 2012. http://www.washingtonpost.com/wp-srv/politics/documents/supreme-court-health-care-decision-text.html  Accessed October 17, 2013.

FACT CHECK: REPUBLICAN PARTY STATEMENTS ON HEALTH CARE REFORM

PREAMBLE: Normally we would not presume to comment on an election issue in the United States. However, this principle is based on the assumption that Americans will place their vote based on accurate information regarding the candidates and the issues that are important to them. It is for this reason that, in this issue of Global Perspectives, we make an exception. We are providing this “fact check” because Republican Vice-Presidential candidate Paul Ryan, in his apparent zeal to prevent the successful emergence of universal health care coverage in the United States (as intended by the Patient Protection and Affordable Care Act of 2010), has been making negative references to the comparative performance of universal health care in Canada: these statements by Ryan are demonstrably misleading.

Ryan appears to make it up as he goes along, more in the manner of a carnival barker than as a candidate for the second most powerful national political post in the world. His superficial grasp of health issues seems prone to confuse and mislead his own voter base and the electorate as a whole, even about the performance of health care in his own country. Perhaps this may be expected of a candidate who, after obtaining a general undergraduate degree, then (aside from working briefly as a short order cook in a McDonald’s restaurant) went almost directly into career politics. In our view, the U.S. can and must do much better than this. The core issue is integrity: it is disturbing to think that this callow individual could hold the reins of power in the event that a sitting President passed away.

One of the campaign consequences of this candidate’s glib views on health care (whether this be in the United States, Canada, or anywhere else for that matter), is that it renders it virtually impossible for Republican Presidential candidate Mitt Romney, to discuss health care policy with any coherence, even though this is arguably his most notable success in public office (as former Governor of Massachusetts).

Ironically, because the Patient Protection and Affordable Care Act has been dubbed by Republicans as “Obamacare” (even though similar to the system now in place in Massachusetts) Romney must toe the party line.

No strength of character therefore has been exhibited by either candidate: one (Ryan) is ignorant and cavalier with the facts, while the other (Romney), despite knowing better, has been effectively muzzled by his own party. Surely U.S. Presidential and Vice-Presidential candidates should be morally stronger than this?

However, at least the facts of the matter can be set straight. In the following brief review we take note of: recent assessments of US health care performance against other countries (including Canada), and the main features of the Patient Protection and Affordable Care Act as upheld by the US Supreme Court in June 2012.

Reference:
Bryn Weese. Toronto Sun (on line) First posted Monday August 13, 2012.
http://www.torontosun.com/2012/08/13/romneys-pick-likes-canada Accessed September 15, 2012.


INTERNATIONAL HEALTH CARE COMPARISONS RELEVANT TO THE U.S. PRESIDENTIAL ELECTIONS

The health care system performance of six developed nations on several key parameters, was recently (2008) ranked by the Commonwealth Fund, a respected American foundation that promotes better access, improved quality, and greater efficiency, particularly for society's most vulnerable, including low-income people, the uninsured, minority Americans, young children, and elderly adults.

The countries included in this exercise were: Australia, Canada, Germany, New Zealand, the United Kingdom, and the United States. Notably the United States ranked 6th (last place) overall, and 6th in 5 out of 9 specific parameters; these include: safe care, access, efficiency, equity (fairness), healthy lives, and health expenditure per capita. Of the remaining parameters, it ranked 5th each for quality of care, coordinated care, and patient centred care. Its only first place ranking was for right care.

Contrasts with Canada are indeed relevant. In particular, for almost half a century, Canadian health care has been guided by the principle of universality (access to core services for everyone) within provincial systems of single payer public administration, with relatively minimal roles for private insurers.

By contrast, alone among developed countries, U.S. health care until now has been dominated by private administration and financing. The high cost of health insurance for those not included in employer-funded plans has resulted in almost 50 million people lacking coverage: insurers denying coverage for pre-existing conditions, and setting caps on life-time payments regardless of medical need. In other words, most health care in the United States is allocated on the ability to pay.

A systematic review of 38 studies reveals that Canada’s system achieves more favorable outcomes when compared with the U.S. predominantly private for-profit system, at less than 50% of the cost.

For more comprehensive global comparison there is the World Health Organization (WHO) landmark study, in 2000, of health systems performance in almost 200 countries. WHO's assessment was based on five indicators: overall population health; health inequalities within the population; overall health system responsiveness (combining patient satisfaction and how well the system acts); distribution of responsiveness (how well people of varying economic status find they are served by the health system); and the distribution of the health system's financial burden within the population (who pays the costs). The findings were both relevant and revealing: France was found to provide the best overall health care followed by Italy, Spain, Oman, Austria and Japan. The United Kingdom ranked 18th, Canada 31st, and the United States 37th (most expensive system in the world). Australia’s performance was ranked 32nd. Most European countries ranked higher than Canada, Australia and the United States.

Dramatic changes are now taking place in the US: under new legislation (the Patient Protection and Affordable Care Act of 2010 to be fully phased in by 2020) of the Obama administration, the US will begin to close the gap on universality and other deficiencies will be addressed. The legislation was upheld by the Supreme Court on June 28, 2012, against challenges by 26 states, several individuals and the National Federation of Independent Businesses.

CONCLUSION
The above brief review of salient facts notwithstanding, as amply demonstrated by the distortions of information evident in the Republican Presidential campaign (see Preamble), there will likely be ongoing political obstructionism from “Tea Party” extremists that will impede progress towards universality.

Background References
The Commonwealth Fund. A Private Foundation working towards a high performance health system. http://www.commonwealthfund.org/About-Us.aspx  Accessed September 15, 2012.

American College of Physicians. Position Paper: Achieving a High-Performance Health Care System with Universal Access: What the United States Can Learn from Other Countries. Ann Intern Med 2008;148:55-75. http://www.annals.org/content/148/1/55.full#T1  Accessed September 15, 2012.

White F, Nanan D. A Conversation on Health in Canada: revisiting universality and the centrality of primary health care. J Ambul Care Manage 2009; 32,2:141-9. http://journals.lww.com/ambulatorycaremanagement/Abstract/2009/04000/A_Conversation_on_Health_in_Canada__Revisiting.9.aspx

Guyatt GH, Devereaux PJ, Lexchin J, et al. A systematic review of studies comparing health outcomes in Canada and the United States. Open Medicine 2007;1,1:E27-36. http://www.pnhp.org/PDF_files/ReviewUSCanadaOpenMedicine.pdf  Accessed September 15, 2012.

The World Health Report 2000 – Health systems: improving performance. Geneva, 2000 http://www.who.int/whr/2000/en/whr00_en.pdf  Accessed September 15, 2012..

Supreme Court of the United States. National Federation of Independent Business et al vs Sebelius, Secretary. Health and Human Services et al. Certiorari to the United States Court of Appeals to the Eleventh Circuit. No 11-393. Decided June 28, 2012. As cited in the Washington Post: Full text of the Supreme Court health-care decision. June 28, 2012. http://www.washingtonpost.com/wp-srv/politics/documents/supreme-court-health-care-decision-text.html  Accessed September 15, 2012.

SUPPLEMENTARY NOTES
The Patient Protection and Affordable Care Act (passed in 2010) core provisions come into effect in 2014 e.g., ability of insurance companies to deny coverage for pre-existing conditions ceases. All provisions are to be phased in by 2020. The Act supports a system far more complicated administratively than in Canada as it remains based on a multitude of insurance providers and gap-filling programs. It will take many years to fully implement, but does have the prospect of bringing the US into line with the principle of universal coverage that has been in observed for decades in all other developed countries.

Readers interested in further information on the Patient Protection and Affordable Care Act in the U.S., as upheld by their Supreme Court, a summary of its key features is available at the following site.
Senate Democrats http://dpc.senate.gov/healthreformbill/healthbill04.pdf

Wikipedia has also been updated on this topic although their full article is much longer and history more detailed http://en.wikipedia.org/wiki/Patient_Protection_and_Affordable_Care_Act