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.

WORLD DEVELOPMENT CALLS FOR INVESTMENT IN AGRICULTURE 2008

PREAMBLE: The World Development Report 2008 (reference link below) calls for greater investment in agriculture in developing countries. This annual World Bank report warns that the sector must be placed at the center of the development agenda if goals of halving extreme poverty and hunger by 2015 are to be realized.

o While 75% of the world’s poor live in rural areas in developing countries, a mere 4% of official development assistance goes to agriculture.
o In Sub-Saharan Africa, a region heavily reliant on agriculture for overall growth, public spending for farming is also only 4% of total government spending and the sector is still taxed at relatively high levels.
o GDP growth originating in agriculture is about four times more effective in raising incomes of extremely poor people than GDP growth originating outside the sector.

Said World Bank Group President Robert B. Zoellick: “At the global level, countries must deliver on vital reforms such as cutting distorting subsidies and opening markets, while civil society groups, especially farmer organizations, need more say in setting the agricultural agenda.”

In this issue we focus on Malawi as a Case Study of the role of new subsidies to enhance agricultural production, despite decades of donor proscription not to subsidize, and take note of a World Trade Organization investigation into the use by the United States of truly massive trade-distorting farm subsidies in violation of international commerce rules.

Reference : World Development Report 2008: Agriculture for Development. http://econ.worldbank.org/WBSITE/EXTERNAL/EXTDEC/EXTRESEARCH/EXTWDRS/EXTWDR2008/0,,contentMDK:21410054~menuPK:3149676~pagePK:64167689~piPK:64167673~theSitePK:2795143,00.html

Case Study - ENDING FAMINE IN MALAWI
After a disastrous corn harvest in 2005, almost 40% of Malawi’s 13 million people needed emergency food aid. Move forward to 2007, and Malawi is selling more corn to the UN’s World Food Programe than any other country in southern Africa. Farmers explain the extraordinary turnaround with one word: fertilizer.

Over the past 20 years, the World Bank and some rich nations Malawi depends on for aid have periodically pressed this small, landlocked country to adhere to free market policies and cut back or eliminate fertilizer subsidies, even as the USA and Europe extensively subsidized their own farmers. But after the 2005 harvest, the worst in a decade, Bingu wa Mutharika, Malawi’s newly elected president, decided to follow what the West practiced, not what it preached, reinstating and deepening fertilizer subsidies.

The country’s successful use of subsidies is contributing to a broader reappraisal of the crucial role of agriculture in alleviating poverty in Africa and the pivotal importance of public investments in the basics of farm economies: fertilizer, improved seed, education, credit and agricultural research. Malawi’s leaders long favored fertilizer subsidies, but reluctantly acceded to donor prescriptions, often shaped by foreign-aid fashions in Washington, that featured faith in private markets and antipathy to public intervention.

In a withering evaluation of the World Bank’s record on African agriculture, the bank’s own internal watchdog concluded in October not only that removal of subsidies had led to exorbitant fertilizer prices in African nations, but that the bank itself often failed to recognize that improving Africa’s declining soil quality was essential to lifting food production.

In Malawi, deep fertilizer subsidies and lesser ones for seed, abetted by good rains, helped farmers produce record-breaking corn harvests in 2006 and 2007. An independent evaluation, financed by the USA and the UK, found that the subsidy program accounted for a large share of this year’s increase in corn production. The harvest also helped the poor by lowering food prices and increasing wages for farm workers.

Malawi’s determination to heavily subsidize fertilizer and the payoff in increased production are beginning to change donor attitudes, say economists who have studied Malawi’s experience. The UK (DFID) contributed $8 million to the subsidy program last year. Bernabé Sánchez, an economist with the agency in Malawi, estimated the extra corn produced because of the $74 million subsidy was worth $120 million to $140 million. The US, which has shipped $147 million worth of American food to Malawi as emergency relief since 2002, but only $53 million to help Malawi grow its own food, has not provided any financial support for the subsidy program, except for helping pay for the evaluation of it. Over the years, the USAID has focused on promoting the role of the private sector in delivering fertilizer and seed, and saw subsidies as undermining that effort. But Alan Eastham, the US ambassador to Malawi, said in a recent interview that the subsidy program had worked “pretty well,” though it displaced some commercial fertilizer sales. And the World Bank now sometimes supports the temporary use of subsidies aimed at the poor and carried out in a way that fosters private markets.

In Malawi, bank officials now support Malawi’s policy, though they criticize the government for not having a strategy to eventually end the subsidies, and... say there is still a lot of room for improvement in how the subsidy is carried out. “The issue is, let’s do a better job of it,” said David Rohrbach, a senior agricultural economist at the bank. Though donors are ambivalent, Malawi’s farmers have embraced the subsidies. And the government moved this year to give its people a more direct hand in their distribution.

Source: Adapted from the article by Celia Dugger. Ending Famine, Simply by Ignoring the Experts. New York Times Dec 2, 2007 http://www.nytimes.com/2007/12/02/world/africa/02malawi.html

WORLD TRADE ORGANIZATION INVESTIGATION INTO US SUBSIDIES
GENEVA (AP) — The WTO has opened an investigation into whether the US was violating international commerce rules that limited subsidies to American farmers, three days after the US Senate approved a $286 billion farm bill. Brazil and Canada, frustrated by US resistance to cutting back on subsidies, asked the WTO to condemn Washgton for exceeding permitted levels of what it called trade-distorting handouts to American producers of crops like corn, cotton, rice, soybean and wheat. The panel is expected to issue a first ruling in 2008. The dispute system often takes years before a final decision is reached, but can force countries to change their legislation or face billions of dollars in retaliatory sanctions. The battle over farm subsidies could become a landmark dispute for the WTO because Brazil’s complaint includes payments for ethanol production. The trade body has largely steered clear of energy issues in its 12-year history.

Source: Bradley S. Klapper. Associated Press. December 18, 2007