Presidential Election 2008:
FIXING THE U.S. HEALTHCARE SYSTEM

By Alan Shapiro

To the Teacher

Fixing the U.S. healthcare system is a major presidential campaign issue and the subject of three student readings: 1) problems with this healthcare system; 2) candidate proposals for reform; 3) healthcare systems in other industrialized nations.

The teacher might also find useful "A Single-Payer Health Insurance System for the U.S.?" available in the high school section of www.teachablemoment.org. These materials include a number of suggested inquiry subjects for student investigation.

Student Reading 1:
Healthcare horror

Devante Johnson was 14 and suffering from kidney cancer. Medicaid (a government program that covers some medical costs for low-income families) paid for his chemotherapy, radiation and other treatment. To make sure his Medicaid coverage would not lapse, his mother, Tamika Scott, sent in the required paperwork to Texas authorities two months ahead of time. But "In Texas as in many other states, there is a concerted effort to undermine programs that bring government-sponsored healthcare to poor and working-class children," New York Times columnist Bob Herbert wrote about Devante's situation.

"'They kept losing the paperwork,' Ms. Scott told me, her voice quivering with grief." She sent in duplicate copies, she made many phone calls, she sent off faxes. Despite these efforts, the coverage lapsed. Devante's treatment stopped. "'They put us on clinical trials. They changed his medicine, and he started getting sicker and sicker.'"

Four months after Devante's coverage stopped, Texas authorities finally renewed it, but it was too late. Devante is buried in Houston's Paradise North Cemetery. ("Young, Ill And Uninsured," New York Times, 5/19/07)

Trina Bachtel, an Ohio woman, was pregnant and had health problems. She went to a clinic for help, but she had a large unpaid balance from care she had received there earlier. Unless she paid $100 per visit-money she did not have-the clinic would not help her. "Eventually she sought care at a hospital 30 miles away. By then, however, it was too late. Both she and the baby died." (Paul Krugman, "Healthcare Horror Stories," New York Times, 4/11/08)

Why are such healthcare horror stories commonplace in America? Answers include:

• Nearly one in every six Americans, 47 million people, have no healthcare insurance.
• Healthcare insurance for many others is inadequate.
• People who don't have insurance or whose insurance is inadequate avoid going to
  doctors for help and often their health worsens as a result.
• Private health insurers screen out potential customers whose health conditions
  indicate they will probably have big medical bills, and sometimes insurers deny coverage to customers for some medical procedures.
• As medical costs keep rising, more employers drop health insurance for their workers.

President Bush has downplayed such problems. "I mean, people have access to healthcare in America," he said last year. "After all, you just go to an emergency room." It is true that hospitals will immediately treat anyone with a serious problem, but they will also send that person a bill for emergency room service.

"Americans have lost confidence in the U.S. healthcare system and yearn for reforms that will free them from worry about losing coverage if their circumstances change or if they fall ill." a Consumer Reports survey found. In a telephone poll more than 80 percent said that a reformed system should guarantee the following:

• Coverage for all uninsured children.
• Protection against financial ruin due to a major illness or accident.
• The ability to obtain coverage regardless of a pre-existing condition.
• Coverage that continues even when people are laid off, changing jobs, or starting their own businesses.
• Premiums, deductibles, and out-of-pocket expenses that are affordable relative to
  family income.
• The ability of people to keep their current health insurance if they choose.

Note: This survey included 1,200 Americans age 18 and older in November 2007 and was published in the issue of March 2008. Consumer Reports is a publication of Consumer's Union, "an expert, independent nonprofit organization whose mission is to work for a fair, just, and safe marketplace for all consumers and to empower consumers to protect themselves." (www.consumersunion.org)

For discussion

1. What questions do students have about the reading? How might they be answered?

2. What problems do people without health insurance face?

3. Why do health insurers tend to refuse insurance to people who have serious medical conditions?

4. Why do medical costs keep rising? If you don't know, how might you find out?

5. What other obstacles to health coverage does Consumer's Union report? What questions do you have about any of them and how might they be answered?

Student Reading 2:
The presidential candidates on healthcare

Healthcare reform is a major issue in the presidential election campaign. Based on its research, Consumers Union says that changes should

1. ensure that all Americans can get high-quality healthcare
2. at a price they can afford,
3. including guaranteed access,
4. and improved delivery of healthcare

For Consumers Union the top standard by which to judge candidates' proposals for change is whether it provides a "guarantee that everyone is covered from cradle to grave regardless of health status or ability to pay."

Another serious question is how reform proposals will contain healthcare costs. Already the U.S. spends twice as much as any other country on healthcare: How will employers, employees, and the government be able to afford the cost of covering everyone--including the 47 million who are currently uninsured--as prices continue to rise?

Major Provisions of Candidate Health Plans

The presidential candidates have laid out their plans in detail on their websites. But specifics, like how much they will cost and exactly where the money will come from, may be complicated and/or cloudy.

Requirements

Senators John McCain, Hillary Rodham Clinton and Barack Obama agree that ideally all Americans should have access to healthcare insurance.

Clinton would require all Americans to have health insurance--and to purchase it if they don't. The Obama plan requires all children to be covered, but not all adults. Both candidates propose that the government would provide financial support to help low-income people buy insurance.

McCain opposes such requirements. Americans, he said, should have the freedom to choose their own healthcare plans or no plans at all.

Clinton and Obama state flatly that insurance companies should be prohibited from denying coverage to people with high-risk medical conditions or from charging such patients higher rates. McCain says he would work with the governors of each state to develop a plan to prevent discrimination in healthcare coverage against people with medical problems.

Help in Getting Healthcare Coverage

Most people get their insurance through their employers. McCain would move away from that model by making employees pay taxes on employer-provided healthcare coverage. He would encourage people to buy their own insurance instead by providing income tax deductions of $2,500 for individuals and $5,000 for families to buy health insurance on their own. (The average healthcare premium for a family is about $12,000 a year.)

Clinton and Obama would require large employers to either provide insurance or contribute to the cost of insuring the uninsured. Obama would exempt the smallest businesses from this requirement and would reimburses all employers for catastrophic health costs. Clinton provides tax deductions to small businesses for healthcare costs. Obama and Clinton provide subsidies for low-income people.

Purchasing Groups

Both Clinton and Obama would create a system that would offer the uninsured a choice of private insurance plans they could buy (similar to a program now available to federal workers). Both Democrats would also offer people the option of buying into a public insurance plan similar to Medicare. (Medicare is the government-funded health insurance program for seniors and the disabled.) In keeping with his philosophy that Americans should be free to do what they choose, McCain does not provide for such groups.

Keeping Insurance Portable

The three candidates agree that individuals who change jobs or start up a private business should be able to take their insurance plan with them.

Guaranteed coverage

None of the candidates' healthcare plans meet the top Consumers Union test-guaranteed coverage for everyone. While the candidates agree on a few requirements, McCain's plan would not change the basic American system. Obama's and Clinton's would, but neither plan guarantees coverage for everyone. Obama's does not require adults to get coverage. While Clinton's mandates coverage, she has not explained how this mandate will be enforced on those who say they can't afford it and leaves out one million people. (www.factcheck.org) In Massachusetts, which has a similar plan, many people failed to sign up.

Restraining costs

No candidate's plan explains how it will solve the problem of rising medical costs. It is likely that Obama's and Clinton's plans in particular would result in huge increases in healthcare costs. This is because more people would be covered, and because both plans would encourage people to purchase private insurance, which is far more costly than public insurance.

Private insurance companies are in business to make money for themselves and their investors. This profit motive--as well as marketing costs as advertising, office staffs to research customer medical histories, and mountains of paper work--all contribute to the high cost of health insurance purchased by an individual or family.



For discussion

1. What questions do students have about the reading and how might they be answered?

2. Which of the candidates' plans make most sense to you and why?

3. What are potential problems in a system guaranteeing universal coverage?

4. What are the forces behind high costs for private insurance?

Student Reading 3:
"Sick Around the World"


"Have you ever paid a medical bill?" T. R. Reid, a correspondent for the Washington Post, asked a woman in Great Britain. "No, never," she replied. Britain has a socialized system. The government owns all hospitals and pays salaries to doctors. No one ever gets a bill, and the money for the system comes from taxes.

In Japan, Reid found that everyone signs up for a health insurance policy with employers paying one-half the bill. The Japanese have the longest life expectancy in the world, but at a cost of one-half what the U.S. spends on healthcare.

In the U.S. health problems and the medical bills that come with them drive hundreds of thousands of Americans yearly into bankruptcy. And while the rich and those with good insurance plans can get excellent care, the U.S. rates 37th among the world's countries on quality and fairness of its healthcare system. Interested in what Americans could learn from other advanced countries, Reid's traveled to a number of them.

Taiwan is another country with health insurance coverage for all. Every citizen has a "smart card" to give to a doctor on a first visit. The doctor puts the card into a reader, which supplies the patient's medical history and a list of medications he or she takes. The bill goes directly to the government insurance office.

Switzerland's healthcare system until 1994 was very much like the American. Then the change came in a countrywide referendum for a national health insurance program. Despite the strong opposition of insurers and drug manufacturers to the cost controls that would come with the program, the Swiss approved a system in which everyone who can afford to buys insurance and the state pays for the poor.

Each of these countries has a universal healthcare system, which means that every citizen, regardless of income or medical condition, is covered. Most of these countries have a "single-payer" system--meaning that there is only one government or nonprofit organization paying all the healthcare bills. This is also called "national health insurance."

In the United States, healthcare bills are paid by some 1300 private insurance companies as well as by various government programs, including Medicare, Medicaid, and the Veterans Administration. A study by the New England Journal of Medicine found that this complex bureaucracy accounts for 31% of the cost of healthcare in the U.S. and is part of the reason Americans spend about twice as much as people in other industrialized countries on healthcare.

While most industrialized countries insure their citizens primarily through a government-run social health insurance system, healthcare itself is usually provided through a mix of private and public hospitals and clinics, "using market ideas that might work for the U.S." (The exception is Great Britain, where the healthcare itself is provided by the government.) But no country trusts healthcare entirely to the free market. Limits include:

1. If there are private insurance companies, they must accept everyone who applies, regardless of medical history, and cannot profit from basic care.
2. Everyone must be covered by insurance.
3. Insurance and drug companies, doctors and hospitals must accept standard, fixed prices to keep costs down.

Note: This reading is based on "Sick Around the World," a Frontline PBS program. A transcript and video are available at www.pbs.org/wgbh/pages/frontline/sickaroundtheworld/

Most Republicans are wary of reform plans like those offered by Obama and Clinton--and even more wary of national health insurance--because they all call for greater government involvement. They believe this inevitably means bigger bureaucracies and greater inefficiencies, longer waits for medical care, reduced quality of care, funding crises, and use of outdated equipment.

However, as Reid's findings indicate, most people in countries with universal care support them because all citizens are guaranteed quality medical care from doctors they choose at a cost they can afford.

Insurance companies have not opposed the candidates' plans because built into them all is a major role for insurers. In fact the plans advanced by Obama and Clinton would bring insurance companies millions of new customers, partly at government expense. However the companies are fiercely opposed to national health insurance, which would essentially put them out of business.

Millions of Americans in certain categories are already covered under a public insurance system. All seniors 65 and over are covered by Medicare, many poor people are covered by Medicaid, military veterans are covered by the Veterans Administration. Government health insurance programs also cover public service workers and their families in federal, state and local governments and in public school and state universities.

American supporters of national health insurance ask: Why shouldn't all Americans enjoy such coverage? As a government official, Vice President Dick Cheney, for example, has excellent health coverage through his government insurance program. The California Nurses Association has been running ads with a photograph of Cheney, who has a history of medical procedures for his ailing heart, and a headline reading: "If he were anybody else, he'd probably be dead now." Well, not "anybody else," but certainly one of the tens of millions of Americans with inadequate health insurance or none at all.

For discussion

1. What questions do students have about the reading and how might they be answered?

2. What are major features in the healthcare systems described in the reading?

3. What meaning is given to the term "universal health insurance"? "Single-payer system"?

4. Where does opposition to universal insurance and single-payer systems come from in the
U.S. and why?

5. What American programs already include the universal and single-payer ideas?

Inquiry

How aware are students of how their personal healthcare needs are paid for? Of healthcare coverage in their families?

Would students be interested in preparing a questionnaire for their parents based on what they have learned from the readings and discussions? What should such a questionnaire cover?

Answers should be kept private but probably will raise issues and problems that students will be interested in pursuing in further inquiry and in class discussion.

Resources

The Kaiser Family Foundation's website provides excellent facts and analysis, including of candidates' plans: www.kff.org.

The website of Physicians for a National Health Program includes much helpful information about national health insurance: www.pnhp.org.

This lesson was written for TeachableMoment.Org, a project of Morningside Center for Teaching Social Responsibility. We welcome your comments. Please email author Alan Shapiro at: ashapiro7@comcast.net.

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