By Mike Magee, MD If you were following the news this fall, you saw an intense battle over future of the State Children’s Health Insurance Program, or S-CHIP for short. At the center of the debate was whether to continue and possibly expand this program -- which provides health insurance coverage for low income children whose families are poor, but not poor enough to qualify for Medicaid. The S-CHIP debate this fall was widely viewed as a proxy vote for what is shaping up to be the number one domestic issue in the 2008 Presidential Election: Health Care.1,2 Just look at all the issues that came up during the S-CHIP debate and how they tie into the larger issue of what to do about our health care system. I count no fewer than ten issues that came up this fall and are sure to come up again:
1. Taxes: How much is too much?
2. State versus national control: How much variability should be allowed in setting state formulas for coverage of people with low incomes? (The high-end allowance currently goes to New York Governor Elliot Spitzer, who has proposed that coverage in his state should be extended to four times the poverty level for families. That means families with an annual income lower than $83,000 could be eligible.3
3. Universal health coverage: Should a modern, developed nation accept nearly 50 million uninsured (one sixth of the population), especially since taxpayers, in one way, shape or form pick up the costs of their care when they get in trouble?
4. Immigration: Should legal and illegal immigrant children be covered?
5. Tax incentives: Is it viable, as some have proposed, to use tax credit incentives to encourage low-income citizens to purchase health insurance?
6. Public/Private partnerships: Can we afford the increased management costs of the complex processes that come with a mixed public/private solution that embraces variability, decentralization, purposeful lack of standardization, and proliferation of middle men?
7. National leadership: Does the embracing of a free market approach let our national leaders off the hook, allowing them to avoid the tough work of organizing a reliable, preventive health care system which promotes access, quality and equity?
8. The American family: As more and more families become four and five generations deep, as opposed to three generations, does it make sense that we have a national health system in which Medicare covers fourth and fifth generation Americans; a public/private system covers at least a portion of the first generation; and a non-portable, variable, employer-based private “mish-mash” of a system covers second and third generation citizens? Should we really have to compete with each other, and manage this level of complexity inside our own families?
9. National Values: How committed are we to the collective security and success of all Americans?
10. Individual responsibility: If we were to decide that health was a right, and that all citizens in the United States must have insurance regardless, what other responsibilities would each of us have to bear in assuring our health and productivity? Would we be prepared to plan, adhere, and, when necessary, alter behavior to assure society a maximum return on its investment in us?
How we choose to organize, govern and structure this effort will define who gets what, what we’re paying for, and whether the time, effort and money was worth it.
As the saying goes, “You can pay me now, or pay me later.” Massively disorganized and variable systems spend a great deal of time “paying later.” Compared to other developed countries, U.S. tax revenues as a percentage of Gross Domestic Product ranks 17th in the world, at 28% of GDP.4 But, as everyone now realizes -- from General Motors to small and large city mayors to millions of Americans on the margins -- the true costs of health system confusion and our failure to get ahead of aging-induced disease curves is the creation of a tax burden that will likely exceed Sweden’s – which is currently #1 in the world.5,6 Swedes are taxed at a rate of 50.1% of GDP.4 But at least they know what they're paying for.
References:
1. State Children’s Health Insurance Program.
2. The Kaiser Commission on Medicaid and the Uninsured.
3. Eight states plan lawsuit against Bush over SCHIP. Associated content.
4. Johnston DC Taxes in Developed Nations Reach 36% of Gross Domestic Product. New York Times, C3, October 18, 2007
5. Magee, M. Threatened by Medical Bankruptcy.
6. Magee, M. Vulnerable Elders in America. |
