Can we build a just, two-tiered healthcare system?

Note: this week's post comes in the form of a news release from the Center for Practical Bioethics. Dr. John Lantos shares his thoughts on the prospects for healthcare reform given the history of the past 16 years on this issue.

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President-elect Barack Obama has promised to provide health insurance for every child in America. How will that be achieved? If recent history is instructive, it will not be by creating a single, egalitarian system.

Instead, we will create a two-tiered system – a publicly funded safety net for the poor and a private market in health insurance for those who can afford it. That’s according to John Lantos, MD, author of a commentary on the issue in October’s Archives of Pediatrics & Adolescent Medicine.

In the commentary entitled “Four Recent Health Reform Initiatives: Implications for Pediatric Health Reform,” Dr. Lantos explored four national programs proposed since 1993 to expand services to children. Two passed and two failed. Every case featured a battle between public and private coverage.

The lesson of our recent political history is that “we create public safety nets for the poor and private markets for everyone else,” says Dr. Lantos. “Oddly, we maintain private markets even if they are no better than public systems and cost much more.”

Dr. Lantos is the John B. Francis Chair in Bioethics at the Center for Practical Bioethics and also served on the Task Force on National Health Care Reform chaired by then First Lady Hillary Clinton in the early 1990s.

The good news, according to Dr. Lantos, is that the infrastructure for a combined public-private program is already in place. Dr. Lantos says such a program would start with an expansion and redesign of federally qualified health centers (FQHC). Such changes would include:

1. An expansion of the grant-funded portions of each FQHC operating budget while also eliminating means testing so all children would be eligible.

2. Competition between free FQHCs and the private system. FQHCs would remain a bare bones operation required to maintain access and quality to ensure funding. The private system would be forced to improve to attract paying clients.

3. A free flow of professional labor between the two systems. If the public system expanded, there would be a need for more pediatricians.

FQHCs could provide primary care and some specialty care for millions of children, even if the children don’t have health insurance.

Dr. Lantos says this may not be so bad. “Primary care for children is not the sort of health service for which health insurance was invented,” he says. “It is not, after all, a rare and unforeseeable event. It is, instead, something all children need.”

Health insurance will still be necessary for specialty care or catastrophic illness. “Routine elements of well-child care are particularly ill-suited to the indemnity insurance model of financing,” he says. “Catastrophic health insurance would be the primary payor for inpatient care.”

“Such a system might harness our deeply ingrained political values,” Dr. Lantos concluded, “in a way that creates an adequate safety net for the poor, an efficient public-private partnership and a vibrant, competitive marketplace for different styles of pediatric care.”

Link: Four Recent Health Reform Initiatives: Implications for Pediatric Health Reform, John D. Lantos, MD, abstract, Archives of Pediatrics & Adolescent Medicine, October 2008