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.

What do you think? Please share your comments by clicking here.

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

The Candidates on Health Care

John Lantos, MD
John B. Francis Chair in Bioethics

October 16, 2008

This week’s New England Journal of Medicine has articles (supposedly) by Barack Obama and John McCain, outlining their health care proposals. They show how the two candidates present radically different views of how to fix the health care system.

The centerpiece of Obama’s philosophy is, “Through a national health-insurance exchange, people without employment-based insurance or who work in small businesses will have a choice of private insurance policies at rates similar to those offered through large firms. To promote competition among insurers, we will also give patients a new public-plan option, providing the same coverage that is offered to members of Congress and their families.”

The centerpiece of McCain’s is, “to replace the current tax exclusion of the value of health insurance from employees' taxable compensation with a new refundable tax credit of $2,500 for individuals and $5,000 for families. Families can use the tax credit to continue their employment-based insurance or to find a plan that better meets their needs.”

In other words, Obama would build, as a safety net, a new public health insurance plan – perhaps an expansion of the Federal Employees Health Benefit plan – while McCain would rely upon the market to force insurance companies to develop affordable options.

Both plans are complex. Both candidates state, as a goal, that all Americans will have health care.

Joseph Antos, of the American Enterprise Institute, offers a critique of the Obama plan (Symptomatic Relief, but No Cure). David Blumenthal, of the Institute of Health Policy, critiques McCain’s plan (The McCain Plan for Health Insecurity). David Cutler and Gail Wilensky offer a video discussion of the future of health care.

Taken together, the essays and discussions offer a concise view of the opposing viewpoints about how to reform health care. Check them out!

To share your comments on the candidates’ proposals, click here.