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Bruised and Broken: U.S. Health System
Older
Americans Increasingly Face a System Coming Apart at the Seams
By:
Trudy Lieberman,
AARP Buletin
March 2003
"Soaring
Health Premiums Creating More Uninsured"; "Despite Efforts,
Medical Errors Go on Killing"; "Half of Doctors Plan to Limit
Medicare Patients They Treat."
As the headlines
these days make all too clear, something is wrong with the U.S. health
care system. On some level everyone knows that—whether it's a drug you
can't afford, a medical mistake that injured a relative or finding a
doctor who will take your Medicare card. It has been coming apart for
decades only to be stitched back together by temporary fixes and, for some
people, by HMOs.
Hit by the
backlash against managed care, relentlessly rising costs and waves of new
technology, the system once again threatens to destruct. What ails U.S.
health care these days is deep and fundamental, many experts believe.
"The heart of the problem is the basic nature of the system—the way
insurance is paid and the way doctors are paid," says Arnold Relman,
M.D., the former editor of the New England Journal of Medicine.
"The system is fragmented, providers are paid on a piecework basis,
and there's no overall accountability."
The system seems
to work for people who stay insured and never have medical problems, but
once they need care or leave a job, they often bump into the barriers that
prevent them from receiving care. No wonder the Commonwealth Fund, a New
York-based research organization, found that Americans are more
dissatisfied with their system than citizens in Australia, Canada, New
Zealand and the United Kingdom.
Discontented as
some people may be, "there's no consensus that we need a whole new
system," says Robert Blendon, professor of health policy at the
Harvard School of Public Health. "People can be quite unhappy and
disturbed, but that doesn't translate into a major political
movement."
And so the system
staggers along with little agreement on how to repair it. Just look at the
political stalemate over a prescription drug benefit for Medicare
beneficiaries. In short, says Harvey Fineberg, M.D., the new president of
the Institute of Medicine, "We are drastically underperforming on
access, we are extravagant in costs"—and, he adds, the country is
just beginning to focus on quality. Americans confronting the realities of
growing old know what Fineberg means.
Some 41 million people have no health insurance—a statistic that many
people pay scant attention to. Middle-class Americans "have other
things to worry about," says Stuart Altman, a professor of health
policy at Brandeis University. "The uninsured are them, not us."
Increasingly, the
uninsured are us as employers cut back on coverage for active
workers, those retiring early and workers already retired. Americans too
young for Medicare but no longer insured through their employers are
finding themselves without health insurance for the first time in their
lives.
According to
William M. Mercer, an employee benefits firm, 46 percent of large
employers offered early retirees health insurance in 1993. By 2001 only 29
percent did. The numbers also tell a grim story for people already retired
and who expected to continue coverage from their employers. In 2001 only
23 percent of large employers offered insurance to retirees compared with
40 percent in 1993. Many employers still providing coverage are shifting
more of the cost to retirees.
Uninsured people
have few affordable options. Existing medical conditions make it hard to
buy a policy in the individual health insurance market, and state programs
designed to help the uninsured aid a limited number of low-income
individuals.
State high-risk
pools offer coverage to people who are uninsurable in the regular market.
But premiums are high.
It is no secret that the United States spends more of its gross domestic
product on health care than any other country. It spends 14.1 percent of
GDP on medical care, while the Canadians spend 9 percent, and the Germans
spend nearly 11 percent. Both Canada and Germany insure all their citizens
and have lower prices for prescription drugs.
Making matters
worse, cuts in Medicare mandated by Congress in 1997 are beginning to
squeeze the incomes and profits of providers and HMOs. As a result, some
HMOs no longer cover Medicare patients and have cut back on drug coverage.
And some physicians are turning away Medicare patients altogether.
"Additional
cuts in Medicare physician payments of the magnitude expected over the
next few years are likely to increase beneficiaries' access
problems," says Paul Ginsburg, president of the Center for Studying
Health System Change, a nonprofit policy research group in Washington.
Throughout the
1990s managed care tried to engineer changes in the system by paying
doctors to care for a group of patients and limiting the use of services.
Through selective contracting with physicians and hospitals, HMOs drove
down the cost of care.
"We
economists are convinced that savings went straight into the paychecks of
workers," says Uwe Reinhardt, an economics professor at Princeton
University. "Managed care was the best hope for getting high-quality,
affordable care short of having a single-payer system. But doctors
unleashed a huge political backlash." Moreover, some people with
valid complaints have come to view managed care as menacing.
With managed care
no longer generating hoped-for savings, patients are being forced to
shoulder more of the country's rising health care costs. And while
evidence mounts that shifting costs to patients could prevent some people
from getting care, that shift is occurring anyway. The Kaiser Family
Foundation recently reported that premiums shot up nearly 13 percent last
year, the highest increase since 1990.
The latest gee-whiz technology is almost instantly available whether or
not it has been proven effective. Yet many Americans fail to get basic
preventive care like Pap smears or cholesterol screening. Twenty percent
of women over age 18 have not received a Pap test in a three-year period,
and about half of all adults with diabetes have not received annual eye,
foot and blood pressure tests.
Even when people
get the care they need, there often are problems. Eight million households
have experienced a medical error that caused serious health problems,
reports the Commonwealth Fund.
And while errors
occur throughout the system, many occur when medicines are given in a
hospital. "The system is massively dysfunctional when it comes to
communication about medicines," says Carol Haraden, a vice president
at the Institute for Healthcare Improvement, a nonprofit group in Boston.
There are
glimpses of improvement on the quality front. The National Committee for
Quality Assurance, a nonprofit group that accredits managed care plans,
recently noted that HMOs had demonstrated slow but steady improvement in
the quality of care they deliver. Thirteen health plans, for instance,
reported that 100 percent of patients who had suffered a heart attack
received life-saving beta blocker treatment.
Still, many
studies of health care quality find huge gaps between the care patients
need and the care they get. Quality varies by location. Doctors are paid
the same whether they give poor or excellent care.
Many experts
believe the way to fix this problem is to encourage doctors and hospitals
to invest in systems to help them track what they are doing and give them
information to improve the quality of the care they provide. Redesigning
payment policies also would offer incentives to provide better care.
Equally
important, Americans have yet to decide two basic issues:
-
Is health care a right? Or is
it a privilege for those lucky enough to have private insurance or to
qualify for government programs?
-
Should insurance cover
everything or should it be reserved for those catastrophic health
events that few can pay for out of pocket?
Until Americans
reach consensus, the system will continue to push to the brink, only to
fall back again leaving unhappy people, many unable to get care, along the
way.
Trudy
Lieberman, a veteran health care journalist, is the director of the Center
for Consumer Health Choices at Consumers Union. The views expressed here
are hers, not those of Consumers Union.
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© 2002 Global Action on Aging
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