City Club Missoula – Doctors discuss ethics of candidates’ health plans

Expanding medical coverage is as much an ethical issue as it is a campaign issue, according to three doctors who spoke at a forum Tuesday hosted by City Club Missoula.

With about 47 million people uninsured in America today, they said voters are gauging which candidate will enact change.

“This is actually a moral tragedy nationally and it is also a community tragedy,” said Dr. John Stone, a professor and former Missoula cardiologist.

By PAMELA J. PODGER of the Missoulian

Full Story: http://missoulian.com/articles/2008/04/16/news/local/news05.txt

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Text of Dr. Thomas Roberts’ comments to City Club Missoula:

"The Missoulian reported last week that about 90 working age Montanans died in 2006 because of a lack of health insurance. Nationally it is estimated that 22,000 people aged 25 -64 died in 2006 for the same reason. 47 million Americans lack health insurance at any one time. 80% of these are working families whose employers don’t provide insurance, and they can’t afford to buy it. People without insurance are sicker and die sooner than people with insurance. 94% of Democrats think that this is a very serious problem. 55% of Republicans feel the same way.

In fact, 69% of Republicans favor keeping the health care system as it is now, or only minor reforms. This is in contrast to the 65% Democrats who favor a plan that would provide insurance for all or nearly all of the uninsured even if it involved a significant increase in spending. Not surprisingly, Senators Obama and Clinton favor expanding health insurance coverage, and they view the government as having a role in creating that expanded coverage. Senator McCain does not.

The fate of the State Children’s Health Insurance Program (SCHIP) is good example of current administration’s and the Republican approach to health care issues, especially in comparison to the Democrats.

President Bush has vetoed 2 iterations of an expanded SCHIP, both passed by large majorities in house and senate. These bigger programs involved increased coverage for uninsured children, at a cost of 10 billion$/yr, as opposed to the current 5 Billion$/year.

Mr. Bush notes “ a philosophical divide… over the best approach for health care’ , “Democratic leaders in congress want to put more power in to the hands of the government by expanding federal health care programs. Their SCHIP is an incremental step toward the goal of government run health care for every American.”

It’s not hard then to understand that Senator McCain would support the administration’s view towards SCHIP and the government’s role in health care, as well as the Republican view that the status quo is fine. Senators Obama and Clinton, echo their Democratic constituents who believe that there are problems in the health care system, and that the government should play an important role in changing this. They are in favor of SCHIP expansion.

If preventing sickness and death is an ethical issue, then expanding coverage is an ethical issue. One could perhaps wonder as does our current president whether government has a role in dealing with this. Only 30% of Republicans feel that the government should have a role, while 60% of Democrats do.

People under 65, with any chronic illness, who are not employed, are essentially priced out of the health insurance market, if they can find any insurance at all. Medical costs are responsible for half of the 1 million personal bankruptcies that occur in the US each year. As the costs of insurance continue to rise the numbers of uninsured continue to rise. Our health care system is the most expensive in the world, by a factor of 2. There is no other developed country in the world where people are even remotely close to having these problems of paying for health care or missing needed treatment. If these are ethical issues, then the Democrats are preparing to address them. Senators Obama and Clinton would support regulations to ensure that insurance companies would not be able to deny coverage to people, regardless of health status. They would require employers to either provide health insurance or pay into a pool for the uninsured. A new public plan would be developed to exist alongside private insurance plans. Health insurance would be made available and affordable, for everyone, though it would require increased government spending on health care. Senator McCain in contrast has suggested eliminating the favorable tax treatment of employer based insurance. Health insurance would become the responsibility of the individual. This echoes the nearly 50% of Republicans who believe that it’s an individual’s responsibility alone to get health insurance, as opposed to 13% of Democrats. Under President McCain, there would be no regulation of insurance companies and even less of a role for the government in providing insurance to those who now cannot get it.

There is tremendous variation in costs across the country. As an example, we all know that the last portion of a person’s life tends to be very expensive. On average at Mayo it costs Medicare $29,000 for the last 6 months of a person’s life as compared to $53,000 at UCLA, nearly twice as much. This wide variation in care costs is common and well documented. It turns out to be mostly related to the number of specialists and hospital beds in an area. It also turns out that more medical care does not mean better care. More care is often associated with worse quality measures.

We know that having more primary care doctors in an area increases the quality of care and decreases overall medical costs. However, financial penalties and increasing workloads are driving primary care doctors like me out of business. While those of us in primary care are getting out if we can, there are few new primary care doctors being produced. Right now, here in Missoula and even more so in the rest of Montana, there is a scarcity of primary care doctors to take care of the poor, the elderly, and those with chronic disease. This is going to get worse.

Our health care system is well designed for maximizing profit. It rewards insurance companies, pharmaceutical companies, medical equipment companies, for profit hospitals, and our specialty based system. Although there are many good and ethical people working in health care, the current system cannot and will not provide medical coverage to everyone who needs it. It will not provide cost effective care with an emphasis on quality. Our profit based system is fundamentally at odds with a value based system. In thinking about our ethical values, our presidential candidates, and our health care needs, we need to understand this. The current administration, Senator McCain, a majority of Republicans and all the vested health care interests will continue to pursue a private, profit based, open market system. Ethical concerns, such as improving medical care for uninsured children, will not be on the table.

If our next president is a Democrat, we can be fairly certain of a different approach; one in which the federal government will certainly take a more active role in looking for solutions to ethical issues like coverage, access, and quality. Whether these concerns can overcome Washington gridlock and drive real change remains to be seen."

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Health Care in the 2008 Presidential Primaries

Robert J. Blendon, Sc.D., Drew E. Altman, Ph.D., Claudia Deane, M.A., John M. Benson, M.A., Mollyann Brodie, Ph.D., and Tami Buhr, A.M.

For the first time since 1928, neither the Democratic nor the Republican party has an incumbent president or vice president among the candidates in its field,1 so both primaries are particularly open to all challengers and very competitive. In this article, we report findings from public opinion polls that assessed how health care issues might affect voters’ choices in the 2008 presidential primaries.

Full Report: http://content.nejm.org/cgi/content/full/358/4/414

(Many thanks to Dr. Tom Roberts for sending this along. Russ)

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Presidential Politics and the Resurgence of Health Care Reform

Jonathan Oberlander, Ph.D.

Comprehensive health care reform disappeared from the national agenda after the Clinton administration failed to enact universal coverage in 1993 and 1994. Instead, Congress adopted incremental measures that enjoyed bipartisan support, including the State Children’s Health Insurance Program (SCHIP) and the Health Insurance Portability and Accountability Act (HIPAA). The retreat from comprehensive reform reflected, in part, the calculus that ambitious plans were too controversial and too hazardous to their sponsors’ political health to attempt. But that political calculus is changing. Health care ranks as the top domestic issue in opinion polls, and talk of major reform is back in vogue as the 2008 election approaches.

Full Story: http://content.nejm.org/cgi/content/short/357/21/2101??eaf

(Thanks again to Dr. Roberts for this article. Russ)