Universal and affordable health care: how can we achieve it?
International Journal of Integrated Care, 9 December 2009 - ISSN 1568-4156
Universal and affordable health care: how can we achieve it?

I was watching a live TV broadcast of the US House of Representatives voting for the health care reform bill (Affordable Health Care for America Act) in a hotel room on November 7th when I was visiting Philadelphia to participate in the annual meeting of the American Public Health Association. The voting continued, despite it being late on a Saturday night. When the House passed the bill at a narrow margin, I naturally imagined that the opening conference ceremony the next day would be full of excitement and enthusiasm, reflecting the long-held support of APHA members in favor of the national health insurance program.

As a regular participant of APHA, I vividly remember the opening ceremony of the APHA annual meeting in 1992 in Washington DC, shortly after the victory of Bill Clinton. “We got the president we have been waiting for!” shouted a speaker, followed by calls from the audience, “Universal coverage! Single payer!”. The atmosphere was so overwhelming that I felt that the time had finally come for the US to achieve a universal coverage. Unfortunately, the reform did not happen in the subsequent eight years under the Clinton administration.

However, the bill that was passed resembled what the APHA members had expected 17 years ago: a single payer. The bill included a provision requiring the federal government to create a public health insurance plan to cover the otherwise uncovered population. The non-elderly population will be given a choice between private and public plans, thereby stimulating a competition between them. A large, single payer will have bargaining power in controlling the price of health care. In the course of policy discussion, the Obama administration proposed an alternative to the single public health insurance plan: health insurance cooperatives (co-ops). Proponents of co-ops might have hoped that they would be able to provide better quality of care while avoiding too much governmental involvement and thereby making the reform more acceptable to other stakeholders.

A decisive factor determining the eventual fate of the newly passed bill will be finance. According to the Congressional Budget Office, if implemented, the new bill would cost over one trillion dollars in ten years (2010–2019). Even considering the increased tax revenue ($583 billion) and $219 billion savings over the ten years, it will accumulate a deficit of $239 billion. In other words, more savings must be achieved to sustain the universal coverage for Americans. Is there any more room for savings?

The Boston Globe featured an article describing the success of Group Health Cooperative (GHC) in Washington State (Michael Kranish, Health co-ops' fans like cost and care, The Boston Globe 19 August 2009). The article emphasized “their patient-controlled structure and non-profit status are not what will ultimately prove most useful. Rather, it is the way they pay doctors and care for patients that holds the most potential for savings”. One executive was quoted as saying “That integrated approach, combined with a heavy use of electronic records and follow-up communication, has led to big savings”.

The author of the article remained cautious enough to add, “But successful models are still rare nationwide”. In other words, the universal and affordable coverage of Americans will only be made possible by the rare but existing models, as exemplified by GHC. We already have ample evidence demonstrating that great cost saving, let alone improved quality, will be achieved when care provided by different specialists and providers is well integrated. The biggest challenge will be if the newly proposed health insurance body, whether it be governmental or cooperative, is able to implement the model of integrated care.

The opening ceremony of APHA meeting this year was not what I had imagined the night before. I did not see the excitement and enthusiasm I had witnessed 17 years ago. Most of the participants I talked with were not so optimistic about the prospect of the reform bill and some were even skeptical about it. It still remains uncertain if the bill will eventually pass in the Senate. It appeared to me there would be a long way ahead before the Americans achieve the long-awaited universal coverage.

Nonetheless, one thing was certain: the US will need to implement a mechanism to enhance quality and efficient health care if it is to achieve a universal and affordable coverage. Our journal has ample evidence to help them make it.

Etsuji Okamoto Prof. dr., National Institute of Public Health Department of Management Sciences, Saitama, Japan and editor of the International Journal of Integrated Care