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Health reform battles in the USA
Correspondence
Lyn Squire [email protected] 7903 Carreigh Parkway, Springfield, VA 22152, USA 1
Oxman AD, Bjørndal A, Becerra-Posada F, et al. A framework for mandatory impact evaluation to ensure well informed public policy decisions. Lancet 2010; 375: 427–31.
Health reform battles in the USA Constance Nathanson’s confused account of “who owns health inequalities” (Jan 23, p 274)1 is wrong on two central assertions: (1) that US Government refusal to address health inequalities explains the health reform battle, and (2) that “universal health care is the USA’s last best hope for reversing health inequalities”. First, the USA does “own” health inequalities, albeit inadequately, through government-sponsored insurance programmes that cover a third of Americans (Medicare for older and disabled people; Medicaid for millions living in poverty); moreover, as Nathanson acknowledges, local health departments routinely provide last-resort care.2 Stating that US public-health programmes are “enviable” while they haemorrhage from massive budget-cutting3 is absurd. Second, the very public-health scholars Nathanson cites as “vocal critics of social inequalities” (whether Marxist or not!) would be the first to say that universal medical care alone cannot resolve health inequities: also essential are societal efforts to tackle directly the conditions in which people live and work: the social determinants of health.4 The last time the USA made major progress in reducing socioeconomic and racial or ethnic inequities in premature mortality was during 1966–80, reflecting the effect of the War on Poverty, civil rights legislation, and the creation of Medicare and Medicaid.5 www.thelancet.com Vol 375 March 27, 2010
The political battle is not about the government “disowning” health inequalities: it is about the US health insurance industry greedily wanting to keep and expand its private consumer base—via legislation mandating that everyone purchase their “products” without any public alternative or serious public regulation. To claim that “[m]any Americans are perfectly content with a two-tier system” is egregious and without empirical basis. We declare that we have no conflicts of interest.
*Nancy Krieger, Anne-Emanuelle Birn [email protected] Department of Society, Human Development, and Health, Harvard School of Public Health, Boston, MA 02115, USA (NK); and University of Toronto, Dalla Lana School of Public Health, Toronto, ON, Canada (AEB) 1 2
3
4
5
Nathanson CA. Who owns health inequalities? Lancet 2010; 375: 274–75. US Institute of Medicine Committee on Assuring the Health of the Public in the 21st Century. The future of the public’s health in the 21st century. Washington, DC: National Academies Press, 2003. American Public Health Association. Q&A with CDC Director Thomas Frieden: ‘These are going to be very difficult times.’ The Nation’s Health 2009; 39: 9. WHO. Closing the gap in a generation: health equity through action on the social determinants of health. Final Report of the Commission on Social Determinants of Health. Geneva: World Health Organization, 2008. Krieger N, Rehkopf DH, Chen JT, Waterman PD, Marcelli E, Kennedy M. The fall and rise of US inequities in premature mortality: 1960–2002. PLoS Med 2008; 5: e46.
Author’s reply I understand that Nancy Krieger and Anne-Emanuelle Birn do not like my piece “Who owns health inequalities?”, but I have had some difficulty in fathoming the grounds for their dislike. Am I too hard on the USA or not hard enough? Their second paragraph is contradictory on that point: they suggest that I give too little credit to the government for Medicare, Medicaid, and public-health programmes of last resort, and too much credit to the government for our “enviable” public health infrastructure.
As they themselves point out, Medicare and Medicaid leave twothirds of the population without government-sponsored insurance (at the mercy of those rapacious insurance companies). And, budget cuts or not, US academic infrastructures in terms of public health and infectiousdisease control are “enviable” relative to those of other developed countries, as I know from my comparative cross-national research. I agree that universal medical care alone will not resolve health inequities. It has not ended inequalities in countries that do have universal medical care and is unlikely to do so in the USA. I note, however, that the programmes and activities Krieger and Birn cite as contributing to the reduction of health inequalities in the 1960s and 1970s were, in fact, governmentsponsored: the outcome of political processes. Absent such processes— requiring the recognition of health inequalities as a significant public and political problem and a responsibility of government—we are unlikely to have either universal medical care or significant progress toward “tackling the conditions in which people live and work”. Krieger and Birn’s quarrel with my statement that “many Americans are perfectly content with a twotiered system” is grounded, I must suppose, either on their belief that the US system is not “twotiered”—meaning that it does not discriminate between the rich and the poor in access to or quality of medical care—a belief I find hard to credit, or on their opinion that most Americans are, in fact, discontented with this discriminatory system. I readily admit that my statement was not based on polling data, but rather on the complete absence of popular outcry against our current system on the ground of its inequality. Many Americans are unhappy with one or another aspect of the system, but there is little evidence that its
The printed journal includes an image merely for illustration AP
I declare that I have no conflicts of interest.
1081
Lyn Squire [email protected] 7903 Carreigh Parkway, Springfield, VA 22152, USA 1
Oxman AD, Bjørndal A, Becerra-Posada F, et al. A framework for mandatory impact evaluation to ensure well informed public policy decisions. Lancet 2010; 375: 427–31.
Health reform battles in the USA Constance Nathanson’s confused account of “who owns health inequalities” (Jan 23, p 274)1 is wrong on two central assertions: (1) that US Government refusal to address health inequalities explains the health reform battle, and (2) that “universal health care is the USA’s last best hope for reversing health inequalities”. First, the USA does “own” health inequalities, albeit inadequately, through government-sponsored insurance programmes that cover a third of Americans (Medicare for older and disabled people; Medicaid for millions living in poverty); moreover, as Nathanson acknowledges, local health departments routinely provide last-resort care.2 Stating that US public-health programmes are “enviable” while they haemorrhage from massive budget-cutting3 is absurd. Second, the very public-health scholars Nathanson cites as “vocal critics of social inequalities” (whether Marxist or not!) would be the first to say that universal medical care alone cannot resolve health inequities: also essential are societal efforts to tackle directly the conditions in which people live and work: the social determinants of health.4 The last time the USA made major progress in reducing socioeconomic and racial or ethnic inequities in premature mortality was during 1966–80, reflecting the effect of the War on Poverty, civil rights legislation, and the creation of Medicare and Medicaid.5 www.thelancet.com Vol 375 March 27, 2010
The political battle is not about the government “disowning” health inequalities: it is about the US health insurance industry greedily wanting to keep and expand its private consumer base—via legislation mandating that everyone purchase their “products” without any public alternative or serious public regulation. To claim that “[m]any Americans are perfectly content with a two-tier system” is egregious and without empirical basis. We declare that we have no conflicts of interest.
*Nancy Krieger, Anne-Emanuelle Birn [email protected] Department of Society, Human Development, and Health, Harvard School of Public Health, Boston, MA 02115, USA (NK); and University of Toronto, Dalla Lana School of Public Health, Toronto, ON, Canada (AEB) 1 2
3
4
5
Nathanson CA. Who owns health inequalities? Lancet 2010; 375: 274–75. US Institute of Medicine Committee on Assuring the Health of the Public in the 21st Century. The future of the public’s health in the 21st century. Washington, DC: National Academies Press, 2003. American Public Health Association. Q&A with CDC Director Thomas Frieden: ‘These are going to be very difficult times.’ The Nation’s Health 2009; 39: 9. WHO. Closing the gap in a generation: health equity through action on the social determinants of health. Final Report of the Commission on Social Determinants of Health. Geneva: World Health Organization, 2008. Krieger N, Rehkopf DH, Chen JT, Waterman PD, Marcelli E, Kennedy M. The fall and rise of US inequities in premature mortality: 1960–2002. PLoS Med 2008; 5: e46.
Author’s reply I understand that Nancy Krieger and Anne-Emanuelle Birn do not like my piece “Who owns health inequalities?”, but I have had some difficulty in fathoming the grounds for their dislike. Am I too hard on the USA or not hard enough? Their second paragraph is contradictory on that point: they suggest that I give too little credit to the government for Medicare, Medicaid, and public-health programmes of last resort, and too much credit to the government for our “enviable” public health infrastructure.
As they themselves point out, Medicare and Medicaid leave twothirds of the population without government-sponsored insurance (at the mercy of those rapacious insurance companies). And, budget cuts or not, US academic infrastructures in terms of public health and infectiousdisease control are “enviable” relative to those of other developed countries, as I know from my comparative cross-national research. I agree that universal medical care alone will not resolve health inequities. It has not ended inequalities in countries that do have universal medical care and is unlikely to do so in the USA. I note, however, that the programmes and activities Krieger and Birn cite as contributing to the reduction of health inequalities in the 1960s and 1970s were, in fact, governmentsponsored: the outcome of political processes. Absent such processes— requiring the recognition of health inequalities as a significant public and political problem and a responsibility of government—we are unlikely to have either universal medical care or significant progress toward “tackling the conditions in which people live and work”. Krieger and Birn’s quarrel with my statement that “many Americans are perfectly content with a twotiered system” is grounded, I must suppose, either on their belief that the US system is not “twotiered”—meaning that it does not discriminate between the rich and the poor in access to or quality of medical care—a belief I find hard to credit, or on their opinion that most Americans are, in fact, discontented with this discriminatory system. I readily admit that my statement was not based on polling data, but rather on the complete absence of popular outcry against our current system on the ground of its inequality. Many Americans are unhappy with one or another aspect of the system, but there is little evidence that its
The printed journal includes an image merely for illustration AP
I declare that I have no conflicts of interest.
1081