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Reforming the US health-care system
In Context
Reforming the US health-care system Both US presidential candidates McCain and Obama have promised to overhaul the health-care system in the USA. But what are the implications of these campaign promises and what could these mean for people with neurological conditions? Norra MacReady reports.
For more on the survey by the Commonwealth Fund see http://www.commonwealthfund. org/publications/publications_ show.htm?doc_id=698138
For more on the seven principles see http://www. nationalmssociety.org/ government-affairs-andadvocacy/download. aspx?id=1288
Health-care reform looms large in the ongoing US presidential election: 80% of the respondents in a survey commissioned in August by the Commonwealth Fund agreed that the health-care system needs to be either fundamentally changed or completely restructured. Both John McCain and Barack Obama have proposed to overhaul the system through various combinations of tax breaks, government subsidies, and regulatory tweaks, such as changes in the way insurance can be sold across state lines. How the health-care reforms proposed by either candidate will affect people with neurological disorders is hard to determine as yet. Whoever wins the election will most probably see their current proposals undergo extensive revisions before Congress deems such reforms worthy of approval. Important questions are still unanswered: both sides have given only sketchy details on their approach to prescription drugs, and long-term care has hardly been mentioned. Sarah Palin, McCain’s running mate and the mother of a child with Down’s
Ron Edmonds/AP/PA Photos
The printed journal includes an image merely for illustration
The presidential debate
986
syndrome, has promised to be an advocate for children with special needs, but she has not yet explained exactly what she meant. Another known fact is her opposition to embryonic stem-cell research. On the other hand, Obama’s running mate, Joe Biden, has voted to expand the number of embryonic stem-cell lines available for research. Neither party responded to requests for interviews.
“There is no doubt that the health-care system and how we finance it is not sustainable in its current form” Several of the organisations contacted for this Feature declined to comment, not wanting to be seen to favour either candidate. However, the National Multiple Sclerosis Society has released a list of seven principles for health-care reform that hint at the ways in which people with neurological disorders, as for people with other serious and chronic conditions, struggle with the shortcomings that are endemic to the US health insurance system. Common frustrations include: bureaucratic stonewalling; arbitrary rules and gaps in coverage; long waiting lists for publicly funded programmes or benefits; inconsistent policies between states; and discrimination by private insurers against people with cognitive or behavioural disabilities (which comprise expensive premiums, high deductibles and co-payments, and strict limitations on, or outright denial of, treatment). Both candidates have paid special attention to autism spectrum disorders (ASD), for reasons that are not clear. Obama has stated that, as President, he would seek to increase funding for ASD research, screening, and treatment by
US$1 billion every year by the end of his first term, and would appoint a Federal ASD Coordinator to ensure a smooth and rapid implementation of those reforms. McCain has been less specific, saying that he would “work to advance federal research into autism, promote early screening, and identify better treatment options, while providing support for children with autism so that they may reach their full potential”. Other than these statements, each candidate seems to be following basic party philosophy on how best to reform the health-care system: McCain, a Republican, favours a market-based approach, whereas Obama, a Democrat, emphasises a larger government role. At present, most Americans with health insurance have an employersubsidised scheme. Most beneficiaries contribute to the premiums or bear certain other costs, such as co-payments, but they are not taxed on the value of the subsidy. This system would change with McCain as President: insurance benefits would be seen as income and would be subjected to federal income taxes. This taxation would be offset by rebates of US$2500 to US$5000. Individuals would be permitted to shop around for coverage on the open market and would not be limited to policies offered by the companies doing business in their particular state, as they are now. At present, each state regulates the type of coverage that insurance companies must offer, and some observers fear that people who obtain health policies from states that have less comprehensive coverage could end up losing important benefits. At present, people with serious, chronic, or pre-existing conditions are at a grave disadvantage when it comes to finding or maintaining coverage: insurers may reject them,
www.thelancet.com/neurology Vol 7 November 2008
limit coverage, or make premiums so expensive that these are effectively de facto rejections. The campaign by McCain calls for the creation of a guaranteed-access plan for people who cannot obtain coverage any other way. However, some states already have such programmes, which face the very problems that this campaign is designed to prevent: high-cost and limited benefits. Therefore, it is unlikely that McCain’s plan would reduce the number of uninsured Americans. Obama’s proposal would offer a choice between public and private plans. People could keep their employer-sponsored coverage or could choose either a government-subsidised national health plan or a private plan offered through a national health insurance exchange. All of these policies would be required to offer, at minimum, similar benefits to those presently available to federal employees. Other features of Obama’s campaign, such as the requirement that employers who do not offer insurance must contribute to the national health plan, or the mandate that parents must have cover for their children, would effectively be paid for by the consumer, through lower wages, higher taxes, or both, although government subsidies would offset some of these costs. Obama would also not allow private insurers to “cherry-pick” customers by denying coverage to individuals because of pre-existing conditions or making premiums prohibitively expensive. The Obama plan would control costs through measures such as broad risk pooling, competition, electronic medical records, disease management programmes, and better coordination of long-term care. However, these strategies involve untested assumptions that might not be successful and could leave the government scrambling for more money within a few years. According to an analysis in Health Affairs, federal outlays under this plan would increase by about US$1·1 trillion over a decade, although others have disputed this calculation.
McCain and Obama have both focused on insurance reform because “that’s what resonates with the public and with business”, says Bruce Sigsbee, treasurer of the American Academy of Neurology (AAN) and chairman of the executive committee of BrainPAC, a political action committee created by the AAN to support political issues of interest to neurologists and patients with neurological conditions. However, the candidates’ proposals have so far ignored other crucial issues, such as funding for research and improving access to care. “These have not been components of either campaign”, notes Sigsbee. In addition, neither candidate has yet hinted at what their priorities will be for committing resources. “There is no doubt that the healthcare system and how we finance it is not sustainable in its current form”, says Rod Larson, chief health policy officer of the Center for Health Policy at the AAN. Among the changes that the AAN would like to see is better reimbursement for neurologists and other cognitive physicians to spend adequate time on assessment, diagnosis, and treatment of neurological disorders. One of the biggest concerns of the AAN at present is the disparity in government spending on procedures rather than cognitive therapies. “Neurologists who treat cognitive problems are told that what they do is not as important as doing a test, which drives doctors to do too many tests to survive in today’s economic environment”, says Sigsbee. Although funding for research has doubled over the past decade or so, in real dollars government spending has remained flat due to inflation. With competition for grant money being keener than ever, research will suffer unless funds are increased. Angela Geiger, a spokeswoman for the Alzheimer’s Association, agrees that more emphasis should be placed on research. With the 78 million baby boomers in the USA starting to turn 65 years old in 2011, Alzheimer’s disease is “fast becoming the health-
www.thelancet.com/neurology Vol 7 November 2008
Victor De Schwanberg/Science Photo Library
In Context
care crisis of the 21st century”, Geiger explains. “By investing in the right research now, we still have time to turn the tide.” Affordable coverage for people with early stages of Alzheimer’s disease is a concern, as is adequate care for people with dementia and other chronic conditions. For example, hospital admissions for congestive heart failure or diabetes multiply several times when these conditions coexist with Alzheimer’s disease. “There are opportunities for state as well as national candidates to do better on all of these issues”, Geiger says. She points out that medical advances coming to fruition today stem from funding decisions made 5 to 10 years ago. At present, “current levels of research are not even keeping pace with inflation”. “We must remember that insurance is meant to share the risk across a large population—those who are healthy and those who are not”, says Larson. “Reform that transfers proportionally more costs to neurological patients, who are already struggling to maintain coverage and related access to necessary therapies and treatments, is not acceptable.” Both presidential candidates are running on a platform of change. As the USA struggles through arguably the worst economic crisis since the Great Depression, whether these health-care reforms will amount to anything more than just talk remains to be seen.
Norra MacReady [email protected]
For more on comparing the plans of McCain and Obama see N Engl J Med 2008; 359: 781–84.
For more on the Obama spending estimate see Health Affairs 2008; 27: w462–71 For more on the disputations see http://www.commonwealthfund. org/aboutus/aboutus_show. htm?doc_id=705935
987
Reforming the US health-care system Both US presidential candidates McCain and Obama have promised to overhaul the health-care system in the USA. But what are the implications of these campaign promises and what could these mean for people with neurological conditions? Norra MacReady reports.
For more on the survey by the Commonwealth Fund see http://www.commonwealthfund. org/publications/publications_ show.htm?doc_id=698138
For more on the seven principles see http://www. nationalmssociety.org/ government-affairs-andadvocacy/download. aspx?id=1288
Health-care reform looms large in the ongoing US presidential election: 80% of the respondents in a survey commissioned in August by the Commonwealth Fund agreed that the health-care system needs to be either fundamentally changed or completely restructured. Both John McCain and Barack Obama have proposed to overhaul the system through various combinations of tax breaks, government subsidies, and regulatory tweaks, such as changes in the way insurance can be sold across state lines. How the health-care reforms proposed by either candidate will affect people with neurological disorders is hard to determine as yet. Whoever wins the election will most probably see their current proposals undergo extensive revisions before Congress deems such reforms worthy of approval. Important questions are still unanswered: both sides have given only sketchy details on their approach to prescription drugs, and long-term care has hardly been mentioned. Sarah Palin, McCain’s running mate and the mother of a child with Down’s
Ron Edmonds/AP/PA Photos
The printed journal includes an image merely for illustration
The presidential debate
986
syndrome, has promised to be an advocate for children with special needs, but she has not yet explained exactly what she meant. Another known fact is her opposition to embryonic stem-cell research. On the other hand, Obama’s running mate, Joe Biden, has voted to expand the number of embryonic stem-cell lines available for research. Neither party responded to requests for interviews.
“There is no doubt that the health-care system and how we finance it is not sustainable in its current form” Several of the organisations contacted for this Feature declined to comment, not wanting to be seen to favour either candidate. However, the National Multiple Sclerosis Society has released a list of seven principles for health-care reform that hint at the ways in which people with neurological disorders, as for people with other serious and chronic conditions, struggle with the shortcomings that are endemic to the US health insurance system. Common frustrations include: bureaucratic stonewalling; arbitrary rules and gaps in coverage; long waiting lists for publicly funded programmes or benefits; inconsistent policies between states; and discrimination by private insurers against people with cognitive or behavioural disabilities (which comprise expensive premiums, high deductibles and co-payments, and strict limitations on, or outright denial of, treatment). Both candidates have paid special attention to autism spectrum disorders (ASD), for reasons that are not clear. Obama has stated that, as President, he would seek to increase funding for ASD research, screening, and treatment by
US$1 billion every year by the end of his first term, and would appoint a Federal ASD Coordinator to ensure a smooth and rapid implementation of those reforms. McCain has been less specific, saying that he would “work to advance federal research into autism, promote early screening, and identify better treatment options, while providing support for children with autism so that they may reach their full potential”. Other than these statements, each candidate seems to be following basic party philosophy on how best to reform the health-care system: McCain, a Republican, favours a market-based approach, whereas Obama, a Democrat, emphasises a larger government role. At present, most Americans with health insurance have an employersubsidised scheme. Most beneficiaries contribute to the premiums or bear certain other costs, such as co-payments, but they are not taxed on the value of the subsidy. This system would change with McCain as President: insurance benefits would be seen as income and would be subjected to federal income taxes. This taxation would be offset by rebates of US$2500 to US$5000. Individuals would be permitted to shop around for coverage on the open market and would not be limited to policies offered by the companies doing business in their particular state, as they are now. At present, each state regulates the type of coverage that insurance companies must offer, and some observers fear that people who obtain health policies from states that have less comprehensive coverage could end up losing important benefits. At present, people with serious, chronic, or pre-existing conditions are at a grave disadvantage when it comes to finding or maintaining coverage: insurers may reject them,
www.thelancet.com/neurology Vol 7 November 2008
limit coverage, or make premiums so expensive that these are effectively de facto rejections. The campaign by McCain calls for the creation of a guaranteed-access plan for people who cannot obtain coverage any other way. However, some states already have such programmes, which face the very problems that this campaign is designed to prevent: high-cost and limited benefits. Therefore, it is unlikely that McCain’s plan would reduce the number of uninsured Americans. Obama’s proposal would offer a choice between public and private plans. People could keep their employer-sponsored coverage or could choose either a government-subsidised national health plan or a private plan offered through a national health insurance exchange. All of these policies would be required to offer, at minimum, similar benefits to those presently available to federal employees. Other features of Obama’s campaign, such as the requirement that employers who do not offer insurance must contribute to the national health plan, or the mandate that parents must have cover for their children, would effectively be paid for by the consumer, through lower wages, higher taxes, or both, although government subsidies would offset some of these costs. Obama would also not allow private insurers to “cherry-pick” customers by denying coverage to individuals because of pre-existing conditions or making premiums prohibitively expensive. The Obama plan would control costs through measures such as broad risk pooling, competition, electronic medical records, disease management programmes, and better coordination of long-term care. However, these strategies involve untested assumptions that might not be successful and could leave the government scrambling for more money within a few years. According to an analysis in Health Affairs, federal outlays under this plan would increase by about US$1·1 trillion over a decade, although others have disputed this calculation.
McCain and Obama have both focused on insurance reform because “that’s what resonates with the public and with business”, says Bruce Sigsbee, treasurer of the American Academy of Neurology (AAN) and chairman of the executive committee of BrainPAC, a political action committee created by the AAN to support political issues of interest to neurologists and patients with neurological conditions. However, the candidates’ proposals have so far ignored other crucial issues, such as funding for research and improving access to care. “These have not been components of either campaign”, notes Sigsbee. In addition, neither candidate has yet hinted at what their priorities will be for committing resources. “There is no doubt that the healthcare system and how we finance it is not sustainable in its current form”, says Rod Larson, chief health policy officer of the Center for Health Policy at the AAN. Among the changes that the AAN would like to see is better reimbursement for neurologists and other cognitive physicians to spend adequate time on assessment, diagnosis, and treatment of neurological disorders. One of the biggest concerns of the AAN at present is the disparity in government spending on procedures rather than cognitive therapies. “Neurologists who treat cognitive problems are told that what they do is not as important as doing a test, which drives doctors to do too many tests to survive in today’s economic environment”, says Sigsbee. Although funding for research has doubled over the past decade or so, in real dollars government spending has remained flat due to inflation. With competition for grant money being keener than ever, research will suffer unless funds are increased. Angela Geiger, a spokeswoman for the Alzheimer’s Association, agrees that more emphasis should be placed on research. With the 78 million baby boomers in the USA starting to turn 65 years old in 2011, Alzheimer’s disease is “fast becoming the health-
www.thelancet.com/neurology Vol 7 November 2008
Victor De Schwanberg/Science Photo Library
In Context
care crisis of the 21st century”, Geiger explains. “By investing in the right research now, we still have time to turn the tide.” Affordable coverage for people with early stages of Alzheimer’s disease is a concern, as is adequate care for people with dementia and other chronic conditions. For example, hospital admissions for congestive heart failure or diabetes multiply several times when these conditions coexist with Alzheimer’s disease. “There are opportunities for state as well as national candidates to do better on all of these issues”, Geiger says. She points out that medical advances coming to fruition today stem from funding decisions made 5 to 10 years ago. At present, “current levels of research are not even keeping pace with inflation”. “We must remember that insurance is meant to share the risk across a large population—those who are healthy and those who are not”, says Larson. “Reform that transfers proportionally more costs to neurological patients, who are already struggling to maintain coverage and related access to necessary therapies and treatments, is not acceptable.” Both presidential candidates are running on a platform of change. As the USA struggles through arguably the worst economic crisis since the Great Depression, whether these health-care reforms will amount to anything more than just talk remains to be seen.
Norra MacReady [email protected]
For more on comparing the plans of McCain and Obama see N Engl J Med 2008; 359: 781–84.
For more on the Obama spending estimate see Health Affairs 2008; 27: w462–71 For more on the disputations see http://www.commonwealthfund. org/aboutus/aboutus_show. htm?doc_id=705935
987