No, said Patricia Lynch, Vice-President of State Government Relations Services at Kaiser Permanente
Access is an area in which Canadian and US systems have made very different choices. In the US, we control access by ability to pay. There are 47 million uninsured low-income people in the US. Many millions more are underinsured. In the US there is no mandate to have coverage and no mandate to provide coverage. It is purely a matter of choice for employers to provide coverage and it is done as part of a wage package that developed during World War Two as a response to wage controls: employers provided health care coverage instead of increased wages. Most of the uninsured are either employees of companies that do not provide coverage and low-income people who cannot afford to purchase that coverage on the individual market.
In addition to employer and individual insurance, the US has a government-sponsored package for very low income people called Medicaid. On paper, this is a very rich benefit package, but it is very difficult for low-income people to find a provider for basic primary care services because Medicaid pays providers very poorly and most providers are not required to participate in Medicaid. Catastrophic services are offered through the emergency rooms which are required to be open to people regardless of ability to pay.
Adapting to current health care realities requires political leadership, and here the health plans used in the US provide a slight advantage. Health plans, which are a market product, serve as a middleman between the voters and government or payers. Health plans can do things beneath the political radar. The biggest payers are the federal, state and local governments, whose spending on Medicare, Medicaid and their own employee programs makes up 44% of total US health care spending.
These programs purchase much of the coverage they provide through these programs from health plans. Health plans are contracted to provide a certain package of benefits. The contract stipulates a number of conditions that need to be met, such as acceptable waits for medical appointments, specialist consults and surgeries, acceptable travel distances to hospitals, information on outcomes, patient satisfaction and cost. Health plans must attract a broad spectrum of providers in order to compete for consumers. They have incentives to maximize cost-effectiveness and quality. When either the providers or consumers are dissatisfied because access is not fast enough or providers are not being paid enough, it is not government that takes the heat but the health plans. Government sets policy and goals, but the health plans are responsible for finding ways to achieve these. That drives innovation.
Although health plans are the product of a market based system, they are also used in comprehensive single-payer government sponsored systems in the Netherlands, Israel and Germany, where competing health plans deliver services under government-sponsored universal coverage. The US also uses health plans to provide services in the Medicare program for senior citizens.
The US is at moral risk to the extent it does not provide access to medical care to all its residents. Doing so is a huge political challenge. Most people in the US agree that the current system does not work and that coverage should be universal. Currently, employer-sponsored insurance is offered to employees without medical screening. However, individuals who buy insurance directly and not through their employer are medically screened for health conditions and can be denied coverage.
Without a mandate for universal coverage, medical screening is necessary to assure that the underlying pool of people covered is balanced, protecting the affordability of that coverage. Without medical screening or a mandate to have coverage, people would make the rational economic decision to purchase coverage only when they expected to need it, which would result in a disproportionate number of sick people purchasing coverage, driving up its cost. There must be a strong incentive for everyone to have coverage.
A new administration and the cost pressures on government make me optimistic that there will be a serious effort to adopt universal coverage in the US in the next few years. I believe the US will continue to incorporate health plans as is done in Europe.