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Healthcare in the era of change

This article first appeared in the St. Louis Beacon: November 7, 2008 -  It’s unclear where health care reform ranks on President-elect Barack Obama’s to-do list. But the mounting number of uninsured and underinsured Americans --as well as of the increase in Americans suffering from largely preventable diseases-- makes one thing clear: our health care system is in crisis.

An estimated 47 million people went without health insurance during 2006, a 22 percent increase since 2000, according to recent data from the U.S. Census Bureau.

The number of underinsured adults in the United States has also grown, with the risks of being underinsured often affecting Americans with higher incomes, according to a report published online June 10 in Health Affairs. Among insured American adults, 25 million were underinsured in 2007, a 60 percent increase from 2003. Most affected were those with incomes at 200 percent of the poverty level or more. Underinsured Americans are more likely to leave prescriptions unfilled, and skip or delay follow-up and preventive care, than those with adequate insurance, according to the report.

"This study captures the result of two distinct trends since the turn of the century: declining income growth among low- and moderate-income families, and health care premium and cost growth that continues to exceed economic growth," the authors wrote. "The coverage erosion for adults with incomes of 200-299 percent of poverty is now putting middle -- as well as low-income-- families at risk.” The authors call for policies that not only reduce the burden on citizen but improve the quality of care they receive.

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Abstract - Emanuel 

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Abstract - Sessions

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Taking Action

Two actions that would spur health care reform are better communication and cooperation between federal and state governments, and comprehensive tax reform, according to two commentaries published in the Oct. 22/29 issue of the Journal of the American Medical Association.

In the first commentary, Dr. Ezekiel Emanuel, of the National Institutes of Health and Sen. Ron Wyden, D-OR, offer the opinion that states are better able to experiment with reform, but face challenges related to authority and resources. They suggest that states should take responsibility for the creation of insurance exchanges, the prohibition of insurance discrimination against those with pre-existing illnesses, and the innovation and direction of programs targeted at their residents’ particular needs.

In the other commentary, Dr. Samuel Y. Sessions, of the Harbor-UCLA Medical Center in Torrance, Calif., and Dr. Philip R. Lee, of the University of California San Francisco, note that 60 percent of U.S. health care costs are financed by taxes and suggest value-added taxes covering universal vouchers. This would place a tax on the services received, but insurers would be required to accept any applicant presenting a voucher regardless of the health status of the patient. It’s a fairly radical plan that foresees phasing out Medicaid and Medicare for new enrollees. The subsidy for employer-provided insurance would be repealed under such a proposal.

"Many liberals support health care reform proposals that increase both taxes and health care regulation, giving conservatives two reasons not to support them. The plan described could appeal to conservatives by relying on increased competition to reform health care and to liberals by virtue of more stable and potentially more equitable taxes. A less regulatory approach to changing health care would be exchanged for more transparent taxes," Sessions and Lee wrote.

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It Will Take a Village

There are many reasons for the high health cares costs; there will have to be a variety of solutions. One issue that must not be overlooked is the tremendous cost associated with diseases and conditions that are largely preventable, including type 2 diabetes, heart attack, stroke, and even some cancers.

Consider that the implementation of 11 prevention measures can prevent up to two-thirds of heart attacks and one-third of strokes, according to an article published in the July 2008 issue of Circulation.

"Aggressive application of nationally recommended prevention activities could prevent a high proportion of the [heart attacks] and strokes that are otherwise expected to occur in adults in the United States today," according to the authors. "However, as they are currently delivered, most of the prevention activities will substantially increase costs. If preventive strategies are to achieve their full potential, ways must be found to reduce the costs and deliver prevention activities more efficiently."

Community-based disease prevention programs, to increase physical activity, improve nutrition and prevent tobacco use, could save our country $16 billion a year in medical costs within five years, according to a new report by Trust for America's Health.

The report, “Prevention for a Healthier America: Investments in Disease Prevention Yield Significant Savings, Stronger Communities,” indicates that while the proposed programs cost less than $10 per person per year, the return on the investment would be $5.60 for each dollar spent in five years. The recommended programs include increasing access to affordable nutritious foods, increasing the number of sidewalks and parks, and raising tax on tobacco. The implementation of these programs could reduce the rates of preventable diseases such as type 2 diabetes, high blood pressure, kidney disease (and many others) by up to 5 percent.

"The savings estimates in the report represent medical cost savings only and do not include the significant gains that could be achieved in worker productivity and enhanced quality of life," the authors wrote.

Dr. Cindy Haines is managing editor of Healthday-Physician's Briefing and president of Haines Medical Communications Inc., a full-service medical communications and consulting firm. As a board-certified family physician, Haines is well-versed in all areas of health care, with particular interest in fitness, nutrition, and psychological health. 

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