Universal health care: How can anyone be against it?

October 1, 2008

While universal coverage sounds like a great idea on the surface, those who champion the cause have yet to answer many complex social, economic, and ethical questions.

For a variety of reasons, 47 million Americans don't have health-care insurance. It may be they are among the working poor who can't afford insurance, or are relatively young and healthy and don't want to pay for it because they don't think they'll get sick. Or perhaps they've been denied a policy because of a preexisting condition.

While many Americans consider these numbers a national disgrace, the real question that needs to be asked is, "What is Universal Health Care?" and what does it really mean? If there is one thing that I learned after 37 years of being involved in health care as a provider, a patient, and the parent of a patient, is that the devil is in the details.

As universal health care relates to women's health, we have to ask ourselves, what exactly are the details? Will universal health care mean that each patient insured will have the same plan? Will all patients have access to every provider-or at least all that accept Medicare? Will providers have to accept a predetermined rate? Where will the money be found to pay for universal access? Will the money come from "savings" in acute uncompensated care? Will preventive medicine be able to eventually reduce our $6,100 per person annual health-care costs? Or will the increased coverage be paid for by managing care (remember how people liked HMOs), decreasing fees to physicians, limiting services, or not funding providers of "uncompensated care" who are now being subsidized? Will there be a mandated "Medical Home?" Will ob/gyns qualify as primary-care providers? Do they want to be?

Health-care reform also raises questions about access to reproductive choice: Will all family planning needs be covered under a universal health coverage plan or only those forms acceptable to the party in power? Will insurance cover contraception? Abortion? Infertility services? Moreover, will referrals be necessary for a woman with abnormal bleeding or a vaginal discharge to see her gynecologist? Will obstetricians only take care of complicated pregnancies while midwives take care of more routine obstetrics?

$2.3 trillion is now being spent annually on health care, and this figure has continued to grow over the last 12 years at a rate that outpaces nonmedical inflation by a factor of 2 to 3. Will universal health care try to control this increased spending on health care? I can assure you that the answer to this is YES. Will it do so by controlling utilization of new technology? Existing technology? Medications? Admissions to hospitals? Length of stay in hospitals? Higher co-pays? Higher deductibles? Lower reimbursements to hospitals? Lower reimbursements to physicians? Increased mandatory utilization of mid-level providers? Use of "health centers" with city employees? Limiting "networks" of doctors or hospitals based on utilization and costs? All of the above? How will this affect women? How will that affect us as ob/gyns?

Will universal health care try to incorporate the new patient safety initiatives? Who is going to pay for improved patient safety as well as everyone having coverage? Will Pay for Performance be the way we separate the good from the "less good" doctors? Or will there really be cost savings by a "Not pay for complications" system? Does this mean that the hospital or the physician of a patient who has a vaginal hysterectomy and gets a postop infection or a bladder injury will not be paid for the surgery?

What are the advocates of universal health care saying about professional liability tort reform? If more people have access to care, will liability risk increase? Do they admit that medical liability issues are a major driving force in the increase in utilization of diagnostic imaging, use of new medications, and the increased costs of medicine? Are they embracing tort reform? Caps? Medical courts?

These questions need to be asked

I don't know the answers to any of these questions. I have been watching the election and the rhetoric closely. I have not heard either of the presidential candidates address these details. I have not heard anyone talk about whether universal health care means one level of health care if you were previously uninsured, another level if you are a Medicaid patient (state determined benefits), another level if you are Medicare or Medicare HMO, and another level if you can afford private commercial insurance or supplemental insurance? I have not heard the candidates talk about "limits," personal responsibility to control obesity, lack of exercise, smoking, illicit drug use, risky behavior, and all the other issues that contribute to one's health and the use of the health-care system.

Personally, until I hear a candidate who addresses these details, I know I can't make any decision concerning which one to support based on what they are all saying about health-care reform. This is a complicated problem that requires technocratic, detailed plans-not the usual glib sound bites of professional politicians.

DR. COHEN is Chairman of the Department of Obstetrics and Gynecology, Albert Einstein Medical Center, Philadelphia, PA, and Professor of Obstetrics and Gynecology, Jefferson Medical College.