Apathy and fear are among the biggest stumbling blocks, experts say
By Joyce Frieden
MedPage Today, Jan. 28, 2015
WASHINGTON — The lack of greater movement toward universal healthcare coverage — especially a single-payer system — in the U.S. can be boiled down to four letters: AFIG, according to Philip Caper, MD.
The “A” stands for Apathy, Caper said Wednesday during a briefing on barriers to healthcare reform sponsored by the National Academy of Social Insurance (NASI). Caper is with Maine AllCare, an organization devoted to getting universal healthcare in Maine.
The attitude of many people is “‘I’ve got mine; why should I worry about anyone else?'” said Caper, a founding member of NASI, whose mission is to increase public understanding of how social insurance contributes to economic security.
“Or think of young invincibles, who think it’s worth the risk to go uncovered,” continued Caper, who was speaking by phone from Maine. “Perhaps apathy is the result of our emphasis on personal liberty and personal responsibility.”
The “F” stands for fear, Caper continued — “fear of change; the fear of losing coverage they already have; or the fear of loss of income or profitability” on the part of those working in the healthcare industry.
“I” is for ignorance, he said, making it clear that he was not equating ignorance with stupidity, rather a lack of information and understanding. “Most Americans don’t understand the healthcare system and don’t understand there are better ways of financing this,” Caper said.
“I definitely include doctors in this group,” he added. “I can tell you from personal experience that it’s almost impossible to get health policy into the medical school curriculum, where the focus is rightly on clinical medicine.”
And finally, there is the “G” — for greed. “This may seem harsh [but] the widely accepted view of healthcare as just another business is uniquely American, at least in degree,” he said. “I have heard some people say the healthcare system is becoming a wealth extraction machine. This view is reinforced by news stories of opportunistic pricing of drugs for chronic diseases such as hepatitis.”
Satisfied With the Status Quo
Another barrier to changing the way health insurance is delivered comes from the fact that many people are satisfied with their employer-provided health insurance, said Laurence Seidman, PhD, professor of economics at the University of Delaware in Newark.
“But they don’t seem to realize two things,” he continued. “First, what would happen if they lose their job? And second, [they don’t realize] that the rising premiums for medical care that their employers are paying is a key reason why their wage and salary growth has been so low.”
Many people also believe that using the private sector to provide services is better than using the public sector, “but it’s not better for things like national defense or health insurance,” he continued. “Many people also believe prices should be set without interference by government. I agree that’s true for most goods and services, but medical care is different [because] consumers can’t shop around; the best mechanism is for the government to represent consumers and negotiate prices for medical care with doctors, hospitals, and drug companies.”
Merton Bernstein, emeritus professor of law at Washington University in St. Louis, pointed out that most of the crowd at the meeting consisted of older people. “Millennials are not here, and that’s the problem,” he said. “How do we reach them to make them understand their stake in universal healthcare that’s affordable and comprehensive?”
Mischaracterization of the issues is another barrier to reform, Bernstein said. “One [mischaracterization] is that Medicare is not adaptable to the entire population because one size doesn’t fit all. People have to be told what in fact Medicare does — it is a massive program that’s the basis of the well-being of tens of millions of people, and it’s enormously popular, and yet it’s treated by many as if it’s an impediment to appropriate care.”
Suspicion of Government
Marcia Angell, MD, of Harvard Medical School in Boston, noted that “We distribute healthcare like a market economy, according to ability to pay, and not like a social service, which would be distributed according to medical need. But the people who most need healthcare are precisely those least able to pay.”
In terms of barriers, “much of the public often opposes the health reform law and [people] claim it expresses their antipathy toward big government. I believe that’s largely a canard promulgated by [the healthcare industry] and much of the media,” said Angell, who is also a past editor of the New England Journal of Medicine. “The issue for the public, I suspect, is not the size of government but the feeling that it doesn’t often work for their benefit and instead serves special interests.”
“Americans have no problems with programs [they consider beneficial] but are very suspicious of the private healthcare industry, which has the largest lobby in Washington,” she added. “So the major barrier … is the ‘medical industrial complex,’ as my late husband, Arnold Relman, pointed out in the New England Journal of Medicine 35 years ago.”
Joseph White, PhD, director of the Center for Policy Studies at Case Western Reserve University in Cleveland, said that three things needed for a policy to work were “technical capacity, institutional capacity, and political capacity … Most of the barriers to [single-payer] are political barriers; most barriers to other kinds of reform are technical barriers.”
The only way to overcome the political barriers would be to get businesses on board and make them realize that single-payer healthcare would be advantageous to them because they wouldn’t have to provide health benefits any more, “but business finds it easier to cut benefits,” White said. “I think it’s fair to say that the people who would be most necessary to cooperate, to overcome the power of the medical industrial complex, are much more interested right now in cutting benefits.”
Joe Antos, PhD, scholar in healthcare and retirement policy at the American Enterprise Institute, a right-leaning think tank here, said it is not clear what kind of reform people want, “for lots of reasons. One of the reasons is, not everybody’s going to agree to everything, so you have to decide who you want to listen to. So I think it is a good question … what is it that people prefer? The partial answer is, they just want something that works.”
Donald Berwick, MD, former administrator of the Centers for Medicare and Medicaid Services (CMS) in the Obama administration, said that after he left the agency and decided to run for governor of Massachusetts, “I did not enter the race as single-payer advocate, but my mind got changed very early” as he looked at the state’s budget and saw the increasing amounts of money going to healthcare. During his tenure at CMS, Berwick was criticized by Republicans for stating his admiration of the British healthcare system, which they said indicated support of rationing healthcare.
When he was campaigning, Berwick said he encountered a lot of confusion about the issue. “The first was confusion between the consolidation of payment in single-payer, and socialized medicine, where the government takes over delivery of care. People thought single-payer meant that the government becomes the provider of healthcare.”
In addition, the rising cost of healthcare was kind of buried, Berwick said. “People sort of know their own contributions to healthcare are going up, but when they actually do the subjective math, they can see the problem.”
Joyce Frieden is news editor at MedPage Today.