Can Barack Obama deliver healthcare to all Americans?
In the UK most of the debate on the change presented by Barack Obama's election has focused on foreign policy challenges and more recently on his plans to revive the US economy, both situations he has inherited. Hardly anything has been said about his own priorities and the policies that saw him elected over Hilary Clinton and John McCain. What excites me about President Obama is the possibility that he might succeed in his ambition to bring universal health coverage to the United States of America.
There is a question over whether “events” mean Obama doesn't get the change to focus on domestic priorities – the affliction of Lyndon Johnson and maybe even, if we were to be kind, also of George W Bush– but there are some positive early signs that Obama intends to make the space to reform American healthcare. All presidencies are eventful and as a close Obama advisor says, with reference to the credit crunch, presidents should never miss the opportunity that a crisis presents.
The paradox of American healthcare
The need to reform the American system is not questioned. The route is, however, and political difference is the major obstacle to the fulfillment of Obama's ambitions.
More about political differences later. What are Obama's ambitions for health? The new president is passionate about ending the massive inequality in the US system, a country where 40 million people are without health insurance. (And just to be clear, the people who are most vulnerable are not necessarily the poorest in society, for whom Medicare makes some provision. It is those who earn low to median wages, for whom insurance is a very expensive choice. These are people who would describe themselves as “middle class” who are un-and-under insured.)
There is a paradox in the American health system. It is both the best and the worst health system of the developed world.
I myself work with doctors in England, specifically professionals who work within the field of gastroenterology: nurses, scientists and, of course, hospital consultants. Each year many attend the Digestive Disorders Week conference in the US (the DDW). Why? Because the American Gastroenterology is the world's leading journal (though being chased down by our own, Gut.) And there is a view that the US leads medicine and science in many areas. It is the place to go to find leading-edge practice and theory. Arguably it is health system provides the best care in the world.
Crucially, though, it is only the best system in the world for those with premium insurance. The paradox of American healthcare is that for those who are uninsured, it is the worst healthcare system in the world. American stands alone in the developed world in legitimating a large health underclass.
Contemporary stories about US healthcare are scarcely believable. On December 30th, the FT recounted a story about a woman who screamed to be let out of an ambulance taking her to hospital. She wanted to avoid the $300 transit charge. Economically and philosophically, such individual sensitivity to the cost of healthcare is a very miserable thing.
Shrugging this shame is Obama's challenge.
It is a challenge he seems keen to take on. He has begun talking publicly about the need for change.
At the beginning of December the President-elect asked the American public to meet with each other in their neighbourhoods to come up with ideas about how to improve the healthcare system. It seems that Obama is preparing America for major reform. One view is that Obama is trying to replicate the new politics he tried to create in his election: local debate about how best to achieve change.
How many health secretaries have written books on health reform?
Underlining Obama's reforming ambition is the appointment of a heavyweight politician as his secretary of state for health. The Washington Post interprets the appointment of Tom Daschle as confirmation that the incoming Obama administration has made health care reform a top and early priority for action in 2009.
Rare amongst health secretaries, the new health secretary has written a book on health reform, published less than a year ago, in March 2008. The Wall Street Journal summarises it thus: any reform must be comprehensive; we can no longer afford incrementalism or inaction.
(One of the things that impresses me about Barack Obama is that he has set out his views in books. When you think about it, it's pretty radical. Can you imagine a British politician doing the same thing? David Cameron is struggling to put together anything more serious than soundbites on policy. Yet in the 'Audacity of Hope' – a title that is easy to laugh at – Barack Obama sets out his political creed and is clear about how he came to it. I find that very impressive.)
But perhaps the biggest danger with Obama's appointment is the high bar we have set in expectation. The same may be true of his health secretary.
Tom Daschle's appointment has raised expectations amongst the policy community. " It has been universally popular amongst the health policy experts and advocates of universal healthcare”, says the Washington Post. American Prospect's Ezra Klein called Daschle's appointment "huge news, and the clearest evidence yet that Obama means to pursue comprehensive health reform."
It's the politics, stupid
But policy credibility is not his main strength. The appointment of Tom Daschle suggests that Obama sees health reform as fundamentally a political problem.
The last attempt at health reform in the States fell on political grounds. After Bill Clinton was elected in 92, he asked his wife, Hilary, to head a commission to explore reform. Her political inexperience and naivety were exploited by a range of opponents, supported by the insurance industry.
Obama seems keen to avoid making the same mistake and, in stark contrast, Tom Daschle's is a very experienced politician. He was the Democrats' Senate Majority Leader from 2001 until 2003.
The BBC's Adam Brookes says the decision to appoint Mr Daschle shows that Mr Obama feels he needs a Senate heavyweight to help him persuade Congress to back major reforms.
According to one US commentator, ‘you don't tap the former Senate Majority Leader to run your health care bureaucracy. That's not his skill set. You tap him to get your health care plan through Congress. You tap him because he understands the parliamentary tricks and has a deep knowledge of the ideologies and incentives of the relevant players. You tap him because you understand that health care reform runs through the Senate. And he accepts because he has been assured that you mean to attempt health care reform.’
As well as having an experienced and skilled politician, there are other positive forces for reform.
The Economist says that unlike last time, 'there is momentum for reform in Congress' and even 'big business is behind the idea of universal coverage because of soaring costs'.
Financial challenges
As well as politics, another barrier to reform has been cost and the economic framework in which health is understood in America. (US healthcare is already the most expensive in the world and the right to spend all an individual can is a seen as a fundamental right – “socialized” healthcare sounds like “socialist” and would constrain choice. It would be the same for all and negate the right to seek the very best care).
The economic crisis may present an opportunity to change this thinking.
The bumpiness of the political road ahead is illustrated by the arguments over the Obama's stimulus plan.
As in England, the Democrats plan to put money into the economy so as to counter the shrinking tendencies within the corporate sector.
Individual states face particular pressures. The Economist says they face a $70bn budget gap this year. To cover this, ‘half have already started cancelling infrastructure projects, cutting health-care benefits or laying off workers’. At the beginning of December, Barack Obama indicated that he wanted to provide funds directly to states to ensure no reduction in services. This move will be opposed by Republicans.
A plethora of plans for reform and little consensus between them
As I've said, although there is support for healthcare reform there is little agreement on exactly how it should be taken forward.
Arguments about reform have already played an important role in the Presidential election.
When battling for the Democratic nomination, Hilary Clinton and Barack Obama repeatedly clashed over a seeming detail of reform. Both candidates promised to move towards universal coverage, but a key argument was about how to go about this. Hilary Clinton wanted to see a mandate placed on all Americans, requiring them to arrange insurance, with a variety of schemes made available. She argued that ensuring universality was key to solving the financial pressures. Barack Obama supported the direction of travel, but not the mandate. He said a mandate would increase costs.
How do you provide care for the people that are most ill?
Once he had secured the Democratic nomination, Barack Obama duelled with John McCain over how best to provide coverage to the very ill, the people that regular insurance companies would not cover. McCain said they should be covered in specific schemes; Obama argued they should join public schemes so as to share the risk.
Obama has appointed Tom Daschle as health secretary so is presumably in sympathy with his views. What does his book say about the uninsured? The Wall Street Journal explains. ‘Mr. Daschle wants to open to all Americans the Federal Employee Health Benefits Plan - a menu of private-insurance options now accessible only to government workers. He would offer, in addition to the current plans, a government-run program, presumably similar to Medicare, although he provides few details. There would also be some form of means-tested premium support (or tax benefits) for Americans who couldn't afford one of the available plans.'
Money, money, money
In their Presidential debates, John McCain accused his rival of having a reform plan that would cost a fortune. Barack Obama managed to deflect the charge, but McCain had a point. Achieving universal coverage will mean some people paying more, and it will also require more constrained choices.
These cost of reform has not been explained. It will be pointed out by Republican opponents. They will also explain that as well as costing more, 'forcing' people into schemes will mean they have to follow collective rules, many of which will limit their available choices.
As the Economist says, Obama 'convinced voters he would somehow expand healthcare without resorting to radical plans'. 'It's time to get real'. In order to reform the US health system, Obama will need to win the argument for reform with the electorate and convince them that they may have to make trade-offs between free choice and a comprehensive system of care, universally available.
Is anyone prepared to make tough choices?
As the Washington Post pointed at the beginning of December, 'few politicians talk about trade-offs. The fee for service payment is driving up costs and the system is hospital centric.
The appointment of Tom Daschle suggests that the Obama administration may provoke debate on what is effective in healthcare and what the government can fund. In order to limit the growth in costs perhaps insurance should not fund the most expensive and experimental treatments.
Daschle's book suggests the creation of a "Federal Health Board. Its duties would include "recommending coverage of those drugs and procedures backed by solid evidence. It would exert influence by ranking services and therapies by their health and cost impacts." While common in Europe, in America this approach would be revolutionary.
Daschle admits that the board is based on the National Institute for Clinical Excellence in Britain and the Federal Joint Committee in Germany. As the Wall Street Journal explained to Americans not familiar with these bodies, 'both are charged with managing the public's access to higher-cost drugs, medical devices and procedures, but both are growing increasingly unpopular in their home countries -precisely because they've become a triumph of cost-containment over patient access and choice.
All eyes on America
In his book, The Audacity of Hope, Barack Obama makes the point that he has been seen as a blank canvass in which people project their own wishes and ambitions, because of his newness to politics. For all sorts of reasons – war in the middle east, environmental and economic pressures – people are building up expectations of what Obama can achieve. And because of his own positive stance – focusing on “hope” - Obama is fueling the same process, to a certain extent.
An article in Time magazine this week examined the expectations and hope attached to Barack Obama’s election outside of the US. Shocked by the expectations, it made the point that Obama had been elected US President; not Secretary-General of the UN. The magazine is right to remind non-American readers that it will be American voters who determine whether Barack Obama’s first term has been successful or not. Obama will be judged on domestic issues.
It is exciting that Obama is making healthcare a major priority. Though driven by different reasons, it is exciting that a consensus is forming around the need to reform US healthcare.
Tom Smith is chief executive of the British Society of Gastroenterology
www.bsg.org.uk
There is a question over whether “events” mean Obama doesn't get the change to focus on domestic priorities – the affliction of Lyndon Johnson and maybe even, if we were to be kind, also of George W Bush– but there are some positive early signs that Obama intends to make the space to reform American healthcare. All presidencies are eventful and as a close Obama advisor says, with reference to the credit crunch, presidents should never miss the opportunity that a crisis presents.
The paradox of American healthcare
The need to reform the American system is not questioned. The route is, however, and political difference is the major obstacle to the fulfillment of Obama's ambitions.
More about political differences later. What are Obama's ambitions for health? The new president is passionate about ending the massive inequality in the US system, a country where 40 million people are without health insurance. (And just to be clear, the people who are most vulnerable are not necessarily the poorest in society, for whom Medicare makes some provision. It is those who earn low to median wages, for whom insurance is a very expensive choice. These are people who would describe themselves as “middle class” who are un-and-under insured.)
There is a paradox in the American health system. It is both the best and the worst health system of the developed world.
I myself work with doctors in England, specifically professionals who work within the field of gastroenterology: nurses, scientists and, of course, hospital consultants. Each year many attend the Digestive Disorders Week conference in the US (the DDW). Why? Because the American Gastroenterology is the world's leading journal (though being chased down by our own, Gut.) And there is a view that the US leads medicine and science in many areas. It is the place to go to find leading-edge practice and theory. Arguably it is health system provides the best care in the world.
Crucially, though, it is only the best system in the world for those with premium insurance. The paradox of American healthcare is that for those who are uninsured, it is the worst healthcare system in the world. American stands alone in the developed world in legitimating a large health underclass.
Contemporary stories about US healthcare are scarcely believable. On December 30th, the FT recounted a story about a woman who screamed to be let out of an ambulance taking her to hospital. She wanted to avoid the $300 transit charge. Economically and philosophically, such individual sensitivity to the cost of healthcare is a very miserable thing.
Shrugging this shame is Obama's challenge.
It is a challenge he seems keen to take on. He has begun talking publicly about the need for change.
At the beginning of December the President-elect asked the American public to meet with each other in their neighbourhoods to come up with ideas about how to improve the healthcare system. It seems that Obama is preparing America for major reform. One view is that Obama is trying to replicate the new politics he tried to create in his election: local debate about how best to achieve change.
How many health secretaries have written books on health reform?
Underlining Obama's reforming ambition is the appointment of a heavyweight politician as his secretary of state for health. The Washington Post interprets the appointment of Tom Daschle as confirmation that the incoming Obama administration has made health care reform a top and early priority for action in 2009.
Rare amongst health secretaries, the new health secretary has written a book on health reform, published less than a year ago, in March 2008. The Wall Street Journal summarises it thus: any reform must be comprehensive; we can no longer afford incrementalism or inaction.
(One of the things that impresses me about Barack Obama is that he has set out his views in books. When you think about it, it's pretty radical. Can you imagine a British politician doing the same thing? David Cameron is struggling to put together anything more serious than soundbites on policy. Yet in the 'Audacity of Hope' – a title that is easy to laugh at – Barack Obama sets out his political creed and is clear about how he came to it. I find that very impressive.)
But perhaps the biggest danger with Obama's appointment is the high bar we have set in expectation. The same may be true of his health secretary.
Tom Daschle's appointment has raised expectations amongst the policy community. " It has been universally popular amongst the health policy experts and advocates of universal healthcare”, says the Washington Post. American Prospect's Ezra Klein called Daschle's appointment "huge news, and the clearest evidence yet that Obama means to pursue comprehensive health reform."
It's the politics, stupid
But policy credibility is not his main strength. The appointment of Tom Daschle suggests that Obama sees health reform as fundamentally a political problem.
The last attempt at health reform in the States fell on political grounds. After Bill Clinton was elected in 92, he asked his wife, Hilary, to head a commission to explore reform. Her political inexperience and naivety were exploited by a range of opponents, supported by the insurance industry.
Obama seems keen to avoid making the same mistake and, in stark contrast, Tom Daschle's is a very experienced politician. He was the Democrats' Senate Majority Leader from 2001 until 2003.
The BBC's Adam Brookes says the decision to appoint Mr Daschle shows that Mr Obama feels he needs a Senate heavyweight to help him persuade Congress to back major reforms.
According to one US commentator, ‘you don't tap the former Senate Majority Leader to run your health care bureaucracy. That's not his skill set. You tap him to get your health care plan through Congress. You tap him because he understands the parliamentary tricks and has a deep knowledge of the ideologies and incentives of the relevant players. You tap him because you understand that health care reform runs through the Senate. And he accepts because he has been assured that you mean to attempt health care reform.’
As well as having an experienced and skilled politician, there are other positive forces for reform.
The Economist says that unlike last time, 'there is momentum for reform in Congress' and even 'big business is behind the idea of universal coverage because of soaring costs'.
Financial challenges
As well as politics, another barrier to reform has been cost and the economic framework in which health is understood in America. (US healthcare is already the most expensive in the world and the right to spend all an individual can is a seen as a fundamental right – “socialized” healthcare sounds like “socialist” and would constrain choice. It would be the same for all and negate the right to seek the very best care).
The economic crisis may present an opportunity to change this thinking.
The bumpiness of the political road ahead is illustrated by the arguments over the Obama's stimulus plan.
As in England, the Democrats plan to put money into the economy so as to counter the shrinking tendencies within the corporate sector.
Individual states face particular pressures. The Economist says they face a $70bn budget gap this year. To cover this, ‘half have already started cancelling infrastructure projects, cutting health-care benefits or laying off workers’. At the beginning of December, Barack Obama indicated that he wanted to provide funds directly to states to ensure no reduction in services. This move will be opposed by Republicans.
A plethora of plans for reform and little consensus between them
As I've said, although there is support for healthcare reform there is little agreement on exactly how it should be taken forward.
Arguments about reform have already played an important role in the Presidential election.
When battling for the Democratic nomination, Hilary Clinton and Barack Obama repeatedly clashed over a seeming detail of reform. Both candidates promised to move towards universal coverage, but a key argument was about how to go about this. Hilary Clinton wanted to see a mandate placed on all Americans, requiring them to arrange insurance, with a variety of schemes made available. She argued that ensuring universality was key to solving the financial pressures. Barack Obama supported the direction of travel, but not the mandate. He said a mandate would increase costs.
How do you provide care for the people that are most ill?
Once he had secured the Democratic nomination, Barack Obama duelled with John McCain over how best to provide coverage to the very ill, the people that regular insurance companies would not cover. McCain said they should be covered in specific schemes; Obama argued they should join public schemes so as to share the risk.
Obama has appointed Tom Daschle as health secretary so is presumably in sympathy with his views. What does his book say about the uninsured? The Wall Street Journal explains. ‘Mr. Daschle wants to open to all Americans the Federal Employee Health Benefits Plan - a menu of private-insurance options now accessible only to government workers. He would offer, in addition to the current plans, a government-run program, presumably similar to Medicare, although he provides few details. There would also be some form of means-tested premium support (or tax benefits) for Americans who couldn't afford one of the available plans.'
Money, money, money
In their Presidential debates, John McCain accused his rival of having a reform plan that would cost a fortune. Barack Obama managed to deflect the charge, but McCain had a point. Achieving universal coverage will mean some people paying more, and it will also require more constrained choices.
These cost of reform has not been explained. It will be pointed out by Republican opponents. They will also explain that as well as costing more, 'forcing' people into schemes will mean they have to follow collective rules, many of which will limit their available choices.
As the Economist says, Obama 'convinced voters he would somehow expand healthcare without resorting to radical plans'. 'It's time to get real'. In order to reform the US health system, Obama will need to win the argument for reform with the electorate and convince them that they may have to make trade-offs between free choice and a comprehensive system of care, universally available.
Is anyone prepared to make tough choices?
As the Washington Post pointed at the beginning of December, 'few politicians talk about trade-offs. The fee for service payment is driving up costs and the system is hospital centric.
The appointment of Tom Daschle suggests that the Obama administration may provoke debate on what is effective in healthcare and what the government can fund. In order to limit the growth in costs perhaps insurance should not fund the most expensive and experimental treatments.
Daschle's book suggests the creation of a "Federal Health Board. Its duties would include "recommending coverage of those drugs and procedures backed by solid evidence. It would exert influence by ranking services and therapies by their health and cost impacts." While common in Europe, in America this approach would be revolutionary.
Daschle admits that the board is based on the National Institute for Clinical Excellence in Britain and the Federal Joint Committee in Germany. As the Wall Street Journal explained to Americans not familiar with these bodies, 'both are charged with managing the public's access to higher-cost drugs, medical devices and procedures, but both are growing increasingly unpopular in their home countries -precisely because they've become a triumph of cost-containment over patient access and choice.
All eyes on America
In his book, The Audacity of Hope, Barack Obama makes the point that he has been seen as a blank canvass in which people project their own wishes and ambitions, because of his newness to politics. For all sorts of reasons – war in the middle east, environmental and economic pressures – people are building up expectations of what Obama can achieve. And because of his own positive stance – focusing on “hope” - Obama is fueling the same process, to a certain extent.
An article in Time magazine this week examined the expectations and hope attached to Barack Obama’s election outside of the US. Shocked by the expectations, it made the point that Obama had been elected US President; not Secretary-General of the UN. The magazine is right to remind non-American readers that it will be American voters who determine whether Barack Obama’s first term has been successful or not. Obama will be judged on domestic issues.
It is exciting that Obama is making healthcare a major priority. Though driven by different reasons, it is exciting that a consensus is forming around the need to reform US healthcare.
Tom Smith is chief executive of the British Society of Gastroenterology
www.bsg.org.uk