In a country where more than one in two personal bankruptcies is due to medical bills, Barack Obama’s election was largely based on his health program.
Barack Obama would have been elected in large part thanks to his health program. This is the hypothesis formulated by Matthew Davis, professor of general pediatrics and associate professor of public policy. In any case, according to a survey conducted by the University of Michigan and published last October, 61% of Democratic voters confided that health issues would determine their vote.
Other experts in American political life are already claiming that if Barack Obama does not keep his promises on improving the health system, he has no chance of being re-elected. It must be said that the expectations of the American people are high. On the list of their concerns, health comes third behind the economic crisis and the war in Iraq. No wonder this when we know that in 2004, 54% of personal bankruptcies were due to medical bills!
So what are the flaws in this health care system that 90% * of American citizens want to see reformed in depth? They are of three kinds. First, no less than 16% of Americans have no health coverage. And 25% are poorly insured. Second major flaw: its cost. In 2006, the United States devoted 15.3% of its GDP to health compared to 8.9% on average in OECD countries. Third and final weakness: the low quality of care. The most powerful nation in the world is ranked 27th in the world for infant mortality and 23rd for life expectancy at birth. Result: the United States occupies the 37th position in the ranking of the best performing health systems established by the WHO. Barack Obama, the 44th President of the United States, will therefore have to fight on four fronts at the same time.
Promote access to healthcare for as many people as possible“My patients are no longer asking for their usual drugs, but the cheapest ones. And now they don’t come into my office on the first sneeze. They are waiting to have pneumonia ”. This testimony from Dr Albert Lévy, a general practitioner in New York, clearly illustrates that the poor quality of social coverage delays access to care. To remedy this, Barack Obama has a credo: to make this coverage “affordable and accessible”. “It is not a question of imposing a unique French model because health is a private good and everything is regulated by competition”, recalls Dr Michel Naiditch, associate researcher at Irdes (Institut de recherche and health economics literature).
Despite everything, the new president wants the state to guarantee access to healthcare, and not just for the poorest or for those over 65 as is currently the case. Concretely, he therefore wants to create the National Health Insurance Exchange (NHIE), which would be a kind of large health insurance subscription exchange bringing together offers from the private and the public. The public offer would be based on a minimum basket of care which remains to be defined. As for insurance companies, they would be forced to cover the risks of all Americans “unrelated to their state of health or their history” and to offer an offer at least equivalent to that of the public. Small businesses would be encouraged to offer coverage to their employees through tax credits.
As for the large firms which would not play the game, they would be forced to pay back a percentage of their payroll to finance the public coverage program. For children, Barack Obama is approaching a French-style system since he wants to make coverage compulsory and young adults can benefit from their parents’ insurance up to 25 years.
* Survey published in May 2008 in the New England Journal of Medicine
Financing the system by combating waste
The hunt for “waste” is on. To finance his health program, Barack Obama decided above all to make it more effective. According to his estimates, 50 to 100 billion dollars go up in smoke because of waste and poor quality of care. Certainly, the removal of the tax shield for American taxpayers whose annual income exceeds $ 250,000 will constitute a resource.
But, as he does not want to increase taxes, Barack Obama intends above all to save money. And there, his recipes are very similar to those implemented in France. He wants to computerize the health system with the creation of an electronic medical record.
In France, the DMP project is still far from having generated savings. The new president also wants to develop the prescription of generics and make compulsory “disease management” programs for chronically ill patients. In addition, the former senator from Illinois has the firm intention of authorizing the reimportation of drugs from other developed countries. And for the good and simple reason that in the absence of any regulation, drug prices are 67% more expensive in the United States than in Europe or Canada.
All the players in the system – doctors, industry and insurers – will therefore be involved. It remains to be seen whether this slimming diet will be enough. Several political scientists interviewed by the Lancet already predict that the bank bailout will force Obama to “revise his project downwards”.
Relieve doctors from judicial pressure
To observe with a magnifying glass the various contracts offered by the insurance organizations is the national sport of the American liberal doctors. “I signed a dozen contracts, testifies Dr. Colette Gordon, general practitioner in Chicago. It’s a complicated system. For a basic consultation, the price can vary between 35 and 55 dollars. Within the same organization, such as the Blue Cross Blue Shield, there are 5 or 6 different plans, or as many reimbursement variants. ”Not to mention that the amounts advanced by patients vary depending on the contract. “Fortunately the ‘co pay’ is written in black and white on their insurance card, sighs Dr. Gordon, who shares with a colleague the expenses of a secretary dedicated to these administrative matters.
Across the Atlantic, city doctors are less than a third to practice alone. “The image of the doctor with his black satchel who travels to see the grandmothers no longer exists”, underlines Denise Silber, American, specialist in health issues and president of a consulting company in France (Basil Stratégies ). They tend to come together in a group practice to share their fixed costs and provide more services to patients. “Between 20 and 50 practitioners, it’s almost a mini clinic,” explains Denise Silber.
The fear of lawsuits also pushes them to work together. “This makes it possible to have witnesses, and to be able to carry out additional examinations on the spot,” notes Denise Silber. “We practice defensive medicine,” regrets Dr. Gordon. If I see a patient who has a migraine, I always order a CT scan to cover me. The fear of lawsuits pushes insurers to increase premiums. “Mine costs $ 35,000 a year,” says Dr. Colette Gordon. They can amount to more than 100,000 dollars depending on the specialties. To limit this increase in insurance premiums which weighs on doctors, Barack Obama wanted to encourage the reporting of medical errors while protecting doctors from professional liability claims, a sort of National Medical Accident Compensation Office (ONIAM ) American style…
“In the United States, the income of doctors is 4 to 5 times higher than that of the French”, assesses Dr Michel Naiditch. On average, all specialties combined, annual net income before tax is $ 221,500. “For some specialists, especially in plastic or orthopedic surgery, they are well over a million,” notes Denise Silber. This explains why the end of the tax shield, promised by Barack Obama to finance the health program, did not please the
majority of doctors.
Develop a culture of good practices
The big black spot in the American system is the quality of care. Benefiting from the latest technologies, such as cutting-edge imaging (26.6 MRI units per million Americans against 3.2 units in France), the system remains “inefficient”, according to the Institute of Medicine. The infant mortality rate is 5 per 1000 in 2006, and among black Americans, it reached 9 per 1000. “We are subject to an obligation of continuing education”, describes Dr. Albert Lévy, general practitioner in New York.
Like the 700,000 doctors in activity in 2008 in the United States, he must renew his license by justifying training sessions, reading publications, training via the Internet. This credit system inspired the French reform of the CME. The pharmaceutical industry may subsidize the work of training organizations, but they are not supposed to interfere with the content. “However, the Josiah Macy Foundation, which specializes in health, recently questioned, in a report, the financial conflicts of interest between the pharmaceutical industry and continuing medical education, as well as teaching methods”, specifies Denise Silber .
An American study has shown that the repositories of good practices are used in cities in only 55% of cases. According to Denise Silber, “The exercise of the American physician is not subject to continuous evaluation, with the exception of the Veterans Care System (VHA), where all records are computerized and the randomized audit is convenient.”
Barack Obama proposed the creation of an “Institute of Best Practices” (Best Practices Institute) which would be responsible for informing insurance and patient choices. A way of indirectly forcing doctors to respect standards that should not please American doctors either.
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