As 2009 drew to a close, US President Barack Obama adopted a celebratory tone as the Senate finally passed his healthcare reform policy, aimed at making the system fairer [see President Obama’s healthcare reform plan here:http://www.healthreform.gov/obamaplan.html]. However, there are a few hurdles yet to clear. Republicans have already made clear they will fight against the bill becoming law and have even described it as authoritarian and a threat to civil liberties. Why is healthcare reform so important to the new President and why does it provoke such fierce criticism?
The US spends over $2.2 trillion a year on healthcare, around 16% of its GDP. This is comparatively high and amounts to more than double the percentage spent by European countries. Outside America, the US system is widely perceived as unequal, unfair and inadequate for such a rich country [a useful WHO factsheet on global health spending per country can be found here:http://www.who.int/mediacentre/factsheets/fs319/en/index.html]. Most individuals buy their own health insurance and in this respect, unlike the UK for instance, the current system does not have universal coverage. As of 2008, some 46 million US citizens (about 15% of the population) did not have health insurance. Anyone who is not insured becomes liable for healthcare costs incurred and, somewhat astoundingly, around half of all bankruptcies in the US are directly or indirectly related to healthcare costs. The state does run a scheme that provides cover for some low-income groups, and as the global recession bites, unemployment rises and health costs increase, the US government finds its state schemes are projected to cost three times more in 2050 than they did in 2007. In sum, the present system is not only unfair and unequal; it’s set to become a lot more expensive for government. Hence, Obama’s key reforms seek to force all individuals to have health insurance, with poorer families given subsidies to help them pay premiums. There would be stricter regulations for insurance companies so they would not be able to refuse insurance to people with pre-existing medical conditions or stop insuring anyone who becomes ill. Finally, Health Insurance Exchanges would be available for those not covered by employers, providing comparative advice including a state-run health insurance option.
Critics of the reforms complain of ‘socialized medicine’, a common refrain from Republicans who favour small government and no state intervention. To pay for the so-called ‘public option’ of a state-run insurance option, the bill before the House of Representatives argues in favour of a ‘health’ tax of 5.4% on very high-income families (those earning more than $500,000 a year). Again, such measures do not sit well with the American ideology of individual enterprise, self-help and the rewards that go with capitalistic risk-taking.
So is this just a very American problem? Probably not. Issues of economic downturn, rising unemployment and increasing health costs affect every healthcare system regardless of the relative balance between public and private provision. The problem could be framed as follows: can we afford to be healthy during a global recession? Put that way, the solution is obvious: encourage economic growth, get back to a sustainable pattern of growth and as the world pulls out of recession the ‘health problem’ is resolved. There is a much wider sociological issue here, though.
When the British National Health Service was launched, advocates argued that a large pool of illness and poor health existed in the country and that, once health services were made universally available, even to the poor, that pool would be drained, the population would become generally healthier and calls on the public purse for healthcare would diminish. The system would certainly be costly initially, but later this would be relatively insignificant compared to spending on defence, education and so on. That forecast has proved to be spectacularly wide of the mark [a brief history of the UK NHS is here in PDF format:http://www.dfidhealthrc.org/publications/country_health/nhs/NHS_history.pdf]. And yet, on the face of it, the assumptions built into the argument are logical and reasonable. People are generally healthier, they do live longer and they do suffer less from infectious diseases. So why are health costs continuing to rise and not diminishing?
Part of the answer is that ‘health’ has been continually redefined, taking in more conditions, new treatments, better monitoring, advancing medical technologies and shifting targets. Let’s take a few examples. In the age of the Internet, societies are now awash with health information and advice. Many people have something approaching expert knowledge of the conditions affecting them and what treatments are available, and are quite prepared to challenge medical professionals who refuse on cost grounds. Smokers, drinkers and other ‘illegitimate’ drug addicts can now expect health services to assist them to stop their habits. Tattoo removal, assisted reproductive techniques such as IVF, dietary advice on healthy eating, free contraception for under- 25s; all of these and many more are provided by ‘health’ services. Clearly what ‘health’ means has changed over time and is still doing so. Similarly, advancing medical technologies such as x-ray and ultrasound scanners, computed tomography scanning and magnetic resonance imaging (MRI) have revolutionized diagnostic procedures, but are also very expensive to buy, maintain and replace. Health, it seems, is becoming ever more expensive in modern healthcare systems.
Sociological critics of this expansive health provision describe the process as one of ‘medicalization’ in which lifestyle matters (e.g. smoking) are turned into urgent health issues in need of medical treatment and new interventions. Because ‘everyone is in favour of good health’, once lifestyle choices become health issues to be tackled, those on the side of health appear obviously rational compared to the irrational people who seem to want poor health. The general acceptance of health as a social good makes healthcare a sensitive policy issue: which serious politician would argue against more spending on health? It also helps to smooth the way for the adoption of more effective and expensive health technologies and fuels the medicalization process. Good health is a key cultural value that is almost beyond challenge.
Yet there are some counter-trends. The very glut of information provided by the Internet has enabled some people to take control of their own health needs without recourse to medics. Adopting preventative measures such as healthier lifestyles, self-monitoring and self-medication may, in time, generate an alternative desire to avoid contact with health professionals and hospitals unless absolutely necessary. Ivan Illich (1975) would see that as positive, given his argument that medics and medical treatments tend to cause as much illness as they actually cure and that reliance on medical professionals effectively deskills the population and produces passivity and dependence [Illich’s ideas in brief, article format here:http://www.davidtinapple.com/illich/nemesis.html]. Reliable, freely available health information and a better educated lay population may also be beneficial for medics, whose explanations and diagnoses may be more readily accepted and acted upon.
For the foreseeable future, the global health debate seems set to focus on costs and benefits. Whatever Barack Obama’s political success in transforming healthcare in the USA, the financial cost associated with the continual expansion of what constitutes ‘health’ will remain a much more deep-seated social and cultural problem for modern societies to resolve.
Philip W. Sutton
Chapter 11 is where health is given a systematic treatment, then health and illness issues can be found in: Chapter 9, pp. 353-74 on ageing, death and dying; Chapter 13, pp. 527-47 on poverty and health; Chapter 14, pp. 581-9 on global inequality. Though not strictly ‘health’ related, there is much in Chapter 5, particularly on pollution, global warming and GM foods, that is helpful.