As this column is being written, America's quadrennial self-flagellation over choosing a new president is underway, and by the time it arrives in your mailbox, a new president will have been elected.
That president will be facing numerous problems, one of which is providing health care to the 300 million Americans in the face of a failing economy, a huge budget deficit, and increasing unemployment, particularly in the manufacturing sector. Because employers laid the foundation upon which health insurance has been built, economic collapse, particularly of the auto industry and its related support industries, would leave thousands of workers without health insurance. Those who are employed will face increasing personal costs to participate in their coverage. In this environment, our ability as physicians to meet the standards of cardiac care will become increasingly difficult.
How either candidate meets the expectations in the next 4 years remains uncertain regardless of who becomes president. If we have a Democratic president along with the presumed ascendancy of a Democratic majority in Congress, it is possible but not certain that significant changes will occur. Sen. Barack Obama has promised a $2,500 decrease in insurance premiums and providing health care to everyone by achieving efficiencies in care.
With a Republican president, it is more than likely we will continue to deal with a stalemate in the face of a Democratic Congress. Nevertheless, Sen. John McCain plans to provide a tax credit for each individual of $2,500 and $5,000 to every family. Those who are uninsured can take their tax credit and apply it to the insurance of their choice when they become insured.
It is clear, however, that no one is totally happy with how health care is provided at the present. There is considerable anxiety about our individual ability to pay for health insurance as the cost of these plans continues to increase. At the same time, the number of uninsured remains unacceptably large—almost 45 million Americans are without health insurance. There has been a slight decrease in the number of Americans without insurance as more families are turning to Medicare and Medicaid as incomes decrease and the population ages. In 2008, as unemployment has risen and individuals have lost their employer-supported insurance, there has been a 2.1% nationwide increase in patients going into Medicaid. In Michigan, where unemployment is approximately 10%, Medicaid enrollment increased by 3.8%. As unemployment increases, we can anticipate this expansion of government coverage to increase.
The recent huge advances made in clinical science with its resultant increase in expensive drugs and devices represent a paradox in an atmosphere of diminishing economic resources. The calls for more aggressive preventive measures to decrease the incidence of coronary heart disease, hypertension, and diabetes is occurring in the face of an expanding population of uninsured patients and decreasing financial resources. Preventive medicine is lacking even for insured Americans.
However, throughout the country, alternative ways to pay and organize health insurance and provide a more inclusive system are emerging.
The Massachusetts health plan is one of those alternatives. It requires that each resident be enrolled in a private, state, or federal insurance program. It mandates universal coverage to those with lower incomes, using a sliding scale of premiums for families who are earning less than three times the poverty level or $63,000. Many of the insured have purchased private insurance, participate in the subsidized plan, or have enrolled in Medicaid. By providing state-sponsored health insurance programs, Massachusetts has seen the uninsured rate decrease to about 5% (N. Engl. J. Med. 2008:358;2757–60). This program, which relies on funding from the Centers for Medicare and Medicaid Services, provides a foundation upon which preventive medicine can be built, as well as an opportunity to mitigate the forces that lead to annually increasing acute care expenses. Whether or not this model can be applied to a larger population, particularly in view of the problematic national economy, our next president faces a significant challenge indeed.