Obama and Belgian Solidarity

This week, after an unforeseen trifle, the health care reform plans of President Obama were finally approved after all. Jan De Maeseneer estimates its importance for the U.S. and Belgium.

With a historic vote, the House of Representatives in the United States approved the reform of the health insurance system in the United States. Initially, this is a good thing for the accessibility of health care in the U.S., particularly for the millions of people who did not have health insurance already. More important is the underlying social choice: In a society where ‘care for yourself’ is the leading motive and where the individual responsibility model (“if you do not succeed, it’s your own fault”) reigns, the statement that only solidarity in the insurance system may form the basis for health care is a major turning point. This ‘new’ model in the U.S. makes health insurance compulsory and superinduces enrollment for the insurers. Until recently, health insurance companies could refuse patients based on their health: People who have had psychiatric problems and those who had problems with alcohol abuse, a chronic disease or a malignant disease could not get health insurance. That “risk selection” is now coming to an end.

The fact that the U.S. has set up collective insurance for sickness brings Americans closer to what we in Europe have expanded in the 19th and 20th centuries. The importance of this step can hardly be overestimated.

General Practitioner

Obama’s work is, however, not finished: The accessibility of health care will improve, but to permanently maintain the system, the cost effectiveness should increase, as the United States currently spends 16 percent of its gross domestic product on health care (in Belgium it’s 10 percent) and spends about twice per capita. This has to do with a system that is largely driven by the medical technology and pharmaceutical industries, and in which the patient, in principle, can shop around from one specialist to another. The reform of health insurance has to be accompanied by a reform of the health care organization in order to reconcile lasting quality and accessibility. Professor Barbara Starfield (Johns Hopkins University), through extensive international research, has shown that countries with strong primary care, where patients go to a specialist through the referral of a general practitioner, score much better in terms of quality and cost. The United States has only in recent years discovered the ‘family physician’ (G.P.), who works in the local community and provides the first relief of symptoms.

What is the relevance of the vote in the House of Representatives to Belgium? Initially, to keep our strong, inclusive social security coverage. However, there is a growing problem: In recent years, the “personal contribution” the patient pays when he or she is ill in Belgium has increased from 23 percent of total health expenditure to 27 percent. People pay more and more when they are ill. And it is clear that we are gradually approaching a limit, where the solidarity system itself stands under pressure.

A second problem concerns hospitalization insurance. Most of these policies are based on a system of risk selection: Some people can not get hospital insurance, and those who have an increased risk often pay a higher premium. This risk selection is at odds with solidarity and is not socially fair.

There is a third area of concern. Apparently, we fail to close the health gap between rich and poor: In 2004, the average life expectancy of a healthy man of 25 years in Belgium was 28.1 years for someone with only a primary school education, but 45.9 years for someone with college or university training. Recent data suggest that this gap has increased. These three challenges call for a structural approach. Internationally, a number of solutions were presented: The World Health Organization recommends investing in a strengthening of primary health care (World Health Report 2008: “Primary Health Care: Now More Than Ever!”). In 2005, the Organization for Economic Cooperation and Development (OECD) recommended encouraging patients to go to the specialist only if they were referred by a G.P., and not to refund patients who consult a specialist directly.

Commercialization

The debate on a future-oriented organization of health care and the necessary ‘choices’ that go with it is currently being conducted: On the one hand, via task arrangements for care pathways for chronic diseases at the federal level and, on the other hand, as part of a conference on primary health care that Minister Vandeurzen is preparing for December 11, 2010.

Finally, the developments in the United States will have a significant impact on what happens, for instance, in Eastern Europe and developing countries. In recent decades, American insurance companies, the traditional American model of market and commercialization, were installed in the Baltic States, Poland, etc., with devastating effects in terms of access to health care for the most vulnerable groups. Also, in Africa (Nigeria, South Africa), “for-profit” U.S. insurance companies are active in the private sector. The changes in the United States will hopefully lead to a different, more inclusive development of all American actors in health care systems throughout the world. That the U.S. and European models will converge more, with solidarity as a starting point, is also a hopeful prospective for developing countries.

Jan De Maeseneer is a professor of family medicine and primary health care at Ghent University. He believes Obama’s reform should inspire Belgians because the health gap between rich and poor is significant here.