Health spending now consumes 16% of the U.S. gross domestic product. What is troubling is that despite this expenditure, Americans seem to be getting less in the way of health care services.

The litany of problems in the health care system is disturbingly familiar: More than one-seventh of the population-more than 45 million Americans-are either uninsured or underinsured, thus denying them full access to medical care services, either primary care or specialty services. Employers continue to cut health benefits or to shift costs for medical care to workers by offering plans with higher deductibles and requiring higher out-of-pocket payments. Health care costs continue to rise steeply, driven by an aging population with a high prevalence of chronic diseases, a fragmented specialty-oriented medical workforce and a set of government policies that appear to be more concerned with favors to powerful segments of industry (technology, pharmaceutical) than concerned with the needs of the poor and middle-class citizen facing rising costs and diminishing services.

A Passing Reference

The current administration has shown little interest in reforming the health sector. President Bush, in his recent State of the Union address, mentioned health only in a passing way. Despite the increasing array of problems in the health sector, Bush could only come up with a few stale proposals that promise little in the way of needed reform, even were they to be enacted.

A recent commentary in The Lancet described it this way: "He dedicated only two short paragraphs of his speech to health care and did little more than tout three old and rather shopworn initiatives. He again promised to promote the use of electronic records and information technology. He again asked Congress to change U.S. medical malpractice laws to cap damages. And finally he pushed health savings accounts."¹

Capping malpractice damages is a move unlikely to effectively control the costs attributable to medical malpractice. In fact, on closer examination, none of these proposals stand to make much of an impact on improving the mounting and pervasive problems in the health system, particularly rising costs and decreasing access.

The Bush administration points to the passage of a prescription drug bill as an accomplishment in the area of health. Thus far, the new Medicare Part D plan seems to be encountering a great deal of difficulty in terms of implementation and in terms of participation by seniors. We all have heard about the confusion among eligible seniors about the enrollment process.

Who Is Benefiting?

Underlying this plan is the sinister belief, widely held among health policy experts, that this modification of the Medicare law will do relatively little to really help Medicare beneficiaries pay for the ever-rising cost of prescription drugs. Many experts believe that the prescription drug bill was more a sop to the pharmaceutical industry than a real assistance program.

According to Marcia Angell, MD, former editor of the New England Journal of Medicine, Medicare Part D represents a "bonanza" for big pharma, since it explicitly prohibits Medicare from using its enormous purchasing power to bargain for lower prices. Medicare can have no leverage in controlling what drug companies are paid for prescription drugs. "It isn't even permitted to peg charges to the average wholesale price, as is now the case when Medicare reimburses for drugs administered in hospitals or doctor's offices," Angell writes.²

To make sure that Medicare will not be able to influence drug prices, the benefits will be administered not by Medicare itself, but by multiple private companies with far less bargaining power. Lately, the practices of these companies has had the unintended negative consequence of putting a financial squeeze on small local pharmacies who, under the new plan, complain that they are not reimbursed by pharmaceutical intermediary payers in a timely manner.³

Title VII Cuts

Another less appreciated but no less important set of problems stems from the administration's cuts in primary care and health professions training support. Funds for primary care programs such as Title VII have been decimated in the past two federal budgets. Title VII provides support for health professions education, specifically offering grants to programs for subsidies to train primary care providers such as family physicians and PAs. Title VII programs for decades provided increased access to primary care, particularly for rural and medically underserved regions. It is likely that Title VII cuts, if they continue, will result in the elimination of all forms of federal support for PA training. In this fiscal year, Title VII funding was proposed to be cut by 50%.

PAs are acutely aware of the myriad problems facing the U.S. health system. They see them every day. In high school civics class, we learned that government is the societal structure that exists to provide people with services that cannot be provided efficiently by the private sector. By this definition, our government has an obligation to ensure equity and assistance to citizens who are unable to obtain essential health care services. By this and other measures, our government is failing us in an area in which governments in every other developed country provide for their citizens.

James F. Cawley is director of the PA/MPH program and professor and vice chair of the Department of Prevention and Community Health, School of Public Health and Health Services at The George Washington University in Washington. He also is professor of health care sciences at the university's School of Medicine and Health Science.

References

1. The state of US health-care reform. Lancet. 2006;367:541.

2. Angell M. The Truth About the Drug Companies: How They Deceive Us and What to Do About It. New York, NY: Random House; 2004:194.

3. Small drugstores hurting. Reported by Jim Acosta on the "CBS Evening News." March 14, 2006. To access, go to www.cbsnews.com, check the "Search Videos" bullet and enter "small drugstores hurting" into the search box.