COMMENTARY
The Hippocratic Oath, the US Health Care System, and the Affordable Care Act in 2015 The original confines of medical knowledge under which the Hippocratic Oath was created have expanded considerably. Given the evolution of technology over the past 25 centuries, some of the Oath’s stances on issues such as abortion, euthanasia, and surgery have been subject to varied interpretations. However, 2 of its guiding principles have proven universal and timeless: protection of patients against harm and injustice at an individual and social level.1 Not providing patients with needed health care is harmful and unjust. This notion is the drive behind the development of 20th century healthcare systems. From the Bismarck Plan in Germany to the Semashko System in Soviet Russia, the majority of developed nations in Europe established gradually and successfully the roots of universal health care from 1883 to 1912.2 Following their model, the American Association of Labor Legislation drafted in 1915 the first proposal for a national health insurance system. Because of concerns over the methods of physician payments, the American Medical Association joined the American Federation of Labor and private insurance companies in efforts to block the legislation. On entrance of the United States into World War I, antiGerman sentiments led our government to commission articles labeling “German Socialist Insurance” as inconsistent with American values.2 Unwavering American exceptionalism, the for-profit health care industry, and physician concerns over personal income security are the trinity that hindered progress toward universal health care. The Cold War rhetoric, the threats of potentially desegregated hospitals, and the American Medical Association’s most expensive lobbying effort in American history (at the time) defeated President Truman’s health care bill.3 In establishing Medicare and Medicaid in 1965, President Johnson took legitimate steps toward universal health care, also causing the nationwide desegregation of hospitals.3 The dearth of progress over the next 6 decades (1955-2013) exemplifies poor governance: a Funding: None. Conflict of Interest: None. Authorship: All authors had access to the data and played a role in writing this manuscript. Requests for reprints should be addressed to Hagop Kantarjian, MD, MD Anderson Cancer Center, 1400 Holcombe, Houston, TX 77030. E-mail address: [email protected] 0002-9343/$ -see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjmed.2015.06.036
political establishment not addressing the needs of the many in favor of select interest groups. Overcoming the many obstacles toward progress in health care often was met with resistance from other avenues. The ideological propaganda against “socialized medicine” in the 1920s slowly morphed into anti-communism, anti-desegregation, and finally anti-welfare-ism. In the 1980s, health care costs became the popular excuse.3 Unlike health care in Europe, the for-profit healthcare industry in the United States generated some of the most powerful interest groups that now act as a strong deterrent to universal health care. Today, our healthcare spending more than doubles most European nations (18% vs 5%-9% of gross domestic product). The US healthcare system is the sixth largest economy in the world. Despite vast spending, several studies, including The Commonwealth Fund in 2014, rank our health care low among developed nations by several objective parameters: low patient satisfaction, high rate of medical errors, worse infant mortality, shorter life expectancy, and poor efficiency.4 From 2003 to 2013, health insurance premiums increased approximately 3 times faster than wages.5 During the depths of the recent recession in 2009, US health insurance profits increased by 56%, and top executives at the 5 largest companies combined received approximately $200 million in compensation.6 The problems associated with the existing healthcare system from 1965 until recently led to endeavors to improve it so that it provides better and more expanded health care at affordable costs. This is the premise of the Patient Protection and Affordable Care Act (ACA); its benefits have been detailed in previous publications.7 The ACA has moved the needle toward better and broader health care coverage for Americans. Presidential candidate Ben Carson said that “Obamacare is the worst thing that has happened.since slavery.”8 The reality is that the previous health care system enslaved 50 million uninsured Americans to the fears of illness and its devastating consequences. One year into its implementation, the ACA appears quite successful, even beyond any previous optimistic projections. The rates of uninsured Americans decreased from 18% to 10%.9 In states that accepted the Medicaid expansion, the rate was even lower (7% vs 14% in states that rejected Medicaid expansion).10 More people are approving of the ACA (43% vs 42%). Some 81% of ACA enrollees are
Jones et al
US Health Care in 2015
satisfied with their coverage, this rate being 91% for people on Medicaid.11 Insurance rate premiums are lower on average, which is unprecedented under our private healthcare system, and healthcare spending is lower than previous estimates.12 None of the scary predictions concerning the ACA materialized: mass cancellation of existing insurance policies, increased cost of care, soaring insurance premiums, job destruction, “death panels,” and ACA death spiral.7 As with most large-scale transformative endeavors, the ACA implementation had unintended consequences, such as those resulting from the expansion of Medicaid. In the original intent, people with annual incomes below the poverty line (
The Hippocratic Oath, the US Health Care System, and the Affordable Care Act in 2015 The original confines of medical knowledge under which the Hippocratic Oath was created have expanded considerably. Given the evolution of technology over the past 25 centuries, some of the Oath’s stances on issues such as abortion, euthanasia, and surgery have been subject to varied interpretations. However, 2 of its guiding principles have proven universal and timeless: protection of patients against harm and injustice at an individual and social level.1 Not providing patients with needed health care is harmful and unjust. This notion is the drive behind the development of 20th century healthcare systems. From the Bismarck Plan in Germany to the Semashko System in Soviet Russia, the majority of developed nations in Europe established gradually and successfully the roots of universal health care from 1883 to 1912.2 Following their model, the American Association of Labor Legislation drafted in 1915 the first proposal for a national health insurance system. Because of concerns over the methods of physician payments, the American Medical Association joined the American Federation of Labor and private insurance companies in efforts to block the legislation. On entrance of the United States into World War I, antiGerman sentiments led our government to commission articles labeling “German Socialist Insurance” as inconsistent with American values.2 Unwavering American exceptionalism, the for-profit health care industry, and physician concerns over personal income security are the trinity that hindered progress toward universal health care. The Cold War rhetoric, the threats of potentially desegregated hospitals, and the American Medical Association’s most expensive lobbying effort in American history (at the time) defeated President Truman’s health care bill.3 In establishing Medicare and Medicaid in 1965, President Johnson took legitimate steps toward universal health care, also causing the nationwide desegregation of hospitals.3 The dearth of progress over the next 6 decades (1955-2013) exemplifies poor governance: a Funding: None. Conflict of Interest: None. Authorship: All authors had access to the data and played a role in writing this manuscript. Requests for reprints should be addressed to Hagop Kantarjian, MD, MD Anderson Cancer Center, 1400 Holcombe, Houston, TX 77030. E-mail address: [email protected] 0002-9343/$ -see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjmed.2015.06.036
political establishment not addressing the needs of the many in favor of select interest groups. Overcoming the many obstacles toward progress in health care often was met with resistance from other avenues. The ideological propaganda against “socialized medicine” in the 1920s slowly morphed into anti-communism, anti-desegregation, and finally anti-welfare-ism. In the 1980s, health care costs became the popular excuse.3 Unlike health care in Europe, the for-profit healthcare industry in the United States generated some of the most powerful interest groups that now act as a strong deterrent to universal health care. Today, our healthcare spending more than doubles most European nations (18% vs 5%-9% of gross domestic product). The US healthcare system is the sixth largest economy in the world. Despite vast spending, several studies, including The Commonwealth Fund in 2014, rank our health care low among developed nations by several objective parameters: low patient satisfaction, high rate of medical errors, worse infant mortality, shorter life expectancy, and poor efficiency.4 From 2003 to 2013, health insurance premiums increased approximately 3 times faster than wages.5 During the depths of the recent recession in 2009, US health insurance profits increased by 56%, and top executives at the 5 largest companies combined received approximately $200 million in compensation.6 The problems associated with the existing healthcare system from 1965 until recently led to endeavors to improve it so that it provides better and more expanded health care at affordable costs. This is the premise of the Patient Protection and Affordable Care Act (ACA); its benefits have been detailed in previous publications.7 The ACA has moved the needle toward better and broader health care coverage for Americans. Presidential candidate Ben Carson said that “Obamacare is the worst thing that has happened.since slavery.”8 The reality is that the previous health care system enslaved 50 million uninsured Americans to the fears of illness and its devastating consequences. One year into its implementation, the ACA appears quite successful, even beyond any previous optimistic projections. The rates of uninsured Americans decreased from 18% to 10%.9 In states that accepted the Medicaid expansion, the rate was even lower (7% vs 14% in states that rejected Medicaid expansion).10 More people are approving of the ACA (43% vs 42%). Some 81% of ACA enrollees are
Jones et al
US Health Care in 2015
satisfied with their coverage, this rate being 91% for people on Medicaid.11 Insurance rate premiums are lower on average, which is unprecedented under our private healthcare system, and healthcare spending is lower than previous estimates.12 None of the scary predictions concerning the ACA materialized: mass cancellation of existing insurance policies, increased cost of care, soaring insurance premiums, job destruction, “death panels,” and ACA death spiral.7 As with most large-scale transformative endeavors, the ACA implementation had unintended consequences, such as those resulting from the expansion of Medicaid. In the original intent, people with annual incomes below the poverty line (
