Phantom Policies and Public Health in the Presidential Election

Kim Campbell, a former Prime Minister of Canada, regretted that elections were a terrible time to discuss substantive policy issues. Canada is not an exception. The discussion of public health coverage and the absence of population health policy in the current US presidential election campaign are good illustrations of Campbell’s point.

Republican and Democratic presidential candidates ignore issues of population health in part because it is extremely difficult to present an easily understandable position on the determinants of population health and how policy can address them. They therefore focus on health care, particularly issues of public coverage, which are more tangible to voters. They differentiate themselves through words that elicit support while enabling voters to read and hear whatever they wish into their proposals. As the health economist Uwe Reinhardt pointed out in 1992, a “full and forthright articulation” of views is dangerous because it identifies winners and losers, and would lead to “political self-immolation.”¹ The result is phantom policies.

Before reviewing the phantom policies of the US presidential candidates, let me first clarify that vagueness in the selling of a project does not mean that it won’t be carried out. Tommy Douglas, the Premier of Saskatchewan from 1944 until 1961 and the originator of universal health coverage in Canada, is a case in point.

In his 1944 election campaign, Douglas stated that the policy problem was that access to care was based on ability to pay rather than medical need and proposed a radical solution: universal coverage on the same terms and conditions for the entire population. However, he had little idea as to how he would actually implement a single-payer model since none existed at that time. This was the phantom in his policy. However, his government later designed and implemented the policy with the help of outside expertise, including two brilliant public health administrators from the United States. On January 1, 1947, 18 months before the British National Health Service, Douglas’ scheme became the world’s first single-payer system.

Douglas’ innovative policy was controversial in Canada. Other leaders of provincial governments and medical associations preferred to address access by subsidizing the purchase of private health insurance. But the Canadian federal government used its spending power to incentivize all provinces to adopt plans consistent with the Douglas model. The model spread, first through coverage of hospital care in the late 1950s and then of physicians’ services in the late 1960s. These policies have remained central in Canada ever since, though some have continually argued for expanding universal coverage while its critics advocate introducing more individual responsibility through user fees and private health insurance.²

US PHANTOM POLICIES

Like Tommy Douglas some 70 years ago, Bernie Sanders proposes to replace private health insurance for essential health care with universal access under a single payer. Sanders has promised to tax and spend quickly to cover the full continuum of healthcare under his plan, something no other high-income country has yet attained although many would aspire to the same goal. How he will achieve this is the phantom in his policy.

Hillary Clinton’s proposals for health policy retain employment-based private health insurance as the core of the health system for adults of working age. Programs that have evolved to fill the access gaps will remain in place (Medicaid as recently expanded, Medicare and State Children’s Health Insurance). The phantoms in this policy are that it does not address disparities in access to care and that, like Sanders’ policy, it does not propose, except in platitudes, to address the socioeconomic determinants of population health status. Moreover, even with a public option as an alternative to private insurance and stronger regulation of the pharmaceutical and medical device industries, her policy is not likely to reduce the rate of growth in health care costs to make per capita costs comparable with those in Canada and every other high-income country.

Each of the current Republican candidates would repeal the Affordable Care Act, which they demonize as Obamacare. However, they rely on phantom policies much more than the Democratic contenders. Trump, Cruz, and Kasich (the three candidates still running at the time of writing) claim that the market can fill the gap left by repealing the Affordable Care Act. They are silent, however, about Medicare in deference to elderly voters, and revive the Reagan-era notion of converting Medicaid into a program of block grants that would enable the states to reduce coverage and, thus, spend less. Although no candidate has said so explicitly, each of them seems nostalgic for a past when access to care was more determined by ability to pay than by government subsidy through tax policy or direct service program. The nonpartisan Committee for a Responsible Federal Budget, for example, estimated that the number of uninsured would nearly double under Donald Trump’s health plan, which is little more than a collection of platitudes about the benefits of broader-based competition for private health insurance and medical savings accounts.³

POPULATION HEALTH COMPLETELY MISSING

Overall, the issue of population health in a larger sense has been absent from electoral debate in the United State. I share John McDonough’s concern that deteriorating health status and (rapidly) growing health disparities have become a national crisis in the United States.⁴ But it is important to see that health and health care are not mutually exclusive.

There is considerable evidence that the design of a nation’s health system—how it delivers and finances care—has significant direct and indirect impacts on health status and wealth creation in a society.⁵ Health system design is one of the key social determinants of health. Multicountry econometric studies have found that systems that offer universal health coverage have a positive impact on population health.⁶ Since health coverage is a central concern of voters in every country, perhaps changing the way we finance, administer and deliver health services, and how these activities can be linked to other interventions would improve population health status and reduce health disparities. But as of now health system design is a universal phantom.

CONCLUSIONS

Canada has had consistently superior population health outcomes compared with the United States, in part as a result of universal health coverage. However, few Canadian political leaders recognize the connection between the particular design of its universal health coverage—its strengths and weaknesses—and population health outcomes. Similarly, there is scant evidence of a recognition of this connection in the current presidential campaign in the United States.