On February 24, President Obama gave a historic first speech to a joint session of Congress. Calling for unity, long-term responsibility, and hope, the President lay out his vision for his first term in office. He emphasized the current economic crisis and Americans’ fears about our jobs, homes and our children’s future.

Notably scant in this speech, however, was Obama’s vision for health care reform.

Health care played a major role in Obama’s campaign, but during his speech, he only mentioned electronic medical records, increased funding for cancer research and the creation of a new advisory body composed of businesses, workers, doctors and other health care providers to help set the path for reform.

As a future physician, I applaud these measures, but I had also sincerely hoped for some more health care “meat” in this historic speech.

Individuals like me who strongly believe that everyone has a right to quality and affordable health care were thrilled when Obama signed into law an expansion of the State Children’s Health Insurance Program and were hoping to get a bigger glimpse of our new President’s real views on reform.

Our health care system is sick and needs a lot of work to provide the type of care that can make Americans proud. Here are the top five problems I see with health care today:

1. More than 45 million Americans have no health insurance and millions more have inadequate insurance.
2. The burden of disease is greatly concentrated among working-class people and people of color.
3. American businesses are suffering too because of our employment-based health insurance model.
4. Private insurance companies make billions by charging as much in premiums as the market will bear and by denying as much care as they can get away with.
5. People in rural and inner-city areas have a hard time finding doctors and other providers because a large mal-distribution of the health care workforce to more affluent and suburban areas.

In fact, this list could continue for volumes.

Of course, I am totally for cancer research and electronic medical records (EMR). As a medical student, I see everyday that EMR is a no-brainer, given how hard it is to find important information in paper charts and unsearchable partial electronic medical records. This may be the most non-controversial topic out there—cancer funding is similar, given that almost everyone has been touched by cancer, either personally or through a loved one.

There are many other questions though that must be answered for us to get reform that translates into real care for real people, and these questions are very controversial.

The role of insurance companies in our new system is the most important question.

We need a system geared to maximize the health of individuals and to improve the nation’s public health. Profit-driven companies make the most money when they charge the highest premiums possible from the healthiest people in society. As soon as sick people start getting onto their roles, they have to start spending on care.

This leads to a system that is not aimed at maximizing our collective health, but instead aims to be as efficient as possible at excluding the people who need care the most.

This is wrong and the profit-drive should be taken out of insurance. Competition is only good when the most profit comes from the best service—currently the most profitable insurance companies are those that provide the worst service.

The second most important question about our new system is the difference between universal care and universal insurance.

A major problem with some reform proposals is that they would force people to purchase insurance plans (ie. through a so-called “individual mandate”) that have bad benefit packages and/or high copays or deductibles. What use is having insurance if it does not cover the care you need, or if even after paying the premiums, you still cannot afford to go to the doctor because of sky-high copays or deductibles? Such reform proposals are bad for normal, everyday working people. What we need, what we demand, is access to a doctor or hospital when and where we need it. That’s real reform.

The third question we need to ask is how the new system will not only fix the disparities in access to care, but also disparities in health outcomes.

People of color have unacceptably higher burden of disease and early death in our country. There are many reasons for this, including the racism in the health field and the inequities in education, housing, access to good food and jobs, bad drug policies, immigration and so on.

One main area that can be easily changed is expanding the number of people of color entering the health professions. We need a physician workforce that actually resembles our country so medicine can provide care to our complex and ever-changing society.   

In the coming months, I believe all of us have to be vocal and vigilant to make sure our priorities are front-and-center in the health care reform debate. Obama’s victory presents a historic opportunity, but his election is not a final victory. It is only a first step.

---

Flávio Casoy is a fourth-year medical student at Brown University in Providence, RI.