Au milieu des titres du Monde une discussion au Parlement sur l’acces au credit pour les malades – encore une fois les Etats-Unis sont cites en exemple. Dieu sait pourtant si le systeme de sante ici en general laisse a desirer.
Les medias n’en parlent que tres episodiquement. Une loi au Massachussetts qui introduit une couverture medicale universelle, une etude de Harvard bien inquietante sur les consequences economiques des maladies, et voila notre sujet – decidemment bien malade - reanesthesie pour quelques mois, couverture rabattue.
L'acces aux soins universel tient a peu pres du miracle dans ce pays et difficile de savoir si l’initiative sera durable : sa grande force de vente est en effet sa gratuite. Ses piliers sont, si je me rappelle bien, que toutes les personnes en etat d’avoir une assurance medicale personnelle soient obligees de payer une cotisation et de s’assurer, ainsi par exemple les jeunes travailleurs pour qui cela n'est souvent pas un poste de depense prioritaire ; d’autre part, que l’acces gratuit aux soins pour les plus demunis permettra une meilleure prevention et traitement avant que la maladie ne devienne grave – exit dont les couts eleves pour l’Etat de traitements curatifs lourds et de maintien de services d’urgence qui assurent pour beaucoup un accueil et des soins aux demunis. Charite bien ordonnée commence par etre a cout nul… reste a voir si le raisonnement financier est adequat, les electeurs pourraient se trouver mal lotis malcontents de voir, contrairement aux promesses, la facture collective augmenter.
« Sick and broke », c’est l’intitule d’une prise de position d’un Professeur de Havard. Son equipe a pu montrer que la moitie des declarations de faillite personnelle viennent de la sante, ou plutot du manque de. Pour leur majorite, ce sont des middle class americains, brutalement declasses voire qui se retrouvent dans des situations de grande pauvrete. Pour leur majorite, aussi, ce sont des beneficiaires d’assurance maladie qui ont pris soin de payer leurs dus, traites, et premiums. Cinq cent mille mericains seraient dans cette situation chaque annee ! Elizabeth Warren suggere que l’Etat souhaite aller plus loin et durcir les conditions de declaration de faillite personnelle – sur ce point peu d’informations, cependant meme le « business as usual scenario » apparaît en lui-meme inquietant.... mais, chut!, le patient dort et quel tantrum si on le reveillait.
Sick and Broke
By Elizabeth Warren
Wednesday, February 9, 2005; Page A23
Nobody's safe. That's the warning from the first large-scale study of medical bankruptcy.
Health insurance? That didn't protect 1 million Americans who were financially ruined by illness or medical bills last year. A comfortable middle-class lifestyle? Good education? Decent job? No safeguards there. Most of the medically bankrupt were middle-class homeowners who had been to college and had responsible jobs -- until illness struck.
As part of a research study at Harvard University, our researchers interviewed 1,771 Americans in bankruptcy courts across the country. To our surprise, half said that illness or medical bills drove them to bankruptcy. So each year, 2 million Americans -- those who file and their dependents -- face the double disaster of illness and bankruptcy.
But the bigger surprise was that three-quarters of the medically bankrupt had health insurance.
How did illness bankrupt middle-class Americans with health insurance? For some, high co-payments, deductibles, exclusions from coverage and other loopholes left them holding the bag for thousands of dollars in out-of-pocket costs when serious illness struck. But even families with Cadillac coverage were often bankrupted by medical problems.
Too sick to work, they suddenly lost their jobs. With the jobs went most of their income and their health insurance -- a quarter of all employers cancel coverage the day you leave work because of a disabling illness; another quarter do so in less than a year. Many of the medically bankrupt qualified for some disability payments (eventually), and had the right under the COBRA law to continue their health coverage -- if they paid for it themselves. But how many families can afford a $1,000 monthly premium for coverage under COBRA, especially after the breadwinner has lost his or her job?
Often, the medical bills arrived just as the insurance and the paycheck disappeared.
Bankrupt families lost more than just assets. One out of five went without food. A third had their utilities shut off, and nearly two-thirds skipped needed doctor or dentist visits. These families struggled to stay out of bankruptcy. They arrived at the bankruptcy courthouse exhausted and emotionally spent, brought low by a health care system that could offer physical cures but that left them financially devastated.
Many in Congress have a response to the problem of the growing number of medical bankruptcies: make it harder for families to file bankruptcy regardless of the reason for their financial troubles. Bankruptcy legislation -- widely known as the credit industry wish list -- has been introduced yet again to increase costs and decrease protection for every family that turns to the bankruptcy system for help. With the dramatic rise in medical bankruptcies now documented, this tired approach would be no different than a congressional demand to close hospitals in response to a flu epidemic. Making bankruptcy harder puts the fallout from a broken health care system back on families, leaving them with no escape.
The problem is not in the bankruptcy laws. The problem is in the health care finance system and in chronic debates about reforming it. The Harvard study shows:
• Health insurance isn't an on-off switch, giving full protection to everyone who has it. There is real coverage and there is faux coverage. Policies that can be canceled when you need them most are often useless. So is bare-bones coverage like the Utah Medicaid program pioneered by new Health and Human Services Secretary Mike Leavitt; it pays for primary care visits but not specialists or hospital care. We need to talk about quality, durable coverage, not just about how to get more names listed on nearly-useless insurance policies.
• The link between jobs and health insurance is strained beyond the breaking point. A harsh fact of life in America is that illness leads to job loss, and that can mean a double kick when people lose their insurance. Promising them high-priced coverage through COBRA is meaningless if they can't afford to pay. Comprehensive health insurance is the only real solution, not just for the poor but for middle-class Americans as well.
Without better coverage, millions more Americans will be hit by medical bankruptcy over the next decade. It will not be limited to the poorly educated, the barely employed or the uninsured. The people financially devastated by a serious illness are at the heart of the middle class.
Every 30 seconds in the United States, someone files for bankruptcy in the aftermath of a serious health problem. Time is running out. A broken health care system is bankrupting families across this country.
The writer is a law professor at Harvard University.
