Health inequalities

December 8, 2009

During my stay here at Harvard I am carrying out a research project on ‘The use of HIS/HES data in formulating and monitoring policies which have an impact on health, with a focus on health inequalities’.

In its Communication – Solidarity in Health: Reducing Health Inequalities in the EU, published on 20 October 2009, the Commission 

has announced a series of actions to help Member States and other actors tackle the gaps in health which exist within and between countries in the EU. One of the actions planned is the regular production of statistics and reports on the size of inequalities and on successful strategies to reduce them.

Over the last years I have, together with my Eurostat team and with the Member States, prepared a framework Regulation (EC) No 1338/2008 on Community statistics in the field of public health and health and safety at work, which the EP and Council have adopted on 16 December 2008.

Part of the EU statistics on public health are collected through a common 120 questions’ Health Interview Survey (HIS), the first wave of which is now ongoing in the European Statistical System (ESS). By asking –  a representative number of households and individuals in Member States – questions on health, lifestyles and use of health care services together with questions on the socio-economic environment, we expect to obtain a good overview of the health status of the population. In addition, an EU project is being carried out – within the framework of the Programme for Community action in the field of Health 2008-2013 – on piloting a Health Examination Survey (HES).

The final aim of my study project at Harvard is to prepare the analysis of the forthcoming EU HIS/HES data and especially to examine the possibilities to use the EU HIS/HES database for studying health inequalities in the EU.

The first part of the study deals with examining how a number of EU countries (UK, DE, BE, PL, FIN, CZ), HR and the USA – that have a previous or ongoing experience with collecting HIS  and/or HES data at national level – have planned, analysed and used these data in formulating national and/or regional policies that aim to reducing health inequalities.

For each of the countries concerned I have prepared a report, which is now being examined by the country-contact persons. On the basis of the information collected, I will start drafting the recommendations for the analysis of the EU HIS/HES database.

A number of faculty members here at Harvard (at the Harvard School of Public Health and Medical School (see picture below), the Kennedy School of Government, the Harvard  Sociology Faculty and the Center of European Studies) have been very helpful in providing contacts and information on HIS/HES data sources and reports in the USA as well as on using HIS/HES data for studying health and society in general.

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Succesful societies

November 15, 2009

On Friday 13 November the Center of European Studies has hosted a panel with Nobel Prize-winning economist Amartya Sen in person and Jean-Paul Fitoussi via videoconference from Paris. They discussed the findings of the recent report issued by the Commission on the Measurement of Economic Performance and Social Progress that was headed by Sen, Fitoussi, and Nobel Prize-winning economist Joseph Stiglitz.

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In addition, Peter Hall and Michèle Lamont were also on the panel. Their Successful Societies program is a Canadian Institute for Advanced Research (CIFAR)-funded program that aims to quantify the measures of societal success. The resulting book, entitled Successful Societies: How Institutions and Culture Affect Health, integrates recent research in an effort to answer the question of why some societies are more successful than others at promoting individual and collective well-being, with a focus on health. One of their conclusions is that population health is determined as much by the structure of social relations as by the structure of economic relations.

The panel brought together the findings of each project, and each panel member commented on the question of what makes a good society, and how can we best achieve it.

As many of the readers of my blog will know, this is a topic very close to my heart, so I was excited to attend this panel discussion and to contribute to the debate….

The House has spoken

November 11, 2009

Last Saturday, the US House of Representatives approved – by a vote of 220 to 215 – its bill for health care reform. President Obama called it  ‘a courageous vote’ and asked the Senate now ‘to take up the batton and bring this effort to the finish line’.

An important amendment, which finally allowed the Democrats to have the bill passed in the House, was the Stupak amendment. This amendment extends – to all health services funded under the Act – the prohibition for payments for abortion except in cases of pregnancies caused by rape or incest or when a pregnant woman’s life is endangered by physical disorder, illness or injury. The Stupak amendment, inserted under pressure from conservative Democrats and through forceful lobbying of Roman Catholic bishops, will however not affect employer-sponsored group coverage, which will continue to cover the vast majority of Americans.

Abortion is still a very controversial subject here in the US, as was demonstrated a few weeks ago through a silent protest at Harvard Yard.

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This vote in the House is an important step, but this is not yet a final victory. The biggest hurdle still to be taken now is the vote in the Senate, where the Republican minority has more power and where the ‘floor debate’ is expected to last several weeks, while it just took one day in the House.

DGs at Harvard

November 4, 2009

On 14 October, Mrs Odile Quintin, the EC’s Director-General for Education, Training, Culture and Youth, has held a lecture – at Harvard’s Center for European Studies – on ‘Challenges for higher education in the EU and in the US – the EU response’.

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And on 22 October, Harvard graduate students could listen to and debate with Mr David O’Sullivan, the EC’s Director-General for Trade, during his lecture on ‘Trade policy in crisis – problem or solution’. His lecture was the second of a series called ‘European and American perspectives’ which Mrs Renee Haferkamp – a retired Director General of the EC – organises  here at Harvard each year during the autumn term.

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With 14 votes against 9, the US Senate Finance Committee has passed last Tuesday the ‘Baucus bill,’ as an alternative legislative proposal for the US health care reform.

The major difference between this bill, proposed by Senator Max Baucus, and the bill adopted in June by the House Democrats is that the Baucus bill does not propose a public option, neither new taxes on higher incomes.

As alternatives the Baucus bill proposes respectively:

– the establishment – at State level – of private, nonprofit consumer-run insurance cooperatives (the so-called co-ops), which will be expected to provide affordable health plans to all Americans;

– a tax on high cost health insurance plans (the so-called ‘Cadillac plans’)  as a measure to reduce medical spending.

From the positive votes, that made the Baucus bill pass, all but one are from Senate Democrats; the one Republican vote is from Mrs Olympia J. Snowe, Senator of Maine.  Her comment when voting in favour was ‘when history calls, history calls’.

Senator Snowe’s vote has a high political significance since it is the first time that a health care reform bill is now not only accepted by Democrats, but also by one Republican, which opens the road towards a bipartisan support.

Both Harry Reid, the Senate majority leader, and Nancy Pelosi, the speaker of the House, are now working independently to merge the voted health care bills into proposals, which each could squeeze through their respective chambers (House and Senate).  Then Democrats hope they will negotiate one final version between them before it will be on President Obama’s desk for signature.

Health care reform has attracted lots of attention in the US and the coming weeks will be decisive in the legislative process. But the call for US health care reform is far from new.

Already in the 1990s the Clinton administration tried to pass a major health care overhaul, which however dramatically failed. George W. Bush repeated that health care reform was necessary, but did not propose a major change. President Barack Obama however has – right from the start of his taking office – declared ‘health care reform’ as the US domestic priority number one.

What is then so fundamentally wrong with the current US health care system?

Some key facts and figures point out the problem:

  1. 46 million Americans (on a total population of 320 million inhabitants) do not have any health insurance at all and an additional 20 million are ‘underinsured’;
  2. Americans spend more on health care than any other country in the world (in the US public and private health care expenditure together represents 16 % of GDP versus 6 to 11% in European countries);
  3. Life expectancy in the US is lower than in most European countries;
  4. US health insurance premiums have doubled since 2000 and are rising three times faster than wages;
  5. 72 % of Americans under 65 had accumulated medical debts or had difficulties in paying medical bills and 61 % of those with difficulty had an insurance (figures referring to year 2007);
  6. About half of all families going broke in the US are caused by health care costs.

All his needs some further explanation…

There are some crucial differences between the health care system in EU countries and in the US. In the EU health care systems the notion of ‘solidarity’ is the most important underlying value for health care, with ‘universal health care’ as the most obvious implication of that value. In the US there is no obligation for Americans to have a health care insurance; there is an important focus on freedom of choice and individualism and the private market plays an important role.

On the other hand there are some population groups in the US that can get health insurance directly through the government-run plans Medicare and Medicaid.

Medicare is a nationwide program which provides health care insurance for people of 65 and over and for people under 65 with certain disabilities. It contains three parts: hospital insurance (A), insurance for doctors’ care outside the hospital (B) and coverage for medicines (C). People do not have to pay a premium for part A, but do have to pay monthly premiums for parts B and C.

Medicaid is a program which provides health care insurance for the poor, but – in contrast to Medicare – it is run at the level of the States and each State can set its own eligibility criteria and can decide on its own type of services. Medicaid does not reimburse costs to the patients but it pays the doctors or hospitals directly. Some States have a better record than others. In Massachusetts for example many initiatives exist to assist poor people with some form of health insurance (only 3 % of people here are un-insured).

All other Americans who want to get a health insurance have to buy a ‘private health insurance plan’ on the market. Employees of large companies can often obtain an ‘employer-insurance plan’ – for themselves and their families – which their companies have bargained with private health insurance companies.  While these types of plans could sometimes give more value for money, they might hamper employees from changing jobs ((this is called here the ‘job-lock’).

A  major problem is also that US health insurance companies often deny health insurance for people who have serious health problems (the so-called ‘pre-existing conditions) or stop health insurance when their clients become seriously ill.

In February this year President Obama has announced eight principles for health care reform, and in June the House Democrats have put forward their legislative proposal (called ‘bill’), which contains:

–       universal coverage: an obligation for all Americans to get health care insurance, what is called here ‘the individual mandate’;

–       affordable options for Americans to obtain health insurance either through a ‘public option’ or through premium subsidies to individuals and/or to employers;

–       more people covered through Medicaid;

–       tax increases for high income individuals and households;

–       a guarantee that people with pre-existing conditions will not be excluded from obtaining a health insurance plan;

–       maintenance of coverage if people change or lose jobs;

–       investments in prevention and wellness;

–       improvements of patient safety and quality of care.

Over the summer US health care reform was at the heart of the public debate and many town hall meetings have taken place all over the country. The most controversial point of the House Democrats’ bill is the ‘public option’, which would allow for the government to propose affordable health care plans.

Many conservative groups are heavily opposed towards any control of the government, which some of them consider as ‘social medicine’ or ‘communism in the style of Castro’.  Also a US Senate panel has rejected ‘the public option’.

The next important step is the process is the vote today, Tuesday 13 October, of the US Senate Financing Committee on another health care reform bill, which is a more moderate health care reform proposal introduced by Senator Baucus. And after that, further negotiations in Congress should then lead to a final compromise text, resulting from the different bills.

It is President Obama’s ambition to have a final text before the end of the year.  I will keep you posted….

Solana at Harvard

October 4, 2009

Javier Solana meets students at HarvardFrom 16 to 18 September Javier Solana, the EU’s High Representative for the Common Foreign and Security Policy CFSP, has come to Harvard.

His visit is the first event of the 2009 lectures of the ‘European and American series – Challenges of the 21st century’ organised each fall by Renee Haferkamp at Harvard University.

During his speech ‘Europe in the world’ of 17 September in the Yenching auditorium, Javier Solana gave an overview of the EU’s foreign policy with focus on effective global governance, on the new mood in the transatlantic relationship and on the need for a close US-European cooperation on climate change.

His presentation was complemented with detailed replies to questions from students and faculty on a variety of issues, from the European Neigbourhood Policy to the Middle East and Afghanistan and the rising power of China.  A long and warm applause concluded this remarkable session and students were queueing to greet him personally !

Visit of Norman JardineOn 22 September, Norman Jardine came to Harvard. As Head of the European Commission’s  ‘Learning and development’ Unit (DG ADMIN/A/3)  he is responsible for the administrative support behind the EU fellows program. We met at the Center of European Studies (CES) where I have the privilege – as EU fellow – to have my office. Norman and I spoke about the practical arrangements and the content of the fellows program at Harvard and he also met Kathleen Molony, who is the WCFIA Director for the fellows program.