Fair Share Healthcare
If you're familiar with Maryland's Fair Share Health Care Act, chances are you have an opinion. The bill passed in January after overriding a veto from the governor, and it's been one of those polarizing issues with a dichotomous yes/ no exchange between the camps on each side. Now that Maryland has taken action, similar bills are in the works around the nation and the debate is picking up steam.

The concept of fair share healthcare is that big businesses should finance health insurance coverage for employees. It's called "fair share" because employees without healthcare coverage benefits can end up on public health insurance rolls in programs such as Medicaid, where taxpayers pick up the costs. The Maryland bill became known as the "WalMart bill" because it is the only business in Maryland that has to make changes based on the new law. Proponents of fair share healthcare argue that the legislation addresses irresponsible corporate practices that create a burden on publicly funded programs; opponents focus on free enterprise and the potential loss of jobs.

Although it's critically important that we have comprehensive, equitable, and affordable access to healthcare for every individual within the borders of the United States, the fair share healthcare trend is not going to do a great deal to move us toward that goal. I support fair share healthcare in principle, but just under the surface it's another temporary patch on a badly flawed healthcare structure.

Although fair share healthcare might not be a meaningful step forward, it's not a step backward either, especially not in the way some conservative pundits have described it. It's really a neat step sideways, and it doesn't address the root causes of our most pressing healthcare issues. There is hope, however, that fair share healthcare legislation will stimulate a discussion that could lead to effective change.

Who would fair share healthcare really help? Among the approximately 45 million uninsured in the United States (18% of our population under age 65), more than two thirds are employed fulltime and about half earn less than $20,000 annually. But fair share healthcare may not reach most of this population.

Although businesses with more than 200 employees generally offer health benefits, 41% of employed individuals in the United States work for smaller businesses, a sector in which a dwindling number of employers offer health insurance coverage. Fair share healthcare in Maryland focuses on only the largest companies, with 10,000 employees or more. Legislation under consideration in other states differs in the details, but most focus on relatively large businesses and in some cases entire business sectors are exempted. A bill under consideration in New York, for example, exempts the manufacturing industry that employs about 560,000 workers.

The primary effect of these laws may be to temporarily relieve political and fiscal pressures, which also relieves any impetus for incremental change and reform. The plight of the large majority of the uninsured will be prolonged, yet again. From a public health perspective, firmly rooted in the utilitarian tradition to provide the greatest good for the greatest number of people, fair share healthcare may be considered an obstacle. In the short-term, however, fair share can't be overlooked. As a physician, it's difficult for me to accept any degree of illness or suffering that we may be able to prevent or reduce, even if it is with a very limited approach for only a small segment of the population.

For now, our choices are bleak -- very limited fair share legislation, or status quo. But we haven't yet discussed another key stakeholder in this puzzle: our elected leaders. Politicians who support fair share healthcare are talking about short-sighted business leaders who dodge their responsibility to provide healthcare coverage benefits. But there has been relatively little discussion of short-sighted politicians. Granted, our current politicians are facing a gap created by generations of leaders. But businesses and the uninsured should not be forced to pay the price for politicians' failure to lead. Policy development is usually an incremental process, and it may not be feasible to implement a comprehensive long-term solution; but it is well within our reach to start moving in this direction.

Commerce is a significant driver of politics in the United States, and we have an opportunity right now to leverage this reality to better protect the public's health. In early February, the Retail Industry Leaders Association filed suit against existing fair share legislation. Although their motivation may not be aligned with public health interests, the outcome may ultimately contribute to improving the public's health. If business leaders successfully resist fair share legislation, our elected leaders will have some additional motivation to develop a meaningful solution. The period around World War II gave rise to employer-driven healthcare coverage. If history shows that the first decades of the 21st century marked a time when businesses divested themselves from these activities and put policy responsibility back in the hands of our elected leaders, we may all be better off.

Maryland legislators think they're forcing WalMart to a new standard of financing healthcare coverage, but perhaps business owners should think about developing their own new standard that calls for dropping these benefits. Although there is no guarantee that businesses will use the saved money appropriately (eg, increasing wages), there are many ways to spend money that are more fiscally responsible than sinking dollars into a fragmented and inefficient healthcare system with escalating costs that outstrip returns. A legislator in Maryland pointed out that if fair share legislation failed, competitors to WalMart would have no choice but to reduce their healthcare plans. This would cause upheaval in the short term, but there's inevitably going to be some pain involved in changing the status quo and moving our healthcare coverage process into a new era -- and now might be the time.

Of course, even with increased wages it would be difficult or impossible for workers to afford healthcare coverage if businesses are no longer offering this benefit. Our elected leaders would need to abandon incremental change and engage in leadership that may be politically risky. Reform would be necessary, but it's the right thing to do. Business leaders have driven public policy in the past, and this time they have an opportunity to put our political leaders in a position where they have no choice but to implement meaningful change.

A realistic alternative is that big business will become even more heavily involved in healthcare, with the encouragement of elected leaders. A WalMart press release in early January announced that "Sam's Club and Extend Benefits Group LLC will join forces to offer a new and innovative health insurance program for businesses." We are all familiar with the concept of "big box" stores; now big box health insurance products have arrived. Perhaps our elected leaders are hoping that private industry will bail out a growing crisis in healthcare coverage, and it is indeed possible that innovations will improve care for some selected workers. But for the unemployed, the poor, and the sick, and in disaster circumstances like Hurricane Katrina or a future pandemic, a huge gap will remain until we have effective political action.