J'ai lu récemment dans l'édition du mois de septembre de Rolling Stone (l'équivalent américain des Inrocks, ze magazine qu'il faut lire pour être au top niveau "unique taste of millions") un article très intéressant de Matt Taibbi, un journaliste politique engagé (à gauche), sur la réforme de ce système, qui embarrasse très fort Barack actuellement. Un article, orienté politiquement mais très didactique, qui a largement éclairé ma lanterne, et qui je l'espère contribuera à éclairer la vôtre si tant est que le sujet vous intéresse.
Bon, quelques mises au point pour commencer: de même que les Américains vivent avec le cliché* qu'en France se soigner est gratuit (alors qu'un prorata est prélevé sur les salaires, que les remboursements sont forfaitaires et que nous avons aussi des mutuelles complémentaires), les Français sont persuadés que le système de santé est totalement privatisé aux US. Ce n'est pas tout à fait vrai: les plus démunis bénéficient d'une couverture "minimale" assurée par le gouvernement (Medicaid), ainsi que les personnes âgées (Medicare). Le reste de la population, en fonction de ses moyens, fait appel à des assureurs privés, dont les plans de couverture sont en général hors de prix (ou alors ils ne couvrent rien), et qui peuvent légitimement refuser d'assurer qui ils veulent, pour des raisons financières mais aussi pour des raisons de santé "préexistante".
Ce sont donc les basses classes moyennes, ne bénéficiant pas des aides gouvernementales - chaque Etat fixant son propre seuil de pauvreté, voir plus bas- et trop pauvres pour se payer une assurances privée, qui se retrouvent le bec dans l'eau. On estime le nombre des personnes sans assurance à 45 millions, soit quasiment 15% de la population.
Le système américain est en fait un gouffre financier (18% du PIB, contre 11% pour notre si "chère" sécu - chiffres tirés d'un article du Monde), notamment parce que les personnes non assurées, ne pouvant se payer un docteur (dans les 500$ la consultation chez le généraliste), "attendent" d'être gravement malades avant d'aller se faire soigner aux urgences. Le coût du traitement est alors surmultiplié, puis l'Etat finit par régler la facture (le particulier ne pouvant pas rembourser).
Ca c'est la base de la situation. Maintenant, pour mieux comprendre un certain nombre de "détails" ainsi que les enjeux de la réforme et où nous en sommes, voici une version raccourcie de l'article vaguement modifiée par mes soins pour en conserver la cohérence: c'est un peu long, en anglais et nécessite de l'attention. Je souligne ou surligne les passages, selon moi, clefs.
Et à la fin, un résumé, forcément réducteur.
The US health care system doesn't work for anyone. It cheats patients and leaves them to die, denies insurance to 47 million Americans, forces hospitals to spend billions haggling over claims, and systematically bleeds and harasses doctors with the specter of catastrophic litigation. [It doesn't even work for insurance-companies]: they see their profits sapped by millions of customers who enter the system only when they're sick with incurably expensive illnesses.
The game in health care reform has mostly come down to whether or not the final bill will contain a public option — i.e., an option for citizens to buy in to a government-run health care plan. Because the plan wouldn't have any profit motive it would automatically cost less than private insurance. Once such a public plan is on the market, it would also drive down prices offered by for-profit insurers.
Here's where we are right now: Before Congress recessed in August, four of the five committees working to reform health care had produced draft bills. The only committee that didn't finish a bill is the one that's likely to matter most: the Senate Finance Committee, chaired by Max Baucus, a right-leaning Democrat from Montana who has received $2,880,631 in campaign contributions from the health care industry. Whether or not there will be a public option in the end will likely come down to Baucus. The early indications are that there is no public option in the Baucus version.
Even worse, Baucus has set things up so that the final Senate bill will be drawn up by six senators from his committee: three Republicans (Chuck Grassley of Iowa who has received $2,034,000 from the health sector, Olympia Snowe of Maine, 756,000$, Mike Enzi of Wyoming, 627,000$) and three Democrats (Baucus, Kent Conrad of North Dakota, Jeff Bingaman of New Mexico). This is what the prospects for real health care reform come down to — whether one of three Republicans from tiny states with no major urban populations decides to forsake forever any contributions from the health-insurance industry.
But the Congress has also sabotaged the bill long before it even got to Baucus' committee. To do this, they used a five-step system of subtle feints and legislative tricks to gut the measure until there was nothing left.
1. Heading into the health care debate, the main idea was a single-payer system. Used by every single developed country outside the United States, single-payer allows doctors and hospitals to bill and be reimbursed by a single government entity. In America, the system would eliminate private insurance, while allowing doctors to continue operating privately.
There are currently more than 1,300 private insurers in this country, forcing doctors to fill out different forms and follow different reimbursement procedures for each and every one. This drowns medical facilities in idiotic paperwork and jacks up prices: Nearly a third of all health care costs in America are associated with wasteful administration. Fully $350 billion a year could be saved on paperwork alone if the U.S. went to a single-payer system.
But even though the Democrats enjoy a political monopoly and could have started from a very strong bargaining position, they chose instead to concede at least half the battle before it even began: they agreed to back down on single-payer and tried to push for a strong public option — a sort of miniversion of single-payer, a modest, government-run insurance plan that would serve as a test model for the real thing.
2. Once single-payer was off the table, the Democrats lost their best bargaining chip, rather than being in a position to use the fear of radical legislation to extract concessions from the right.
The situation was made worse as the flagging economy ate away at Obama's political capital. Polls showed the percentage of "highly engaged" Democrats plummeting, while the percentage of "highly engaged" Republicans — inspired by scare stories from Rush Limbaugh and Sarah Palin about socialized medicine and euthanasia — rose rapidly. Democrats, who on the morning after Election Day could have passed a single-payer system without opposition, were now in a desperate hurry to make a deal.
The public option is hardly a cure-all. But the basic idea of the public option is sound enough: create a government health plan that citizens could buy through regulated marketplaces called insurance "exchanges" run at the state level. Simply by removing the profit motive, the government plan would be cheaper than private insurance. The logic behind the idea was so unassailable that its opponents often inadvertently found themselves arguing for it.
But conservative opponents of the plan expressed concern that doctors in the public option "must be fairly reimbursed at negotiated rates, and their participation must be voluntary". They wanted (and obtained) compensation rates for doctors to be jacked up, on the government's tab. In the end, the bill required the government to negotiate rates with providers, ensuring that costs would be dramatically higher.
In one fell swoop, the public plan went from being significantly cheaper than private insurance to costing, well, "about the same as what we have now," as one Senate aide puts it. This was the worst of both worlds, the kind of take-the-fork-in-the-road nonsolution that has been the peculiar specialty of Democrats. The party could now sell voters on the idea that it was offering a "public option" without technically lying, while at the same time reassuring health care providers that the public option it was passing would not imperil the industry's market share.
3. Given that five different committees are weighing five different and often competing paths to reform, it's not surprising that all sorts of bizarre crap winds up buried in their bills, stuff no one could possibly have expected to be in there.
One example: allow the makers of complex drugs known as "biologics" to keep their formulas from being copied by rivals for 12 years — twice as long as the protection for ordinary pharmaceuticals.
Another favor to industry buried in the bills involves the issue of choice: Democrats have been careful to make sure that a revamped system would not in any way force citizens to give up their existing health care plans.
There's a flip side, though: If your employer offers you acceptable care and you reject it, you are barred from buying insurance in the insurance "exchange." In other words, you must take the insurance offered to you at work. And that might have made sense if employers actually had to offer good care. But actually there is no real requirement for employers to provide any kind of minimal level of care. On the contrary, employers who currently offer sub-par coverage will have their plans protected by this clause.
This clause has potentially wide-ranging consequences. One of the biggest health care problems we have in this country is the technique used by large employers —Walmart is the most notorious example — of offering poor health insurance that forces employees to take on steep co-pays and other massive charges. Low-wage workers currently offered these plans often reject them and join Medicaid, effectively shifting the health care burden for Walmart employees on to the taxpayer. If the clause survives to the final bill, those workers who did the sensible thing in rejecting Walmart's employer plan and taking the comparatively awesome insurance offered via Medicaid will now be rebuffed by the state and forced to take the Walmart offering.
Veteran legislators speak of this horrific loophole as if it were an accident — something that just sort of happened, while no one was looking.
4. From the start, Obama acted like a man still running for president, not someone already sitting in the White House, armed with 60 seats in the Senate. At no time has he come out and said what he wants Congress to do, in concrete terms. Eight months after being elected president of the United States is too early to have an opinion on an issue that Obama himself made a central plank of his campaign?
This is a crystal-clear example of how the Democratic Party likes to act — showering a real problem with a blizzard of ineffectual decisions and verbose nonsense, then stepping aside at the last minute to reveal the true plan that all along was being forged off-camera in the furnace of moneyed interests and insider inertia.
No single-payer system, no meaningful public option, no meaningful employer mandates and a very meaningful mandate for individual consumers.
In other words, the only major reform would be the one forcing everyone to buy some form of private insurance, or suffer a tax penalty. If things go the way it looks like they will, health care reform will simply force great numbers of new people to buy or keep insurance of a type that has already been proved not to work.
5. The bill alone is 1,017 pages long and contains countless inscrutable references to other pieces of legislation. There are five different versions of this creature, each with its own nuances and shades, and reconciling the costs of each of the five plans looks like a pretty difficult task.
For instance: All five of the bills envision a significant expansion of Medicaid. As it stands, Medicaid awards benefits according to a jumbled series of state-by-state criteria. Some states, like Vermont, offer Medicaid to citizens whose income is as high as 300 percent of the federal poverty level, while others, like Georgia, only offer Medicaid to those closer to or below the poverty level.
The House plan would expand Medicaid eligibility to automatically include every American whose income is 133 percent of the poverty level or less. For those earning somewhat more — up to 400 percent of the poverty level — federal subsidies would help pay for the cost of a public or private plan purchased via the insurance "exchanges." That worries state governments, which currently pay for almost half of Medicaid — and which are already seeing their Medicaid rolls swelled by the economic meltdown. A massive surge in new Medicaid members — as many as 11 million Americans under the current proposals, according to the Congressional Budget Office — might literally render many big states insolvent overnight.
By blowing off single-payer and cutting the heart out of the public option, the Obama administration robbed itself of its biggest argument: that health care reform is going to save a lot of money.
To recap: First, they gave away single-payer apparently as a bargaining chip to the very insurers mostly responsible for creating the crisis in the first place. Then they watered down the public option so as to make it almost meaningless, while simultaneously beefing up the individual mandate, which would force millions of people now uninsured to buy a product that is no longer certain to be either cheaper or more likely to prevent them from going bankrupt. The bill won't make drugs cheaper, and it might make paperwork for doctors even more unwieldy and complex than it is now. PhRMA [Pharmaceutical Research and Manufacturers of America] which last year spent more than $20 million lobbying against health care reform, is now gratefully spending more than seven times that much on a marketing campaign to help the president get what he wants.
It is a fight to the finish now between Really Bad and Even Worse.
Then again, it's more than a little conspicuous that the same electorate that poured its heart out last year for Obama has not been seen much in this health care debate. The handful of legislators who are fighting for something real should be doing so with armies at their back. Instead, all the noise is being made on the other side. Republicans, at least, understand that politics is a fight that does not end with the wearing of a T-shirt in November.
Bref, un savant mélange comprenant les ingrédients suivants:
- quelques petites lâchetés de politiciens qui veulent se fâcher avec personne, pensent plus à leur réélection et/ou leur porte-monnaie (de Obama à certains Congressmen impliqués dans la réforme), et beaucoup de concessions trop faciles, au niveau du plan de couverture universelle par l'Etat fédéral et du système de paiement des frais de santé (concession aux Républicains et aux compagnies d'assurance privées).
- un bon gros lobbying, de ces mêmes compagnies d'assurance et des industries pharmaceutiques qui ont arrosé à qui mieux mieux.
- beaucoup de contre-vérités de la part des "right-wing conservative" (et des lobbies) et d'ignorance de la part du public ricain moyen qui voit dans toute intervention de l'Etat le spectre des goulags et une atteinte à sa liberté de crever dans sa caravane.
- un mauvais timing et trop de tergiversations de la part du camp Démocrate.
- une machine à légiférer qui envoie de la rillette (1000 pages sans les petites notes et exceptions) pour accoucher d'un bon gros paquebot impossible à manier.
- un soutien populaire qui s'arrête au port de T-shirts et aux bumper stickers à l'effigie d'Obama.
va sûrement conduire à une réforme qui ne sera qu'une réformette: elle coûtera cher, ne déplaira pas aux assureurs privés et aux compagnies pharmaceutiques, permettra au Parti Démocrate de se la jouer sauveur sans que les Républicains ne perdent vraiment la face, et surtout ne changera pas grand'chose au quotidien pour les malades.
Le point le plus important, que l'Etat devienne LA centrale de paiement, notamment pour diminuer les coûts liés aux formalités administratives propres aux 1300 assureurs privés, a été retirée de la table des négociations avant même qu'elles ne débutent: trop socialiste, trop contre la libre entreprise.
La deuxième idée, celle d'une couverture universelle proposée par l'Etat, beaucoup moins chère que les couvertures privées parce que n'ayant pas pour but d'amener des bénéfices, risque d'être vidée de sa substance. Elle existera bien, mais sera probablement d'un prix quasi-similaire à celui des assurances privées.
Du coup, quoi de neuf: une nouvelle taxe pour obliger les non-assurés à le faire...
Quand on n'a pas trop d'idées ou de couilles pour vraiment changer les choses, une petite taxe fait souvent l'affaire.
Finalement, la politique américaine, c'est pas très différent de la nôtre... (voyez la taxe carbone).
Obama a donné un discours paraît-il incisif il y a une dizaine de jours, cela changera-t-il la donne? A suivre cet automne.
(pour l'article entier: http://www.rollingstone.com/politics/story/29988909/sick_and_wrong/1)
* Pour lire quelques "clichés" (ou semi-vérités) sur le système français, voir par exemple cet article du Washington Post (avec interviews de Marseillais en sus) au demeurant pas inintéressant