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 Date:9/15/2009 Wake Up Call |
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Here’s to Your Health Healthcare expert Marianne Udow-Phillips discusses the politics and policy of health reform, circa 2009. 
Last week, U.S. President Barack Obama gave a forceful speech to Congress and the American people calling for a "season of action" on health care reform. As he made the case for reform, he reminded us that every other developed country in the world offers its citizens some form of universal health care, disadvantaging U.S. businesses competing in the global economy. He laid out an approach and set of policies, with ideas from both sides of the political aisle, that builds on what works in the existing system and offers options for fixing what does not. Yet during the speech, the president was heckled as no president has ever been, not even when confronting equally large and controversial topics such as social security, financial crises, or war plans. Why does health care reform garner such emotion? Why has this issue bedeviled U.S. presidents for the last 100 years?Why is health care reform so difficult? The U.S. spends far more than any other country in the world (in 2007, almost twice as much per capita as our nearest neighbor, Canada) and gets less for its money on measures such as life expectancy and infant mortality. Researchers, most policy makers, and many consumers agree that health reform is necessary. But even with this broad consensus and supporting data, health reform still engenders the kind of emotion that has been on display in the last month or so. There are three pre-eminent issues that make this a very personal issue for many – and a challenging issue for politicians. First, health care represents one-sixth of the U.S. economy and any major change to the system involves trade-offs that benefit some sectors and disadvantage others. Second, despite statistics and polling data showing that Americans want change in general, more than 80 percent of Americans are actually satisfied with their own health insurance. Third – and clearly reflected in today’s debate – many Americans have a deep seated suspicion of government initiatives. As the history of health reform in this country shows, though they may be unfounded, fears about changing the status quo can be more easily brought to the surface than can a passion for “reform.” In town halls throughout the country this summer, people expressed the fear that health reform – particularly a “public option” for coverage – would result in government involvement in clinical decisions related to individual patients. At its most extreme, this fear has led some to conclude – incorrectly – that the proposed reforms would result in denial of care to those most in need or attempts to hasten the death of some patients. In fact, these concerns have no basis in proposed legislation or any historical action of government. The actual legislative language regarding end of life decisions would have provided reimbursement for doctors who counsel patients about advanced directives or other end of life issues, and would also expand coverage for hospice care - both provisions that have been long supported by patient advocates and families. And all payers – public and private alike – make decisions about what health services will and will not be covered. Today’s public programs (e.g., Medicare, Medicaid, the VA) make no more stringent decisions than those made by private payers. Indeed, anyone with private coverage who has tried to get a preventive health exam and found that “screening” exams aren’t covered or who has tried to get coverage for something that could be considered a pre-existing condition should know that private coverage today is often more restrictive than public programs. With the exception of the Johnson era, when seniors’ passion for reform helped pass Medicare legislation, fear of political backlash has derailed all major reform efforts since Teddy Roosevelt’s administration. But the reforms that have been successfully enacted – Medicare, Medicaid, Medicare drug benefits, the Children’s Health Insurance Program – have been wildly popular. Health care reform is possible, but it must be enacted within the context of the current system and cognizant of American values and fears about moving too far from the status quo. That doesn’t mean that change must be incremental; rather, it means that important pieces need to be incorporated over time and within a framework that builds on what is already in place. Despite much of the rhetoric of the day, politicians can be reasonably confident that as long as that framework is used, the changes will be greeted favorably. What is possible in reform? Even with the challenges inherent in the legislative process around reform, there is no question that quality, access, and cost trends in U.S. health care can be substantially improved. In his speech, the President noted how important and achievable it is to improve the quality, access and cost of health care. So, what can really be achieved in this regard? First, with regard to quality of care, there is considerable support for many strategies to improve patient outcomes. These include efforts that would:
With regard to access to care, there is broad support for insurance reforms such as prohibiting the ability to exclude people from coverage based on their health status. There is also widespread support for all Americans to have coverage of some sort and considerable consensus that Americans should be required to purchase health insurance with subsidies for the low-income uninsured. The challenge in the debate is what level of subsidy to provide and how to pay for it. The bulk of the projected reform cost in current plans is related to providing those subsidies. Reducing the cost of health care is difficult to accomplish without fundamental change to the system. To produce significant savings, we must restructure the way physicians and hospitals are paid to better align their incentives with cost effective, quality care; and reduce variation so that care is delivered based on evidence. We must also find a way to address the rising cost of care in the U.S. related to our higher use (compared to the rest of the world) of technology and services that do not produce concomitant improvements in outcomes. Making these changes is not only politically controversial but also administratively complex and would take time to show results. Bills in Congress today envision an independent advisory commission to make some of the tough decisions needed to moderate the health care cost trend. But the independent advisory commission idea cannot be “scored” as savings by the Congressional Budget Office because it is a new concept. So while the costs associated with expanded coverage are clear cut, the cost saving approaches envisioned in the legislation don’t yet have a track record with data to support them. Despite the current furor about health reform, in the end, President Obama will likely achieve some significant changes to the way care is paid for and delivered in this country. Those changes will mean that more people will have coverage than have it today and those that are sick won’t be denied coverage for their illnesses. There will also undoubtedly be creative strategies included focusing on improving quality and reducing the rate of increase in health care spending. What is passed won’t please everyone – and won’t necessarily look anything like what was proposed on the campaign trail. But, health reform in the early 2000s is likely to be the most substantive we have seen since the passage of Medicare and Medicaid in 1965. Marianne Udow-Phillips is the director of the Center for Healthcare Research & Transformation (CHRT), a non-profit partnership of the University of Michigan and Blue Cross Blue Shield of Michigan with a mission to promote evidence based care delivery, improve population health, and expand access to care. Visit: www.chrt.org. |