This editorial from today’s edition of The New York Times makes their case for supporting the current health reform legislation before Congress. The responses of Don McCanne, MD are in red and bracketed with ***.
The Case for Reform
Editorial
The New York Times
December 29, 2009
Reforming this country’s broken health care system is an urgent and essential task.
*** Absolutely! ***
Given all of the fabrications and distortions from Republican critics, and the squabbling among Democratic supporters, it is no surprise that many Americans still have doubts.
*** Unfortunately, the Republicans are handicapped by their ideological opposition to government solutions for social problems. Their proposal for a free market of cheap underinsurance products sold across state lines would only make problems worse by further impairing the effectiveness of our current inadequate and inequitable risk pools. The squabbling of the Democrats is based on a disagreement over whether to take the bold step of providing a truly effective universal public insurance program, such as an improved Medicare for everyone, or to take what some believe to be the politically expedient step of trying to modify our current dysfunctional system, even though it means falling far short of the goals of universality and affordability. ***
President Obama and Democratic leaders have a strong case. They need to make it now.
*** They have a very weak case. President Obama and the Democratic leadership chose to try to modify our current dysfunctional system, leaving tens of millions without insurance and perpetuating the financial hardships faced by many who need health care. ***
Here are compelling reasons for all Americans to root for the reform effort to succeed and urge Congress to complete the job:
THE HEALTH OF MILLIONS OF AMERICANS
The fact that 46 million people in this country have no health insurance should be intolerable. Every other major industrial country guarantees health coverage to its citizens, yet the United States, the richest of them all, does not.
*** The current proposal would leave close to 20 million people without insurance, a number that is destined to increase as health care costs continue to rise. Supporting a policy that ensures that so many will continue to be without health insurance is what should not be tolerated. A public insurance program is designed to automatically cover everyone. ***
Claims that the uninsured can always go to an emergency room for charity care ignore the fact that American taxpayers pay a high price for that care. And it ignores the abundant evidence that people who lack insurance don’t get necessary preventive care or screening tests, and suffer gravely when they finally do seek treatment because their diseases have become critical.
*** The modest marginal cost of providing care for additional patients in the emergency room is not a major issue. The crucial problem is the deterioration of our primary care infrastructure that is required to provide individuals with a source of seamless continuing care. The proposed legislation does take some important steps toward addressing this serious deficiency, but they would be much more effective with a single, unified financing system integrated with our health care delivery system. ***
The American Cancer Society now says the greatest obstacle to reducing cancer deaths is lack of health insurance. It is so persuaded of that fact that two years ago, instead of promoting its antismoking campaign or publicizing the need for cancer screening, it devoted its entire advertising budget to the problem of inadequate health insurance coverage.
*** We previously commended the American Cancer Society for taking this forward-thinking position. ***
We consider it a moral obligation and sound policy to provide health insurance to as many people as possible. While the pending bills would fall short of complete coverage, by 2019, the Senate bill would cover 31 million people and the House bill 36 million who would otherwise be uninsured under current trends.
*** It is both a moral obligation and sound policy to provide health insurance for everyone, which a universal public insurance program would do. The design of the current proposal is both immoral and unsound because it leaves an intolerable number of individuals uninsured – a number close to two-thirds of the population of Canada. We may criticize Canada’s queues, but we would be outraged if they prohibited two-thirds of their population from even having a place in the queues. Why is there no outrage here when we would leave a similar number without coverage? ***
MORE SECURITY FOR ALL
Horror stories abound of people — mainly those who buy individual policies — who were charged exorbitant premiums or rejected because of pre-existing conditions or paid out for years and then had their policies rescinded when they got sick.
Such practices would be prohibited completely in three or four years under the reform bills. Before that, insurers would be barred from rescinding policies retroactively and the bills would establish temporary high-risk pools to cover people with pre-existing conditions.
*** Although private insurers have been appropriately condemned for using trivial reasons to rescind policies, many rescissions were for the legitimate reason (legitimate in a business sense) that individuals who were uninsured and then developed serious problems purchased coverage without reporting their newly acquired problem – a form of fraud. That defeats the insurance function of pooling all of the healthy in with the sick. The proposal before Congress still permits rescissions for fraud. This problem would totally disappear in a public financing system in which enrollment for life is automatic. Also, the experience with high-risk pools to date has been very dismal. The need for high-risk pools would be eliminated by a single public universal risk pool. ***
The legislation would also allow unmarried dependent children to remain on their parents’ policies until age 26 (the Senate version) or age 27 (the House version).
*** What do they do at 26 or 27? Would everyone at that age have a great job with generous employer-sponsored benefits? If not, would they be eligible for plans in the exchange, and could they afford their portion of premiums and out-of-pocket expenses that is estimated to be about 20 percent of their income? Again, this problem would disappear in an equitably-financed public program in which everyone is automatically enrolled for life. ***
If reform legislation is approved, employees enrolled in group coverage at work would also be more secure. If workers are laid off — an all too common occurrence these days — and need to buy policies on their own, insurers would be barred from denying them coverage or charging exorbitant premiums for health reasons.
*** Just like COBRA, laid-off employees who no longer have a paycheck must then pay the full insurance premium that was formerly heavily subsidized by their employers. Partial subsidies are not adequate for a person with no paycheck. Even if eligible for the backup of Medicaid, shifting in and out of programs is disruptive to care. ***
CUTTING COSTS
Americans are justifiably concerned about the rising cost of health insurance and of the medical care it covers. The reform bills won’t solve these problems quick
ly, but they would make a good start.
*** The reform bills do not solve the problem of rising costs, and they don’t even make a good start. The proposals for accountable care organizations and bundling of payments create nightmare logistical problems that are dismissed as something we can figure out later. The excise tax on higher-premium plans will result in diminished benefits, shifting more of the financial responsibility to those individuals who need care and are already burdened with excessive out-of-pocket expenses. As health care costs continue to increase, more plans will be pared of benefits in order to avoid the excise tax. Making essential health care less affordable is a perverse policy proposal. Strengthening the power of an independent MedPAC-like board to reduce spending only within the Medicare program threatens to diminish the support of those in the health care delivery system who already feel threatened by what they perceive to be already low reimbursement rates. Price discrimination is a major problem in our dysfunctional financing system, but it cannot be adequately addressed by a payment advisory board limited to Medicare. Although the current proposal would look at the private sector, it would have no power nor even the ability to slow cost increases in the private sector. Under a universal public financing program, the board would be able to recommend measures to improve resource allocation for our entire health care delivery system, while balancing the demands of patients, health care providers and taxpayers. ***
Despite overheated Republican claims that the reforms would drive up premiums, the Congressional Budget Office projected that under the Senate bill the vast majority of Americans (those covered by employer policies) would see little or no change in their average premiums or even a slight decline. Those who buy their own policies would pay somewhat more — but for greatly improved coverage.
*** Except for a few regulatory requirements for the insurance industry, most Americans will see no improvement. They will continue to be burdened with ever higher health care costs, reflected in higher premiums and greater out-of-pocket cost sharing. Being guaranteed the right to buy insurance is of little consolation for those who can’t pay for it. Those in the individual market are often uninsured because they can’t afford the stripped-down plans currently available. Requiring greater benefits makes these plans even less affordable. The inadequacy of the proposed subsidies which are limited to plans purchased through the exchange will provide little consolation for those who are not eligible for or who cannot afford the plans in the exchange. A universal public system equitably financed based on ability to pay would eliminate the need for individual or employer-sponsored private plans. ***
Most people who would be buying their own policies would qualify for tax subsidies to help pay their premiums, which could reduce their costs by thousands of dollars a year. And small businesses would qualify for tax credits to defray the cost of covering their workers.
*** The primary reason to propose tax subsidies is to keep the insurance industry alive. It is much less efficient than establishing a single universal risk pool financed by equitable taxes. Furthermore, the proposed subsidies would leave all but the wealthiest of us exposed to a potential obligation to pay about 20 percent of our incomes for health care. That is a burden that most would find very difficult to bear. ***
The inexorably rising cost of hospital and medical care is the underlying factor that drives up premiums, deductibles and co-payments. No one yet has an answer to the problem.
*** Balderdash! All sane economists agree that a single payer monopsony would solve the problem. Conservative economists might not like a government solution, but they agree that it would actually work. It’s time for the practitioners of the dismal science of economics to engage in normative economics. These are not only numbers we’re dealing with; they are about the lives and well being of people. ***
But the bills would launch an array of pilot projects to test new payment and health care delivery systems within Medicare. These include, for example, incentives to coordinate hospital and post-hospital care to head off needless readmissions, better coordination of care for the chronically ill, and incentives for doctors to provide a patient’s total care for a flat fee instead of charging for each test or service provided.
*** Continual improvement in health care delivery is an important goal, but it is in no way unique to the current legislative proposal. A single payer monopsony would have a greater capability of realigning incentives for optimal care. ***
The Senate bill would set up an independent board to spur the use of programs that save money or improve care — subject to Congressional veto. Optimists believe the savings might come quickly but this could still take many years. Without passing a reform bill, there is little chance of success.
*** See the first comment under “cutting costs.” ***
THE TIME HAS COME
For decades, presidents from both parties have tried in vain to reform the health care system and cover the uninsured. Still many Americans wonder, given the deep recession, whether it makes sense to do it now. The first thing to keep in mind is that the C.B.O. says that the reform bills are paid for over the next 10 years and would actually reduce future deficits.
The need is clear and the political timing is right with the Democrats controlling the White House, the Senate and the House. If this chance is squandered and Republicans gain seats, as expected, in the midterm elections, it could be a decade or more before reformers have another opportunity. Americans shouldn’t have to wait any longer.
*** Most of the major features of this legislation are not scheduled to begin for years, yet we are told that it is urgent that we pass this bill within the next several weeks. The urgency is not based on sound health policy but is based on the political goal of proving President Obama and the Democrats with a political victory well in advance of the next elections. That might be good politics, but it is an unforgivable neglect of duty that is being committed by our public stewards. The policies of a single payer Medicare for all program are much less complex than the dysfunctional model being foisted off on us with the misnomer of reform. Because of the toll of financial hardship, physical suffering and even death, there is urgency in the need to act. But we can act now and have the program fully up and running long before the dates proposed in the current legislation. The New York Times says that we are squabbling, by definition arguing about trivial matters. Racking up a political victory on the scorecard is trivial. Doing that while glibly accepting a system that will leave so many broke and uninsured is unconscionable. ***
NYT editorial, The Case for Reform: http://www.nytimes.com/2009/12/30/opinion/30wed2.html