Balanced coverage of reform that isn't
The Hartford Courant
February 12, 2003
Who's Shaping The Debate On Health Care Reform?
By Theodore Marmor and Kip Sullivan
The 2003 debate about health care reform, unfortunately, is likely to be as muddled as it was a decade ago, when President Clinton promoted universal health insurance under the banner of managed care and the inflation rate in health insurance premiums was also in double digits.
Now, as then, those with interests in rising health expenditures will try to make sure the American public does not understand the real causes of the recent surge in medical inflation. Their loudest argument is that Americans overuse medical care and that such overuse would only worsen if all Americans were insured.
Overuse does exist, the evidence indicates. But so does worrisome underuse. And overuse cannot explain the latest burst in health insurance prices or the sharp rises in what drugstores and doctors charge. There is no credible evidence that Americans received a lot more medical care in the past few years. But the price of health care has skyrocketed nonetheless. That inflation is because of the market power of insurers, drug manufacturers, hospitals and other suppliers of medical services.
Advocates of medical savings accounts and other high-deductible plans talk of overuse because they think they have an answer to it. With a few exceptions, these advocates avoid discussion of underuse. They know they have no solution for underuse and that their practices will almost surely aggravate it. But that does not dissuade them from disseminating the overuse thesis at the meetings of health insurers and the gatherings of groups like the National Association of Manufacturers.
In that context, a sensible discussion of medical inflation, let alone universal health insurance, is very difficult. It is almost impossible when the news media act like an echo chamber, amplifying the voices of the already heard. Well-financed interest groups have lobbyists who are paid and prodded to comment and who show up regularly in debates that journalists try to "balance." The trouble is that there are 50 industry spokespeople for every underfinanced representative of ordinary citizens. The news all too often then turns out to be what prominent figures in the medical-commercial complex claim.
No wonder that Americans support the reform principles of universal coverage but express fear at most efforts to act on them.
Comment: Forums on reform today are amazing. As Marmor and Sullivan note, much of the discussion is on shifting to "consumer-directed" health care, based on the theory that the primary problem that needs to be addressed is the waste resulting from patients' incessant demand for unnecessary health care services.
The irony is that the problem of overutilization is not due to patients' quests to get more. It is due to practice patterns that fail to acknowledge that sometimes no medical intervention is a preferred course to an intervention that, in reality, is not beneficial or may even potentially be detrimental. Unnecessary hysterectomies, arthroscopies, antibiotic usage, body imaging and similar excesses are selected and controlled by the physician to whom the patient has turned for the best advice on health care decisions. These are problems that call for systemic reform that would improve physician behavior (another topic). Placing financial penalties between the patient and health care (consumer-directed care) results in decreased use of all services, including, especially, beneficial services. The most serious impact of this is in the care of patients with major medical needs. Erecting financial barriers will often prevent those with the greatest need to have precisely the services they require. This is perhaps the worst health care "reform" ever devised, the epitome of non-solutions.
The forums on health care still acknowledge that the numbers of uninsured continue to increase, that health care inflation continues to exceed the general rate of inflation, that the level of disparities are unacceptable, and, ironically, that the rate of under-insurance (consumer-directed!) is dramatically increasing to the point of causing a surge of personal bankruptcies for medical costs of both insured and uninsured patients. But then the forums go on to address the shift from the age of managed care to the age of consumerism. Where is the discussion of real solutions to these real problems?
Well, there is some discussion. But much of it is directed to finding compromises with this "consumerist" element that has gained control of the debate. Thus the discussion has shifted to tax credits, health reimbursement arrangements or MSAs, association health plans, and other reforms which may tweak the number of uninsured, but will leave those with the greatest health care needs highly vulnerable to financial risk. It is mind-boggling that those supporting universal access to comprehensive services are considering compromise as if there were something of substance with which to compromise. There isn't. Consumer-directed proposals have nothing to offer in the way of solutions to the real problems in health care.
Those covering the health care debate must insist on receiving answers to the questions they should be asking about these real problems in health care. I emphatically recommend reading the article, "Soaring health premiums creating more uninsured," by Nancy McVicar of the Sun-Sentinel in Florida. She addresses the real problems and discusses realistic solutions. Admittedly, she does discuss our approach, but then, is there any other that is better?