Will Congress reform health care?
Uninsured Americans and the new Democratic Congress Is universal coverage now more likely?
By Uwe E Reinhardt
BMJ | November 23, 2006
Editorial
In August 2003 I published a paper entitled “Is there hope for the uninsured?” My answer then was “most probably not.” As economic forecasts go, this one has been accurate so far. The question now is whether the Democrats’ ascendancy to power in Congress requires a recalibration of that dire forecast, especially in light of the recent unveiling of a proposal for universal coverage by America’s Health Insurance Plans, the national association of private health insurers in the US. My revised answer is “probably not,” although I would love to be proved wrong by subsequent events.
It is not for want of attention that so many uninsured Americans find themselves in their predicament. Their plight has been explored in a decades’ old series of conferences, town hall meetings, workshops, public hearings before Congress and state legislatures, television talk shows, and even, in recent years, exuberant nationwide observances of “cover the uninsured week.” An entire industry has sprung up in the health services research community, dedicated annually to counting and categorising the number of uninsured people, arguing over the accuracy of the various counts, and debating whether uninsured people are worse off for their lack of coverage.
An equally energetic research enterprise has sprung up to create health reform proposals designed to bring universal coverage to the US. Although some of these proposals have been crafted with scholarly detachment, they mostly embody distinct political ideologies or the pecuniary interests of groups who profit from health care. The previously mentioned health insurance proposal unveiled by the health insurance industry on 13 November 2006 is a classic example of this genre. Although America’s Health Insurance Plans would tolerate a modest expansion of government insurance programmes for poor Americans, for the most part the plan calls for federal subsidies towards the purchase of the private health insurance policies the association’s members sell. It is, like all such plans, designed to allow the originator to do well by doing good.
It may be asked why, during more than a century with so many health reform proposals on the table at any time, not one has become the law of the land, if only by accident. The answer seems to be twofold.
Firstly, unlike Europeans, Americans tend to believe that poverty is the product of free choice rather than lineage and bad luck. The persistence of that myth, despite empirical evidence to the contrary, has made it difficult to raise taxes for universal health insurance, even though the US has the lowest ratio of taxes to gross domestic product in the Organisation for Economic Cooperation and Development.
However, a more important obstacle to universal health insurance in America is that, although all politically powerful interest groups have their own preferred strategy for universal coverage, these groups always prefer the status quo as the alternative — a phenomenon known as Altman’s law (after Brandeis University economist Stuart H Altman). Because no single plan has garnered the support of a political majority, we always revert to the current non-system mix of employer, government, and self coverage or no coverage. And Altman’s law holds.
The Democrats’ ascendancy to congressional power will probably trigger another national conversation on the plight of uninsured people. But even if the Democrats mustered the courage and the votes to raise taxes or enlarge the nation’s already huge deficit for the sake of universal coverage, President Bush’s veto pen would undoubtedly nip that idea in the bud, ironically appealing to the very budget deficit for which he is largely responsible.
Thus, it is a safe bet that any flurry of activity on uninsurance will be just another instalment in the never ending series of America’s national conversations on the topic — a conversation that resembles nothing so much as the rambling of a drunken lover at a bar — big talk, little action. In health care it has become “the American way.”
http://www.bmj.com/cgi/rapidpdf/bmj.39042.375544.BEv1?hrss=1
And…
Health reform looks to the states
Bipartisan support increases for ‘test labs’ around the nation
By Guy Boulton
Milwaukee Journal Sentinel
Nov. 26, 2006
(Liberal Rep. Tammy Baldwin and conservative Rep. Tom Price) are part of a group of lawmakers and policy analysts that would use states as laboratories to test different approaches for expanding insurance coverage, improving quality and controlling costs.
The idea appeals to conservatives and liberals alike. It recognizes that states have taken the lead in health care reform. And it acknowledges that there may not be one sweeping solution that works equally well in states as dissimilar as Massachusetts and Mississippi.
It also concedes that Congress - mired in the debate over whether the solution is more government involvement or less - is unlikely to agree on the best way to reform the health care system.
The (three) bills all differ slightly. But each would encourage states to come up with ways to make the health care system work better. The proposals would be reviewed by a commission or task force. The most promising ones would be sent to Congress for fast- track approval.
The idea is for the proposals to cross the political spectrum. And, in this, the idea implicitly acknowledges one of the realities of health care reform: No one really knows the best way to expand coverage, control costs and improve quality.
“You can’t possibly know the right solution,” said Stuart Butler, a health care economist with the Heritage Foundation, a conservative policy research organization.
“You may be half right,” he said. “But it’s only by trying these ideas in practice - modifying them based on experience - that you gravitate to a right answer.”
“When you think about what it is going to take to get health care reform,” Butler added, “a key part of this is going to be trust and the ability to work together.”
Everybody’s first choice still is for everyone else to agree with them.
“But that,” he said, “isn’t going to happen.”
http://www.jsonline.com/story/index.aspx?id=535435
Comment:
By Don McCanne, MD
Is covering everyone an idea that is only half right? Is funding health care equitably so that it is affordable for each individual an idea that is only half right? Is improving efficiency by reducing administrative waste an idea that is only half right? If the right solution means that we fix the financing of health care so that it works for everyone, then we really do understand how to do that.
Apparently the Next Big Thing in health care reform is for Congress to grant the states the opportunity to achieve universal coverage. It is not as if the states haven’t been actively involved in this process. In fact, the federal government already has been giving states budget-neutral permission slips to experiment with various reforms.
Of the fifty states, after a half century of efforts, how many of them have achieved universal, affordable health care coverage? None, of course. They are busy struggling with funding issues, high-risk pools, Medicaid, regulatory oversight of private insurers, and many other policy issues that inevitably fall short on reform goals. When we already know how to fix the system, why would we insist on continuing with fifty different state laboratories to experiment further with well understood health policy science?
This is simply a process designed to further fragment our public and private insurance systems, and prevent us from ever having a universal program of social insurance such as Medicare for All. It is not a process designed to establish trust so we can work together. Rather it is a process designed to deceive. It is a decoy set up by the conservative/libertarian faction that has lured the centrists and the progressive/liberal factions.
As long as those in the center and on the left, with a false sense of compromise, sing the praises of those on the right who would constrain and limit government at the cost of a modicum of egalitarianism, we will be unable to prove wrong Uwe Reinhardt’s prophecy.