Friday, January 13, 2006
The Oregonian
Former Gov. John Kitzhaber has offered a proposal to extensively reform America’s health-care system. The plan would have the state collect Medicaid money (it does this already), Medicare money (federal insurance through Social Security) and tax savings that employers get when they pay for health insurance for their employees. He would do this by having the federal government “waive” existing restrictions on states (this could apply only to Medicaid; Medicare benefits belong to workers). The resulting pool of money ($6 billion) would support preventive care and care for “other common but often costly ailments.”
Presumably, existing services would remain (although this was not specified).
The flaws in this proposal are huge. Federal limitations in many instances serve valuable purposes. Medicare and Medicaid have very different purposes (insurance vs. welfare), structures (federal payment vs. federal/state payment) and beneficiaries (retired workers vs. the poor). Constitutionally, the federal government could not assign retirees’ Medicare benefits (earned through decades of work) to a state, nor could they constitutionally deny federal tax deductions to the employers in one state (Oregon) while extending them to the other 49 (or consider the deterrence of out-of-state or interstate employers).
Most importantly, the proposal does not increase the funding for services or expand covered people or services at a time when 43 million Americans lack health insurance.
The analogy Kitzhaber draws is to his Oregon Health Plan efforts, which were admirable and innovative. But this is different. OHP was limited to Medicaid, a federal/state program, specifically contemplating waivers. And even then, we have watched the failure of the Oregon Health Plan during the past five years. There are no state dollars in Medicare or federal taxes. The Kitzhaber proposal would require national legislation; there is no chance for a single state to lead in this way. And, as national legislation, it is far too little to address major needs.
But the critics, too, have it wrong. The proposal would not create a “single-payer” program. But it should. Our health-care failure is not that we have covered too many health services, but too few. The flaw is not that we pay too much — $1.3 trillion — but that we get too little for what we pay.
And Kitzhaber himself has it wrong in saying that health care is not as important as education or the economy. It is central to both.
In the end, Kitzhaber’s proposal is not, contrary to many commentators, nearly bold enough. We need adequate funding; national planning for health facilities and services (we had this for a decade in the 1970s and ’80s); effective cost control (especially through bulk buying of drugs, as the Veterans Administration does); a broad definition of health to address smoking, obesity and alcoholism and to offer preventive health care; and a single-payer system retaining employers and insurers as delivery mechanisms, along with state agencies to reach the uninsured and the unemployed.
Paradoxically, we are getting there a bit at a time, and have been since 1970. Contrary to Kitzhaber’s proposal, incremental steps work. In the past 35 years, we have added health care for the poor, the aged, children, veterans and workers. We have improved hospitals, doctors, insurance and drugs. We now need to pull them together, fund them adequately and make them work. If we fail, the fault will be ours.
Arthur B. LaFrance is a law professor at Lewis & Clark Law School who teaches Bioethics, Health-Care Delivery and Health, Poverty and the Law.