Now that Nancy Pelosi has her place in history and perhaps the pool table she wants for her birthday, it's time to sit down and take stock of what we did and didn't do by passing health care reform. Here's what I think we did, besides scaring the spit out of half the country:
1) We increased access to health care for people who previously were uninsured or uninsurable -- we are moving toward community rating by age or condition instead. It will still not be free or necessarily even cheap to get insurance, but you can get it and you can't lose it if you get sick or have a lifetime cap imposed on you
2) We mandated that the young and healthy support those who are not young or healthy, against the day when they, too, might be similarly unfortunate
3) We made it possible for people to stay on their parents' policies while pursuing their educations or working their low-paying entry-level jobs
4) We cut some of the waste and fat from Medicare, redistributing a base level of care and getting rid of the "advantage" extras. Seniors hate this, but it will keep Medicare solvent for longer
5) We forced the insurance companies to re-think their business models
6) Hopefully, we will reduce the use of costly emergency room services for primary care by doing the above
But although we almost fell apart as a society doing even these small things, we have only addressed a small part of the complicated health care equation: access to care. We still haven't adequately addressed cost, or quality. According to a study released by ACCCHS, Arizona's version of Medicaid, Arizona is projected to have to spend $11.6B in general fund monies, $13 billion overall, between 2011 and 2020 to cover unfunded mandates on expanded coverage. Arizona had just decided to reduce its coverage to close a budget deficit, but is not prohibited from getting rid of KidsCare (our version of SCHIP). Where is Arizona going to get the money? It is going to have to raise taxes, which is anathema to its legislature. After all, this is a state in which John McCain is being challenged from the right.
And Robert Reich points out that this is a very conservative reform bill, because it still allows for free market competition and high deductible plans ($4000 per family, $2000 per individual), which have only recently become part of the insurance landscape. Many people are apt to feel this is still out of reach.
In fact, key elements of the law are right out of the conservative playbook, says the Columbia Journalism Review.
What haven't we done?
1) We haven't changed the provider incentives, instituting widespread reimbursement reforms. We should be reimbursing for outcomes, not procedures, and we avoided that thorny question, although there are small demonstration programs in the bill that could lead us there through back doors.
2) We haven't attacked tort reform, although my personal opinion is that would go away if we attacked the quality issue: they are two sides of the same coin. When I hear that hand-washing isn't effectively enforced at many major hospitals, I wonder why we don't have MORE litigation rather than less. Even a car mechanic is forced to a higher standard of delivering quality than some medical centers.
3) We haven't done anything to reign in the high cost of devices and drugs, although many of them are largely ineffective. I'm not sure I know how to propose a solution for that, because biotech and medical entrepreneurship involves a lot of research and very long time-to-market that raises the R&D costs on the front end. And when we try to speed the process from the government end we get studies fraught with conflict of interest and drugs like Vioxx that are rushed to market until they start to kill people.
4)We haven't changed the model of delivering sick care rather than health care, although I hope that providers will try to manage costs by trying to promote wellness.
5) We haven't begun the public health and expectation -- setting that we have to do with an aging population and a shortage of resources (both money and talent).
There. Will. Be. Rationing. Get used to it.