Health Care Reform: Prove It or Lose it

In an effort to be the first president since Lyndon Johnson to succeed in reforming our nation's health care system, President Obama is exhibiting honorable flexibility. Taxing health care benefits for employees? He was against it when running for office, but he is considering it now that the federal budget deficit is growing so rapidly. A new public insurance plan? He promised this spring that it would be a central part of his health care reform efforts, but now he is willing to put it aside in pursuit of more important goals.

And what are those more important goals? First and foremost, the President wants to expand people's access to health insurance, so that their medical care will no longer be threatened by job loss or by what an insurance company determines to be a "pre-existing condition;" and second, he is committed to controlling health care costs, aware that our future fiscal solvency depends on slowing the growth of Medicare and Medicaid.

The time may come for Obama to shed one of these two laudable goals. Indeed, if blue dog democrats begin turning away from health care reform because of budget concerns, Obama will need to give up his immediate plans to expand access to health insurance, and focus his efforts, instead, on showing the American people that he knows how to control health care costs.

I recognize the moral horror that my proposal will create among those people who, like me, are outraged that a wealthy country like ours allows 50 million people to go without health care insurance. Obama is correct, in fact, to be exhorting Americans to recognize our moral duty to offer basic health care coverage to all our citizens.

But with ballooning budget deficits and an economy still on the brink of disaster, it may not be politically palatable to expand health insurance coverage right now. Most conservatives, and even many moderates, are understandably worried that the government will do the easy job of spending money it doesn't have, while ignoring the more difficult job of making our health care system more efficient. After all, Obama has not really laid out a clear plan for how he will control health care costs. Instead, he is simply asking people to trust him: somehow, with a teaspoon of electronic medical records and a few milligrams of "comparative effectiveness research," he will cure the health system's inefficiencies and make our financial problems go away.

I suspect that Obama already realizes that he cannot achieve both of his goals -- expanding access and controlling costs -- in the initial stages of his reform efforts. Instead, his administration appears to be taking a Massachusetts-style approach to health care reform: expand coverage first and then, after costs spiral further out of control, take on the difficult job of ratcheting down health care costs. In this approach, expanded coverage is the horse that pulls health care reform along what will no doubt be a long and winding road.

This access first approach is morally laudable and may even be politically wise. But politics moves quickly -- who, after all, would have predicted three months ago that "death panels" would play such a large role in public discourse about health care reform?

If fiscal concerns threaten to impede Obama's health plan, he will need to change direction. At that point, the best way to expand health care coverage to all Americans will be for Obama to focus, over the next few years, on proving to Americans that he can control health care costs -- indeed, that he has a legitimate plan for controlling government expenditures more broadly. With this proof established, Obama will then be able to propose reforms that will expand health insurance coverage, and the American public will have confidence that these reforms would not break the bank.

With so many Americans worried about rising taxes and runaway budget deficits, Obama should consider putting the cart of cost control in front of the proverbial horse. If Obama can prove to us that he can rein in Medicare costs, the American public will gladly follow him further down the path of health care reform.

Peter A. Ubel M.D. is author of Free Market Madness: Why Human Nature Is at Odds with Economics -- and Why It Matters (Harvard Business Press, 2009), and George Dock Collegiate Professor of Medicine at the University of Michigan.

 

Comments

[Ken Maddox]

Of course we could go back to, say the 1850s, a simpler time. That was a grand ol' time in the USA. A civil war looming, slavery, small family farms, basically no health care, and above all poverty for most everyone.
Or we could charge past the civil war to the reconstruction where we had everything they had before the war except slavery, plus we gained fatherless homes, an unsettled political environment, and still basically no health care.
Some institutions existed for the care of the poor and unwell. We had Poor Farms, Insane Asylums, Snake Oil salesmen, and no infrastructure to speak of past railroads and telegraph lines.
Welcome to Utopia.

[TRex86]

Spending (cont'd.). If the private sector is to survive health care must become a public trust and the industry a public utility. JLike water and electricity we need medical care. The key stakeholders should be regulated regarding fees, premiums, capital expenditures, basic benefits, etc. The general framework can be designed in Washington; implementation can be fine tuned in the states. The goal is to redistribute current spending to assure universal coverage. Since we spend twice as much per capita as European countries (and get worse outcomes) cash aplenty iis n the system. Some inefficiencies of the private sector could be squeezed out under a public utility model.
Far easier and more efficient is single payer Unicare (Medicare for all). Issue a credit card at the point of service. Ka-ching, you're covered with a basic package of benefits. A "public option" would be next best, but it would inevitably lead to vast shifts into the publically funded market as the insurance companies cannot compete in the face of runaway costs--all of which brings me back to cost. We must look hard at items 2-5 that I listed below. Three and four would likely be addressed in a public utility system, technology assessment would be as well to a lesser extent. That leaves number five. After our recent brush with "death panel" demagoguery it will need thoughtful reflection. Maybe the president can reconvene the presidential ethics advisory committee.
To be continued...

[MrMaus]

From each according his ability, to each according to his need.

[TRex86]

It's hard to deliver that Marxist ideal in a country of 300 million people. What we should deliver is equity--fairness in how we deliver health care to everyone. Unfortunately we live in in the land of Social Darwinism (nothing to do with real Darwinism) where it is from each according to your political connections, to each according to your poliical connections. The rich are getting richer richer and the poor are sliding into abject poverty.

[PlaceboStudman]

Spending? Money? Why are we even saying word about money and how much we spend when it is perfectly clear that nobody knows exactly what they are getting for the money they spend.

Seriously, sometimes I think I am the only person in the country, and certainly the only person on HuffPo who has ever spent any significant time in the hospital or with their doctors

Maybe, just maybe, when the majority of people yank their heads out of the sand and face a real health crisis, and realize that the treatments for many of our medical ailments are as bad or worse than the ailments themself, maybe then we will have a real honest debate about QUALITY of care

[TRex86]

Spending cannot be controlled unless it is, well, controlled. This means direct regulation of the key stakeholders in health care: hospitals, insurance/HMO's, Pharma, and physicians. Even then it will be difficult because several of the contributors to uncontrolled spending require value judgements. Briefly, half of spending growth is due to general rates of inflation. The other half is driven by five key phenomena: 1. a rapidly aging population; 2. technological innovations; 3. imbalances in service capacity; 4. profiteering; and 5. marginal treatment decisions.
I will discuss 2-5 in another post. Regardless of other causes Medicare is colliding with the fact that each 1% increase in people over 65 brings a 5% increase in spending. The greatest costs come with people over age 85, which is the fastest growing segment of the population. Their costs are exponentially higher. Since Medicare is a highly efficient, single payer system the cost savings imputed to other segments of health care are irrelevant.
How to preserve this program? Tres simple. Dump the Part D fiasco and cover prescriptions via Part B (prices negotiated by a central high volume buyer). As to the financing of this program, it should be from general revenues, the progressive income tax. Dump the payroll tax. If necessary means test the program, making high income/assset rich people pay a higher porportion of costs. Take a lien against real property if they lack liquidity. (I would also roll Medicaid into Medicare, but that too is for another post).

[mergina]

Oh yes. The pressure is on his highness to MANDATE that 40 million more Americans be added to the Insurance Companies growing mountain of profit, with little or NO real reform anywhere NEAR being passed. Being passed, those two words that mean so much but mean so little with a Congress that is BOUGHT AND PAID FOR, OWNED AND OPERATED, PROPPED UP SOLELY FOR YOUR ENTERTAINMENT by the Corporate Masters and pull all of their strings at YOUR EXPENSE. Nothing is more sacred to them than the almighty. That would be the ALMIGHTY $$$$$$$!

[Poolorie]

Dr. Ubel, what do you suggest we tell the 18,000 people who die every year w/out health insurance? Should they wait till we get it right? What if it was your family member who died for lack of health insurance? I understand the need to get it right but if we have the will, it can be done.

Its a disgrace that a country such as ours can deny health care to anyone, especially if they are poor.

[mergina]

The don't care. They are blinded by greed. They are insured. UNINSURE THEM ALL. CANCEL ALL OF THEIR INSURANCE POLICIES, every last one of them, and see how fast they pass laws to get it back.

[EbonBear]

Modification: The CongressCritters who vote against a public option (I'd prefer single payer but that isn't on the table) lose their health insurance.

[rmajh5]

Congressman Eric Cantor, when recently questioned about healthcare by a woman in need of care and unable to afford it suggested the woman contact charitable organizations in her area. This advice would be good if our American charities were able to respond to the needs of so many of our American citizens. But they aren't, and Congressman Cantor does not figure that America through its democratic government should be responsible for taking up the task.

We are the only major democracy in the world which refuses to add healthcare as a civil right for all of our citizens. If we were attacked tomorrow by a military army, there would be no question that we would all assume the duty of fighting to protect our nation just as we did during World War 2. But when it comes to calling upon ourselves to protect ourselves from the very real threats of physical and mental illnesses which ravage too many of our people, such a call of duty is dismissed as socialistic.

We in America still have a long way to go before we can claim to have lived up to our ideals. And for the moment, we appear to be backsliding.

[chlai88]

Well said.