Breaking Down the Issue
By Mark Liebow, MD, MPH
The versions of federal health care reform legislation being discussed in Washington address three main themes: 1) cover the uninsured, 2) regulate the private insurance market more effectively, and 3) improve the health care delivery system in order to increase quality and reduce costs. Each of the proposed bills has many parts, and we have heard numerous opinions about how these ideas would change health care as we know it. This has caused much confusion about what the reform bills might really do. Here’s my take on the themes as well as what legislation best can fix and influence.
Covering the uninsured is something government could do if the political will were there. It would be comparatively easy. All it takes is getting everyone signed up for health insurance and finding enough money to pay for covering the uninsured. Most people who are uninsured cannot afford to buy private insurance (or even a “public option” policy), so they will need subsidies to afford it. To finance this, we’ll need to collect new taxes, reduce current tax deductions such as those for charitable contributions or health insurance premiums, or use money saved by improving health care delivery. It’s never easy to raise taxes or reduce deductions, and savings from care delivery may take years to realize. However, we appear to be moving toward consensus on how to pay for subsidies.
Regulating the private insurance market is a classic government function and is often a topic of legislation. Problems such as insurance companies refusing to sell individual policies to people with pre- existing conditions are well-known and can be solved through regulation. However, those problems will best be eliminated if everyone is in the market, which is why we’re talking about employer and individual mandates for coverage. A hot topic is whether there should be a public insurance plan to compete with private plans. Legislators’ positions on this seem to be determined by their opinions about the role of government. A public plan could be helpful as a check on private insurers, especially in a system where everyone has to have insurance, as it would provide an option for people if private insurers try to evade regulations. The federal government covers its employees without a public plan, but its system is tightly regulated. Many people fear that plans covering 160 million people can’t be regulated as carefully as those covering 4 million. Most insurance companies have made a public commitment to health care reform, but they may fight vehemently against some of the rules being proposed in the bills that have come out of committees such as prohibiting the cancellation of paid-up insurance policies (except in the case of fraud) or refusal to sell policies to individuals with pre-existing conditions.
Improving the health care delivery system has provoked the most discussion, even though this is the area legislation can affect least. As doctors, we know that the delivery system will not be improved by legislation as much as by professional efforts at the practice or health system level. The federal government can create incentives for us to do the right thing (or penalties to discourage us from doing the wrong thing), but it can’t just pass a law requiring physicians to make management better and costs lower for patients with chronic disease. Also, the science has to be in place before doctors can be expected to change the way they practice. We used to do cataract surgery as an inpatient procedure. Once it became clear it almost always could be done safely on outpatients, third-party payers refused to pay for most inpatient cataract surgeries and doctors started doing these procedures on an outpatient basis. However, this was years after the first outpatient cataract surgery was done. Making other changes to health care delivery also will take a long time, and further research and testing will be needed before they can be implemented across the country.
Not only will it take time to realize savings from such changes, but it also will be hard to predict accurately what those cost savings will be. This will complicate discussions about financing the proposed legislation. The Congressional Budget Office traditionally has been conservative in “scoring” such savings, many of which will not be realized within the 10-year period it uses in its projections. This is why cuts in fees to physicians and hospitals are commonly proposed as financing means—as their budgetary effect can be easily calculated.
No one will be for or against every part of any health care reform bill that comes up for debate. But our legislators soon will be forced to weigh whether what they like in the bill outweighs what they don’t like. We should do the same and let them know what we think.
Mark Liebow is an internist at Mayo Clinic.