A healthy debate on reform
By Tim Damos
Since taking office in January, President Barack Obama has pushed Congress to pass legislation that would make high-quality health care affordable for all Americans and reduce the number of uninsured. That prompted a national debate that has come to a climax with two major Democratic reform bills pending in Congress. The Baraboo News Republic asked three experts with different backgrounds and perspectives to weigh in on the first major attempt at health care reform in more than 15 years. BNR: Will reform the proposals fix what many see as a health care system in major need of reform? If so, how quickly would an overhaul provide relief for Americans currently struggling financially with serious health problems? If not, what do you propose as a viable alternative? ARTHUR TAGGART: Washington lawmakers are attempting to address the serious crisis in our health care system without disturbing the status quo. Repackage the same old thing, call it reform, and hope for a different result. While the proposals being crafted in Washington won’t do much to rein in spiraling costs and look like a "bail-out" for the health insurance industry (watch for lottery-sized CEO bonuses), we can’t ignore the fact that millions of Americans will get coverage. Democrats won’t want to wait until 2013 for implementation because of the mid-term elections. Nor should they, since an estimated 43,000 American citizens die prematurely each year because they can’t afford medical care. For 70 years "reform" has always meant increased taxpayer spending on patients that insurance companies don’t want to cover. A true universal system covers everyone by creating the largest risk-sharing pool possible and spreads risk equitably among the young, the healthy, the aging and the infirm. Instead of offering us that choice, we can say "no" with those who would leave 46 million uninsured, or we can pass whatever Blue Dogs will tolerate and leave something like 20 million uninsured in ten years. CURT GIELOW: The current proposals in Washington are principally health insurance reform, not health care reform. They will do little to contain health care cost escalations. In fact, I expect health insurance costs to go up, not down. Control of health care costs will come about when we collectively do the following: Provide incentives to patients and providers for wellness initiatives; pay providers for results, not procedures; use quality and efficiency information to drive "best practices" in providers and thereby weed out over-utilizers; provide real federal tort reform on non-economic damage awards to stop "defensive" wasteful medical orders; promote the idea of dying a natural death with dignity through advanced directives, POLST (Physicians Orders for Life Sustaining Treatment) and other forms of patient rights directives.
BARBARA WOLFE: The proposals if enacted will surely improve our health care system. How quickly depends on when the reforms are implemented. The two changes most directed at providing relief for those struggling financially with serious health problems are improvements in the insurance market, including regulations to immediately reduce and eventually eliminate pre-existing condition clauses, and subsidies to families to purchase health insurance. The House bill would set up an insurance exchange where individuals and smaller employers could purchase insurance. This should both reduce the cost of insurance and also make it easier to shop intelligently for coverage. The exchanges would require private insurers and the public option to offer comparable plans. The Senate bill would create something similar. In terms of those with pre-existing conditions, there is to be a temporary high-risk pool with caps on premiums. In addition, nearly immediately there would be restrictions on private insurers in terms of pre-existing conditions — the period they can look to discover such conditions is to be limited to 30 days and can only last for three months. Families within certain financial guidelines would also be eligible for subsidies to help pay insurance premiums, while families with incomes below 100 percent of the federal poverty guideline would remain on Medicaid. Under the House plan the percent of income a family may be asked to contribute is somewhat greater but is still capped. Under both plans, cost sharing is also capped on a sliding scale. BNR: Gov. Jim Doyle has said he is concerned other states may see more benefits under a final reform bill because they have not worked as aggressively as Wisconsin to cover their uninsured. Would Wisconsin take a back seat to other states under these bills? TAGGART: Wisconsin does have a relatively low percentage of uninsured residents compared to most states. It’s hard to construe that as a bad thing. Having a low number of uninsured means that Wisconsin would be an excellent laboratory for real, meaningful health care reform. GIELOW: Wisconsin has developed a tiered public health insurance policy through Medicaid, Badger Care, BadgerCare Plus, Senior Care, etc. that allows nearly all some coverage, including children. Wisconsin has been aggressive in these developments, and therefore other states will most likely benefit more than Wisconsin from a federal mandate. WOLFE: If I understand this correctly, Wisconsin may gain less than other states that have been less aggressive. BNR: Do you support a public option? If so, should states be allowed to opt in, opt out, or should there be a trigger mechanism that only allows states in which private insurance has become unaffordable to the average family to offer the government plan? TAGGART: A good public option should encourage healthy competition, create an incentive for private insurers to reduce administrative overhead, and discourage wasteful bonuses. This would help slow down the typical, double-digit premium increases we see year in and year out. A poor, stripped-down public option would simply create a convenient dumping ground for insurance companies to offload sicker, costlier patients. Let’s remember that private insurance is already unaffordable to the "average" family everywhere in the United States. If you’re lucky you get it with an employer’s help. GIELOW: I do not support a public option. The federal government need not compete with the private sector. The same outcome could be achieved if federal regulations on the health insurance industry were changed to require nationwide plan benefits for a low-cost, limited-benefit plan available to anyone who wants it. A tax incentive could be provided to encourage its utilization. We should also allow national competition for purchasing private health insurance across state lines, thereby developing competitive national plans. WOLFE: I support a public option. And I prefer that the public option be established along with the implementation of the health reform plan. I think the combination of carefully defining three to four benefit packages and then having a public option compete with private plans is likely to generate competition and hence lead to lower cost for insurance. Individuals and small firms will be able to go to the exchange and readily compare the premiums for the same set of benefits. Having a public option should increase pressure to compete on cost. BNR: There have been differing claims about how much these bills will cost. What are the correct figures? Are these proposals affordable, and will expenses for things such as new prevention and wellness programs help save money in other areas? TAGGART: We already have the most expensive health care system in the world — $2.5 trillion annually or over $7,000 per person — but we leave 46 million uninsured. We rank nowhere near the top 10 worldwide in any meaningful health indicator. There are insufficient cost-containment features in the current measures. We will continue to pay costly middlemen a percentage of each health care transaction, and the number of transactions will increase. Prevention and wellness programs are billed as "bipartisan". Let’s blame Americans for making poor health choices. Why do other countries do a better job at health and wellness while we specialize in expensive critical care? Japan ranks first in nearly all health outcomes. The Japanese may have a healthier diet and perhaps they are less sedentary. The real difference is that they see doctors more frequently. This, too, is cultural. Physicians are respected advisers, and when your health is monitored your outcomes improve. In Japan everyone is covered, from birth to a dignified death. Until we elevate health care provision to a more revered status than that of a commodity transaction, we will not compete effectively with the rest of the world in either health outcomes or cost. GIELOW: First, the American economy could afford a well developed and thought-out health care reform plan. However, this is not being discussed. The current federal talks will not contain costs, nor lower insurance premiums. There is too much pork in this current legislation and it’s too far from being real reform. It’s a tax bill we can’t afford. Simpler, easy-to-understand health insurance reforms are possible but apparently can’t be crafted by politicians too interested in feeding at the trough of taxpayer funds. WOLFE: It is always difficult to predict costs in health care. There is new technology, changing ways we might provide care, greater use of IT and so on. I think there is potential in the increased use of comparable effectiveness research to both improve quality of care and reduce costs. And there is potential in both wellness programs and continuing care program to again improve quality and reduce costs. Send e-mail to tdamos@capitalnewspapers.com About the experts Arthur Taggart Arthur Taggart is executive director of the Epilepsy Foundation Southern Wisconsin and chairs the Coalition for Wisconsin Health, a group of organizations that support publicly financed, single-payer health care. Curt Gielow Curt Gielow is executive dean of the Concordia University Wisconsin School of Pharmacy and adviser to the Wisconsin Medical Society. He has worked as a Republican state lawmaker, hospital executive and pharmacist. Barbara Wolfe Barbara Wolfe is a professor of economics, public affairs and population health sciences at the University of Wisconsin-Madison. She has been a faculty member since 1977 and holds a doctorate in economics from the University of Pennsylvania.