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August 13, 2009
I was complaining to my wife the other day. “I’ve been thinking and writing about the Israeli-Palestinian conflict for 25 years, and nothing seems to change. It’s always the same arguments, and no sense of progress,” I said.
“Oh, boo hoo hoo,” she said. “I study health-care reform.”
Sharon is a principal in Health Management Associates, a health policy research and consulting firm. For most of her career she has been studying the effects of reform — and stasis — on health-care issues: expanding coverage, improving quality, containing costs.
Sharon is more wonk than activist— that is, she has her opinions, but her typical client is a foundation or government that wants to know objectively if an innovation works or doesn’t work. So when she says something doesn’t work, I tend to trust her. And as you’ll see by the transparently nepotistic interview I conducted with her this week, she doesn’t think our health system works, or not as well as it should.
“In the richest country in the world, we’re spending twice per person on health care than other industrialized countries, over 45 million people don’t have health coverage, and costs are spiraling out of control, eating up more and more of families’ and the country’s budgets,” she tells me.
Do any of the current proposals begin to address the most pressing problems?
“Yes, the major proposals developing in Congress and supported by the Obama administration would make a big dent in the coverage problem. They would provide subsidies for lower-to-mid-income people to buy health insurance, change the rules so insurers can’t reject people or charge higher premiums for those with prior health conditions, and expand the federal-state Medicaid program for the poor and near-poor. They’d also require nearly everyone to have coverage, so the costs of emergency room visits and hospital services for the uninsured would no longer get shifted to premiums paid by the rest of us.”
Where do they fall short? Won’t they force everyone into inferior plans?
“The administration and congressional leaders have learned from the past, when fears (warranted or not) of taking away people’s current plans sank reform efforts. We all remember Harry and Louise, right? Under the current proposals, most people who are happy with their current, job-based insurance or Medicare could keep what they have. The government would define a minimum package of benefits, so everyone would have at least basic services covered and not be caught ‘under-insured’ when the hospital bill comes.
“What’s new in the plan is this: ‘insurance exchanges’ where people can more easily compare and buy plans, and a possible new public plan to compete with the private options. They’d be available for people and businesses who don’t have (or can’t get) coverage, or can barely afford what they currently have.”
Can government possibly offer a plan that is popular and efficient?
“Medicare, which covers some 44 million elderly and disabled Americans, is both. Basically a ‘single-payer system,’ Medicare’s been more successful than private insurers in reining in costs and maintaining access to doctors.”
But doesn’t our system work better than nationalized systems in Canada and England?
“Chronically ill patients in the U.S. are more likely to forgo care because of costs and experience more errors and inefficient, poorly organized care than adults in other Western nations, including Canada and Britain. Besides, our current system has de facto rationing, based on who can afford insurance, who gets left out due to pre-existing conditions, and what services the insurance companies decide they’ll cover.”
On the flip side, what’s the most effective (and truthful) criticism of the current legislation made by its opponents?
“Expanding coverage on this level is expensive — upward of $1 trillion over 10 years — and there’s disagreement even among reform supporters about how to pay for it. All of the options — tax increases, spending cuts, etc. — are politically unpopular. (Interestingly, the same critics who argue that the plan is too expensive reject the provisions that are most likely to reduce costs, like a public plan competing with private insurance.)”
You’ve been at this most of your career. Has there been any progress?
“There has been some progress. The federal-state Children’s Health Insurance Program (CHIP), which was reauthorized earlier this year by the Obama administration, has considerably reduced the number of uninsured kids. And some states, including New Jersey, have been very active in expanding publicly subsidized coverage and access to care. But states on their own are limited in what they can do and are vulnerable to budget constraints (and cutbacks!).
“Federal action is needed to move us toward a place where all Americans have access to affordable health care.”
If Congress can agree on a reform package, does this mean you’ll have to find a new issue?
“There will always be a need for people to evaluate change and recommend improvements. But just in case, I’m reading up on the Mideast crisis.”
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