We may be closing in on the moment when we will need to start the healthcare reform discussion from scratch.
I know thats an argument being made by healthcare opponents in an effort to delay and ultimately stymie reform, but that doesnt mean a delay wouldnt be warranted if we cannot alter the terms of the current debate.
Basically, the debate has gone off track. Weve moved away from the real issues the dual needs of expanding and improving care and are now doing little more than running in place, focusing on side issues like the federal deficit.
The legislation on the table as of the middle of October leaves the perverse incentive system in place, grants subsidies to the entities that benefit most from our dysfunctional system and does little to improve the care provided.
Going back to the beginning may be our only hope, because it would allow us to readdress the primary issues that should be driving the debate.
1. Expanding care: The ultimate goal must be expanding coverage to include the nearly 50 million Americans that lack insurance and who are paying for care out of pocket and too often face an untenable choice:
forgoing care, which endangers their health, the health of their families and the health of their communities.
going to emergency rooms for care, which is more expensive than a visit to a family physician and often is paid for via state charity care programs, i.e., our tax dollars.
The legislation on the table in particular, the bill proposed by the Senate Finance Committee, creates the illusion of universal coverage by forcing Americans to buy into the existing system or face penalties. They will get some help in the form of subsidies, but there are no controls on cost, meaning many of the folks who cant afford insurance now likely wont be able to afford insurance in the future.
This places the responsibility for the failing system at the feet of consumers who are at the mercy of the system, rather than on the folks who control the larger game. It is like blaming the third baseman for the location of third base.
2. Distorted incentives: The existing system, as numerous news reports point out, pressures doctors into performing procedures that may be more expensive than available alternatives, unnecessary tests and unnecessary treatments. Costs rise under this model, but healthcare outcomes do not necessarily improve.
A June 1 story in The New Yorker by Atul Gawande, a physician, on the differences in cost and care between McAllen and fellow border city El Paso, Texas, offers a glimpse into how these incentives work with doctors and hospitals that focus on quantity of care probably the majority spending significantly more than those focused on outcomes.
Communities have to be weaned away from their untenably fragmented, quantity-driven systems of health care, step by step, he writes. Doctors and hospitals should be rewarded if they band together to form accountable-care organizations, in which doctors collaborate to increase prevention and the quality of care, while discouraging overtreatment, undertreatment, and sheer profiteering.
3. Cost and its impact: The amount we, as a nation, collectively pay for health care should cover every person living and working in the United States. But the high costs we spend more per capita than any other industrialized nation, according to several international studies - mean that too many are without insurance and cannot afford care.
Consider these numbers from the National Coalition for Health Care, a group advocating universal coverage:
We spend about $2.5 trillion a year on health care, or 17.6% of our gross domestic product.
Healthcare spending is increasing faster than almost any other expenditure in our economy and is expected to increase by about 6.2% a year and reach $4.4 trillion.
Employer-provided plans have more than doubled in cost over the last decade and making it much more difficult for businesses to continue to provide coverage to their employees and for employers who are paying a larger and larger share of the bill to afford coverage themselves.
The upshot? Economic uncertainty.
Economists have found that rising health care costs correlate with significant drops in health insurance coverage, the NCHC says, and national surveys also show that the primary reason people are uninsured is due to the high and escalating cost of health insurance coverage.
The NCHC also says that nearly two thirds of personal bankruptcies were linked to medical expenses, even though about four of five who filed were covered.
The high cost of insurance also leads to job loss. Employers like General Motors often pay more in health costs - both for current and retired employees than they do in wages, while small businesses will pay nearly $2.4 trillion dollars over the next ten years in health care costs for their workers, causing the loss of 178,000 small-business jobs.
And yet, our system provides inferior care to the majority of Americans, as the Commonwealth Fund, a private nonpartisan foundation advocates for reform and funds research, has repeatedly found in recent years.
The various bills on the table - and most of the alternatives considered politically possible fail to address these problems, not only leaving in place a system that values profit over care but helping to expand it and make it even more profitable. The insurance industry will get new customers and massive subsidies, but operate as they always have with impunity. The majority party, unfortunately, seems more interested in passing something than in passing something good, in claiming to have reformed the system than in actually reforming it. The reform moment is passing and with it any chance we have to truly fix our broken healthcare system.
Hank Kalet is a poet and newspaper editor in central New Jersey. Email firstname.lastname@example.org; blog, www.kaletblog.com.
From The Progressive Populist, November 1, 2009
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