Healthcare Reform 2009

NOTE: This and Dr. Hertzka's article contain solicited opinions from two of SDCMS' physician leaders. Neither article reflects the opinions of SDCMS or CMA as a whole. They are published here to provoke thoughtful discussion and consideration of opposing views on the issue of healthcare financing reform currently underway in our nation's capitol. Please feel free to join the discussion by sending your letters to the editor to Editor@SDCMS.org.

In the months and years to come, there will certainly be no shortage of retrospective analyses of the events that currently comprise the efforts to reform what is, by all reasonable viewpoints, a most dysfunctional system of financing the healthcare provided to America's citizens. That there is a need for such reform is universally agreed upon, with the glaring exception of the one industry that continues to thrive with the status quo: private companies that sell health insurance policies. For the health insurance industry, it would be hard to imagine a more profitable system. For everyone else, it's hard to contemplate a less beneficial one. The United States pays far more than any other country for healthcare but ranks nowhere near the top in the quality of its citizens' health. This has been the case for at least the past 60 years. No wonder, then, that repeated efforts have been made to find a way to make the care we receive become worth what we pay for it. Despite these massive costs, there remain fully 47 million Americans who are uninsured.

The year 2009 will be looked back upon much like so many of these previous efforts. At this exact moment in time, it is anyone's guess as to what, if any, legislation will finally emerge from our Congress. There is, however, something unique about the present situation. Never before has there been such intense acrimony and hostility accompanying the debate. One can argue over why this is so. It's hard to imagine that either side looks upon what has transpired so far as an optimal and gratifying exercise in policymaking. The depth of feeling that has been created over this issue certainly has the potential to make future bipartisan and cooperative efforts on other issues just that much harder to secure.

For these reasons, then, it is, I believe, not unreasonable to look back over the past several months and consider whether it had to be this way. What strategies might have been employed by the "liberal" side that would have rendered the matter what it should have been: a reasoned, informed, and courteous negotiation with the goal of producing not only improved quality of healthcare but a sense of cooperative accomplishment with a focus on common ground instead of differences? In the following paragraphs, I will present some thoughts on how the liberal community, of which I proudly consider myself a member, could have and should have stepped forward to promote the well-being of its citizens by reforming the system by which healthcare is financed. I do so not out of any sense of impending failure or capitulation to those who are in opposition. I believe (and by the time you read this, I may be proven wrong) that there is still an opportunity for success. As Winston Churchill once said, "Americans always manage to do the right thing, but not until they've tried everything else first."

The most easily identified failing on the part of reform proponents was the violation of Santayana's timeless warning that those who do not study history are doomed to repeat it. Over and over again our presidents, dating all the way back to Harry Truman, have found their efforts to bring healthcare access to all citizens met by powerful resistance by those whose vested interests lay in avoiding any changes. As recently as 1965, the efforts of President Lyndon Johnson to pass Medicare were characterized as a Communist plot designed to take away freedom. None less than future president Ronald Reagan appeared in a propaganda film that warned of the dangers of this program. He said that if Medicare comes to pass, "We will spend our sunset years telling our grandchildren what America was like when men were free." One of the saddest features of this fear-mongering campaign was that the major promoter of it was none other than our own American Medical Association (AMA). In the more recent iterations of reform, such as that proposed by President Clinton in 1993, the role of chief naysayer had been passed to its present occupier, the health insurance industry. To its great credit, AMA this time around has displayed the wisdom and presence of mind to make efforts to work with the administration in a cooperative fashion so as to remain at the table and seek the changes it requires in a harmonious fashion.

It would have been ever so much more effective to have headed off the most frequently voiced argument against the offering of a "public option," i.e., that it will put the private carriers out of business. This could have been easily accomplished by citing the history of another form of insurance, that of workers' compensation. In the early 20th century, a number of states proposed the creation of state funds overseen and operated by governments to offer an alternative to businesses that were required to purchase this insurance so as to protect injured workers. Such funds were vehemently opposed by private insurers who complained that they would not be able to compete against the government (sound familiar?). When the funds were created, the private carriers reduced their premiums by an average of 30 percent and have continued to compete effectively to this day. This is quite likely what would happen if a public option for health insurance came into being at this time. To have put forward this historical event at the outset would have deprived the opponents of today's efforts of their favorite misrepresentation.

A lack of clear and precise language as to what the goals of reform are has created a good portion of the fear and anger that have been so prominent. The Obama administration, in an effort to avoid the Clinton mistakes, has failed to spell out its objectives, preferring to let Congress create the legislative package. This brings to mind the oft-quoted line that there are two things that are just too unpleasant to watch being created: sausage and legislation. As a result, Congress has created numerous proposals, with major differences among them. Even the term "universal coverage" suffers from vagueness. Does it mean that all people are provided with free healthcare with no personal expenses? Or does it mean that everyone is legally required to purchase a policy no matter what the cost? And what kind of policy is meant by that term? Is it to be comprehensive or catastrophic? What do we even mean by "insurance"? In its most traditional definition, insurance means the bringing together of large numbers of risk-sharers for the purpose of avoiding individual financial catastrophe. Somehow, that definition no longer seems to be in play as policies have become so comprehensive that often quite minor expenses are covered, such as doctors' office visits. Clearly, that is not insurance as it used to be known. If the individual mandate is to come to fruition, it must be made clear whether required policies are to be comprehensive or catastrophic. The latter should not engender major costs, but should largely eliminate medical bankruptcies. This distinction should have been made clear at the outset of the reform effort.

It would have been immensely helpful had it been appreciated that many perceive government involvement in healthcare in terms only of the single-payer systems of England and Canada, as they are so frequently cited as examples of how regulated care doesn't work. Little or no attention has been paid to the numerous universal coverage systems in place in Europe that work extremely well. France is recognized to have a system that employs private health insurance that is highly regulated and that provides high-quality care at reasonable costs. So too with Spain, Germany, and Switzerland, but no effort was made by the proponents of reform to educate both the public and Congress as to the wisdom of emulating these systems.

Finally, it has been discouraging to hear the term "public option" promoted and reviled in the absence of any clear definition as to what it means. One might well assume that it means a change in the Medicare system so as to open it up to anyone who wishes to buy into it, no matter what their age or disability status. Such a proposal is not only clear and easy to understand, but does not require the creation of new bureaucracies. This level of clarity has not been forthcoming.

This linguistic imprecision ties directly to the issue of failure to be clear about the monetary costs of reform. As stated above, costs are massively variable depending on the nature of the reform being sought. If Medicare membership were to be offered to all citizens, there would need to be a massive rededication to eliminating the so-called "big three": fraud, waste, and futility. Estimates range to 30 percent as the amount of money expended on these three features of care. Currently, Medicare pays very little attention to fraud, which is a major cost factor. Arguably the biggest cause of wasteful spending is defensive medicine, which nearly all of us feel compelled to resort to in an effort to protect ourselves against lawsuits. We patiently await proposals to include reasonable tort reform so as to dramatically reduce wasteful medical costs. Among the most sensitive reform issues is the problem of futility. It has been estimated that up to 50 percent of the money spent on an individual's lifetime of healthcare is expended in the final 30 days of life. It's hard to imagine that we can't do better than that. This, however, is a very sensitive issue, suggesting that we must bring an end to costly and hopeless medical endeavors. Is there, for example, any reasonable justification to fund treatments with the colon cancer drug Erbitux at a cost of $10,000 per month when it has been shown that it extends survival for an average of only 45 days? Try, however, getting Medicare to refuse to cover this treatment, futile though it may be, and the Sarah Palins of the world will rant about "death panels."

Another avoidable failure was the absence of any effort to enforce party discipline among congressional Democrats. In 1965, Lyndon Johnson took an extremely hard line in personally approaching and persuading any party member who may have been wavering. This resulted in the sort of unity that allowed Medicare to pass. It is difficult to understand how conservative Democratic congressional representatives, known as "Blue Dogs," mostly from under-populated states, can have been permitted to oppose their own president on his most difficult initiative. The law should have been laid down well in advance and in no uncertain terms. In Lyndon Johnson's terms, a "trip to the woodshed" would have been in order.

Finally, the Obama administration was remiss in not powerfully emphasizing the win-win nature of the proposed reforms. It has been a sad spectacle to witness lower-middle-class Americans fighting against a program that is so obviously in their best interests to support, especially those who have been rendered so hysterical and ill-informed as to shout about "keeping the government away from my Medicare!" It would have been remarkably easy to inform the citizenry about how the only losers in the reform package will be the insurance companies, the very same people who refuse to cover you if you've ever had any sort of illness in the past and who so often stand in the way of care recommended by your doctor.

Although I happen to believe that meaningful healthcare reform is an idea whose time has come, the process of generating public and Congressional support for it has been much harder than it needed to be. We've reviewed a few of the ways in which some of the difficulties could have been avoided. There are probably going to be more shortcomings before the matter is settled. The industrialized world is watching, perhaps with bemused detachment, to see if the United States can at long last join with the majority of countries that long ago settled upon the realization that universal access to quality and affordable healthcare is in everyone's best interests.