Is the House Health Care Bill Better than Nothing?
by Marcia Angell
Published on Monday, November 9, 2009 by Huffington
Post distributed by Common Dreams
Well, the House health reform bill -- known to
Republicans as the Government Takeover -- finally
passed after one of Congress's longer, less
enlightening debates. Two stalwarts of the single-payer
movement split their votes; John Conyers voted for it;
Dennis Kucinich against. Kucinich was right.
Conservative rhetoric notwithstanding, the House bill
is not a "government takeover." I wish it were.
Instead, it enshrines and subsidizes the "takeover" by
the investor-owned insurance industry that occurred
after the failure of the
To be sure, the bill has a few good provisions
(expansion of Medicaid, for example), but they are
marginal. It also provides for some regulation of the
industry (no denial of coverage because of pre-existing
conditions, for example), but since it doesn't regulate
premiums, the industry can respond to any regulation
that threatens its profits by simply raising its rates.
The bill also does very little to curb the perverse
incentives that lead doctors to over-treat the
well-insured. And quite apart from its content, the
bill is so complicated and convoluted that it would
take a staggering apparatus to administer it and try to
enforce its regulations.
What does the insurance industry get out of it? Tens of
millions of new customers, courtesy of the mandate and
taxpayer subsidies. And not just any kind of customer,
but the youngest, healthiest customers -- those least
likely to use their insurance. The bill permits
insurers to charge twice as much for older people as
for younger ones. So older under-65's will be more
likely to go without insurance, even if they have to
pay fines. That's OK with the industry, since these
would be among their sickest customers. (Shouldn't age
be considered a pre-existing condition?)
Insurers also won't have to cover those younger people
most likely to get sick, because they will tend to use
the public option (which is not an "option" at all, but
a program projected to cover only 6 million uninsured
Americans). So instead of the public option providing
competition for the insurance industry, as originally
envisioned, it's been turned into a dumping ground for
a small number of people whom private insurers would
rather not have to cover anyway.
If a similar bill emerges from the Senate and the reconciliation process, and is ultimately passed, what
First, health costs will continue to skyrocket, even
faster than they are now, as taxpayer dollars are
pumped into the private sector. The response of payers
-- government and employers -- will be to shrink
benefits and increase deductibles and co-payments. Yes,
more people will have insurance, but it will cover less
and less, and be more expensive to use.
But, you say, the Congressional Budget Office has said
the House bill will be a little better than
budget-neutral over ten years. That may be, although
the assumptions are arguable. Note, though, that the
CBO is not concerned with total health costs, only with
costs to the government. And it is particularly
concerned with Medicare, the biggest contributor to
federal deficits. The House bill would take money out
of Medicare, and divert it to the private sector and,
to some extent, to Medicaid. The remaining costs of the
legislation would be paid for by taxes on the wealthy.
But although the bill might pay for itself, it does
nothing to solve the problem of runaway inflation in
the system as a whole. It's a shell game in which money
is moved from one part of our fragmented system to another.
Here is my program for real reform:
Recommendation #1: Drop the Medicare eligibility age
from 65 to 55. This should be an expansion of
traditional Medicare, not a new program. Gradually,
over several years, drop the age decade by decade,
until everyone is covered by Medicare. Costs:
Obviously, this would increase Medicare costs, but it
would help decrease costs to the health system as a
whole, because Medicare is so much more efficient
(overhead of about 3% vs. 20% for private insurance).
And it's a better program, because it ensures that
everyone has access to a uniform package of benefits.
Recommendation #2: Increase Medicare fees for primary
care doctors and reduce them for procedure-oriented
specialists. Specialists such as cardiologists and
gastroenterologists are now excessively rewarded for
doing tests and procedures, many of which, in the
opinion of experts, are not medically indicated. Not
surprisingly, we have too many specialists, and they
perform too many tests and procedures. Costs: This
would greatly reduce costs to Medicare, and the reform
would almost certainly be adopted throughout the wider health system.
Recommendation #3: Medicare should monitor doctors'
practice patterns for evidence of excess, and gradually
reduce fees of doctors who habitually order
significantly more tests and procedures than the
average for the specialty. Costs: Again, this would
greatly reduce costs, and probably be widely adopted.
Recommendation #4: Provide generous subsidies to
medical students entering primary care, with higher
subsidies for those who practice in underserved areas
of the country for at least two years. Costs: This
initial, rather modest investment in ending our
shortage of primary care doctors would have long-term
benefits, in terms of both costs and quality of care.
Recommendation #5: Repeal the provision of the Medicare
drug benefit that prohibits Medicare from negotiating
with drug companies for lower prices. (The House bill
calls for this.) That prohibition has been a bonanza
for the pharmaceutical industry. For negotiations to be
meaningful, there must be a list (formulary) of drugs
deemed cost-effective. This is how the Veterans Affairs
System obtains some of the lowest drug prices of any
insurer in the country. Costs: If Medicare paid the
same prices as the Veterans Affairs System, its
expenditures on brand-name drugs would be a small
fraction of what they are now.
Is the House bill better than nothing? I don't think
so. It simply throws more money into a dysfunctional
and unsustainable system, with only a few improvements
at the edges, and it augments the central role of the
investor-owned insurance industry. The danger is that
as costs continue to rise and coverage becomes less
comprehensive, people will conclude that we've tried
health reform and it didn't work. But the real problem
will be that we didn't really try it. I would rather
see us do nothing now, and have a better chance of
trying again later and then doing it right.
(c) 2009 Huffington Post
Marcia Angell, M. D., is Senior Lecturer in the
Department of Social Medicine at Harvard Medical
School. She stepped down as Editor-in-Chief of the New