Tuesday, November 10, 2009

Is the House Health Care Bill Better than Nothing?

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


http://www.huffingtonpost.com/marcia-angell-md&cp [1]




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 Clinton reform effort in 1994.

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

will happen?


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

England Journal of Medicine on June 30, 2000.




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