As we await another historic vote in the House on whether lawmakers will support the Senate version of reform, it’s worth asking whether incremental reform would have been a better path.
Despite the all-out push by the Democrats for some version of their health care reform legislation, it is hard not to conclude that Americans seem to prefer incremental reform and that the current bills exceed the level of comfort for many Americans. This should not come as a surprise since almost 75 percent of Americans are satisfied or very satisfied with their health care.
Polls can be tricky — it depends on how the questions are asked and when they are asked — but there have been consistent signals from the American public that the Democrats seem determined to ignore. The majority, or at least a plurality, has been disapproving of the “Obama plan” since last summer. Many Americans believe that their own health care costs will increase and the quality will decline if reform legislation is passed.
This was also the case with the failed effort in 1994. And, as the administration has itself noted repeatedly, many Americans would rather that the president focus on the economy instead of health care, in spite of repeated statements by the administration that health care reform is economic reform.
In the event that the current efforts fail, I believe there are discrete blocks of change that should be considered as important next steps. Incremental proposals make reform more complicated — many of the pieces of the current reform bills are interrelated — but they can provide significant and sustainable changes in the right direction.
First, coverage could be expanded to all uninsured people below the poverty line, either through Medicaid or by allowing these individuals to purchase insurance through an exchange or other negotiated purchasing process. Since about one-third of the uninsured are below the poverty line, this will have a significant effect on the number of remaining uninsured. It will also require signficant funding, but a far smaller amount than is currently being contemplated.
Second, many of the interesting pilot studies that are part of the current legislation should be a part of any future legislation. As has become all too clear, we don’t really know how to make the transformation from the delivery system we have now, which rewards institutions and clinicians for doing more and more complex procedures, to one where the incentives reward those who produce high quality, low cost care. Unlike current pilots and demonstrations, those that produce desirable outcomes — lower costs at same or improved quality or improved quality at same or lower costs, should be allowed to become part of Medicare without additional authorization from the Congress.
Third, unlike current legislation, medical liability reform needs to be a part of any serious effort that encourages the more conservative practice of medicine and should be regarded as an important enabler of cost containment. An evidenced-based strategy of liability reform might help cross the chasm between Republicans and Democrats on this issue. For example, physicians and institutions that agree to follow a set of patient safety measures developed by the Institute of Medicine and standards developed by medical societies or special groups should be provided immunity from liability unless there have been provable charges of criminal negligence.
Finally, physician payment reform needs to be considered a direct part of health care reform rather than continuing the current myth that somehow it can be considered separately. Yes, it will take real money to fix. The Congressional Budget Office estimates the cost to be approx $220 billion over 10 years, far more than the current estimated savings from health care reform legislation. Further, it is impossible to imagine reforming the delivery system without reforming how physicians are reimbursed. Pilot programs that test new reimbursement systems need to start as soon as possible, and Congress should only provide short-term relief from Medicare’s sustainable growth rate pressure until a new system is ready to be legislated. Otherwise change will never occur.
These are not small changes. They will clearly require additional funding compared to the status quo. But they represent a far more limited and circumscribed set of changes than what is currently being contemplated, and they contain measures to appeal to both Republicans and Democrats. It seems to be political folly at best to ignore consistent and strong messages from the public about what they do and do not want, or to assume the polls reflect that Americans don’t understand what is being proposed. November will “tell the tale” if such incremental pieces of reform would have been the better road.