At long last, health reform legislation appears headed for a series of final votes in the next few weeks. The ultimate outcome in treacherous political waters is uncertain. What should happen, from the perspective of a consumer advocacy organization, is abundantly clear: Congress should pass legislation this year to begin dramatically improving health care access, delivery, payment, and cost management in the United States.
What drives our position is the widely recognized and urgent need of individual consumers and families, the economy, and public health for this reform. There is also one argument we find particularly compelling: virtually every major federal health care program that has been enacted over the last fifty years—from Medicare and Medicaid to COBRA, SCHIP, and the Medicare Part D drug benefit—has improved the health, financial security, and well-being of the U.S. population and, ultimately, has been embraced and supported by the public.
Many of these programs were politically contentious and took years to enact. But today, few people outside Washington and health policy circles remember or care about the political blood on the floor, how many pages the bill was, or the final vote tally. All they know is that they gained new options and benefits. In the end, it’s not about the political process; it’s about programs and policies that make people’s lives better.
We strongly believe that enacting a comprehensive and integrated health care bill this year would unfold in the same way.
Reform opponents have ceaselessly hammered away on several talking points over the last year, ramping up the volume in recent weeks. We’ll take this (hopefully one last) opportunity to quickly address them:
■ “The American people do not support this bill.” The reality is more complicated. Competing polls go back and forth, as they have for the past year. Their bottom-line results often have been twisted and contorted. But one thing has remained consistent in the findings: when asked about many of the specific, major provisions in the bills, people consistently are in favor. In a recent Newsweek poll, for example, 81 percent supported the idea of insurance exchanges; 76 percent supported guaranteed issue; and 75 percent agreed that most businesses should be required to offer insurance, with financial incentives for small businesses to do so. In fact, since the mid-1980s, hundreds of polls have found that a majority of Americans support “covering the uninsured,” expanded insurance pooling (e.g., exchanges), employer mandates, subsidies to help people buy insurance, and restricting insurance company practices that permit denials of care, dropped coverage, preexisting condition exclusions, and outrageous rate hikes.
■ “It’s a government take-over.” No, it’s not. Period. Yes, it would expand Medicaid. But by and large the legislation not only preserves but strengthens the private health sector by funneling millions more people into it, as well as $450 billion in new spending over the first ten years that will go to private insurers. Those insurers, in turn, pay private hospitals, doctors, drug companies, and pharmacies. At the same time, the existing private system where most people get coverage at work is preserved. And in the exchanges, people will shop exclusively for private coverage if no public insurance option ends up in the final legislation.
■ “Premiums will rise.” True, but less than they would without reform, we are convinced. The annual average cost of family coverage more than doubled between 1999 and 2009, from $5,800 to $13,400. And it’s on course to double again by 2019 if nothing is done and no reform is passed. The task at hand is to slow the growth of premiums. The proposed legislation seeks to lower the cost of care primarily by changing the incentives facing doctors and hospitals. This, in turn, should translate to more reasonable premium increases over time. There are also solid provisions aimed at enhancing competition and innovation among insurers. And President Obama has added a measure we support and think the vast majority of Americans will, too: new federal authority to evaluate outsized rate increases to see if they are justified. This type of review is already taking place in a few states, but the majority of U.S. consumers lack this basic protection.
■ “It doesn’t do enough to control costs.” While we support more aggressive measures and believe they may be needed in the future, the legislation takes important steps to constrain costs. It launches dozens of initiatives and pilot projects to test ideas, old and new, for prodding doctors and hospitals to become more efficient and for paying them on the basis of the quality of care they deliver, not the quantity. It targets nursing home, home health, and pharmaceutical costs as well—in measured ways that seek to avoid marketplace disruptions. Today the plain fact is that while government and private payers are trying many good ideas for constraining cost growth (paying for quality, paying for performance, bundled payments, and the like), no one knows for sure what is going to work best. This legislation sets us on a clear path to find out.
■ “It spends $1 trillion we don’t have and will bust the budget.” The trillion-dollar expense has been cited out of context for the entire year of debate. Bear this in mind: as a nation, we’ll spend a projected $35 trillion on health care from 2010 through 2019 without health reform. If we were really adding a trillion more dollars in that ten-year period, that would add 3 percent to the $35 trillion. However, the respected number crunchers at the Centers for Medicare and Medicaid Services Office of the Actuary estimated in January that the legislation would actually increase national health spending over the next decade by just 0.6 percent because it reduces wasteful spending, mostly in Medicare. Also, 90 percent of that $1 trillion in new spending is allocated to helping people buy coverage: expanding Medicaid and tax subsidies to help families buy private health insurance. What’s more, this new spending is paid for and, according to the Congressional Budget Office does not add to the federal deficit.
■ “It will destroy Medicare.” This is a distorted and disingenuous allegation. The legislation seeks to reduce Medicare spending by roughly $500 billion over the next decade, compared to current projections. But Medicare spending is not “cut” at all. If the Senate bill becomes law, Medicare spending will still rise from an estimated $517 billion in 2010 to $896 billion in 2019, according to the forecasters at CMS. That’s about 10 percent less than would happen if the Senate bill does not become law. Almost all that 10 percent comes out of inefficient programs (such as Medicare Advantage). The legislation also puts the federal government in the lead of reforming a health system where at least 20 percent (the estimates go up to 30 percent) of expenditures are wasted on inefficient or wasteful medical services. In addition, the legislation strengthens Medicare in many ways: adding new preventive care benefits, reducing the size of (and perhaps eliminating) the Part D drug benefit doughnut hole, and, according to both the CBO and the CMS actuaries, lengthening by almost ten years the time before the Medicare Hospital Trust Fund dips into the red.
■ “Incremental would be better. And let’s slow down, too.” Twenty-five years of incrementalism has not solved our core problems—in fact, they’ve gotten worse during that time. In addition to both the rising number of uninsured and soaring costs, the delivery of care today is more fragmented than a decade ago, with little or no reduction in the risk of harm to patients from poor quality and service. That said, some incrementalism is appropriate, and we believe this legislation includes it. For example, we think it’s a good idea to proceed deliberatively and incrementally, and based on evidence, when it comes to changing the way doctors and hospitals get paid, in order to insure against disruptions. But incrementalism that expands coverage to three million people over the next decade is pointless; it’s not incrementalism, it’s token reform. The biggest argument against incrementalism or slowing down now is the cost crisis. We simply don’t have the luxury as a society to put off comprehensive reforms for another decade, if we are to try to prevent health care spending from overwhelming the budgets of families as well as of the federal and state governments. Sometime between 2016 and 2020, health costs will become the dominant force driving the long-term deficit and burgeoning national debt, unless we act now. And we can’t solve the cost crisis without comprehensive reforms that rationalize the health care market, bring everyone into the system, and vastly increase the transparency of the workings of the insurance market.
We hear all the time from consumers who experience firsthand the shortcomings of our current system. Tell the million or more people who have lost their jobs and health insurance in the last year that we need to go slow on health care. Or the hundreds of thousands of people with individual coverage who will see their premiums jump 15 percent to 40 percent this year. Or small businesses that face having to drop their employees’ coverage due to similar rate increases. Or state Medicaid directors who strain to improve that safety net program under tight budgets.
Failure to enact reform this year poses a very high risk of a long-term stall for the comprehensive and integrated reform we need. That’s a political problem, yes. But far more important, it’s a human problem. Not enacting reform now would mean that more Americans would go without the insurance and care they need, and pay more for both than they should. It’s irresponsible to let this fester any longer.