[R-G] Is the House Health Care Bill Better than Nothing?

Sid Shniad shniad at gmail.com
Tue Nov 10 13:07:31 MST 2009


http://www.huffingtonpost.com/marcia-angell-md/is-the-house-health-care_b_350190.html?view=screen
*
*Huffington Post
   November 8, 2009

*Is the House Health Care Bill Better than Nothing?*

*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.*

Marcia Angell, M.D.
Physician, Author, Senior Lecturer, Harvard Medical School

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.



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