Health Care Reform: After The Fact

Well, it finally happened. After all the Tea Parties, the Coffee Clubs, the Lemonade Lounges, and the Beer Bunches, Congress went ahead and passed health care reform. It’s now the law of the land. I’ve been avoiding trying to think too much about it. Frankly, one reason is because that in my brief career in public service I’ve enjoyed working with people from all parts of the political spectrum, and taking any hard and fast position is bound to annoy someone I like and respect. It’s probably selfish on my part to put personal relationships over politics, but its reality. I’ve always held in my mind a lesson learned from friends in South America. I couldn’t figure out why they never wanted to talk about the subject at hand when I hit the door, but were perfectly content to wait days, even weeks, before really getting down to work. “Friends first, then business,” was the reply. Since then, it’s always seemed like a better way to run my life.

A second is probably some guilt over not really having a position, or at least one that I’ve publicized. Sure, I’ve nibbled around the edges, but that’s about all. I’ve learned that one of the privileges of having your own blog is the ability to take shots at everyone without actually having to put your own opinion on the line. The third, and probably most important reason I tried to avoid comment is that I’m honestly not sure what I think, and I’m honestly not sure why I’m not.

But after some weeks of reflection, I feel like I ought to say something. It is the largest piece of social legislation since Lyndon Johnson’s Great Society, and (more to the point) it affects me both personally and professionally.

So here’s the bottom line. All citizens of the United States should have access to a basic level of health care. Nobody should be denied access because they are unfortunate enough to have a chronic illness or condition. The new law is a major step forward. This is an idea I absolutely agree with. Period. Full stop. End of sentence.

I think what bothers me is that I’m not sure the new law will do what it’s supposed to. There’s an employer mandate to force businesses of a certain size to support health care coverage for employees. But if the fines for non-compliance with the mandate are less than coverage costs, why should an employer buy in? Similarly, if an individual finds that the extra bill for not buying coverage is less than the coverage itself, will they still choose to buy? And if someone doesn’t report their lack of insurance to the IRS or doesn’t pay the fine, will the government enforce the law, putting people in prison because they don’t want to buy health insurance? (By the way, medical care is free in prison.)

In a previous blog, I’ve noted that the majority of physicians in this country don’t want to see Medicaid patients in their practice, so it’s hard to see (barring the growth of a new health care sector of high-volume, low-cost Medicaid clinics) how the new influx of Medicaid patients will actually get to see a physician. The administration’s effort to raise primary care Medicaid payment rates to match those of Medicare is a start, assuming that Medicare cuts (a backbone of funding for the new law) don’t dampen the enthusiasm of physicians to accept these patients as well. But unanswered are the questions of access to specialty care under the new legislation, reimbursement for preventive care and counseling, and diminution of medicolegal risk.

And I’m still at a loss to figure out how the law will lower health care costs. If insurance companies are (rightly) compelled to insure those persons with pre-existing conditions, premium rates will assuredly rise across the board. Taxes on medical devices simply drive up the cost of the device. If individuals are purchasing private sector insurance policies with government subsidies, federal expenditures necessarily rise. If employer support for coverage flags, how much more will it require in government subsidies to keep people insured? If new Medicaid recipients are allowed unfettered access to services, costs will spiral out of control. And even assuming that the new law is “cost-neutral” (which is, I think, a suspect prospect), what the estimates do is note that the rate of medical inflation over the next decade will be lower, not that costs will decrease in any way from the present value.

There’s a few philosophical issues as well. I’m not bothered by the issues of increasing federal debt. (I should be, but since it’s clear that neither party in power since 2000 has cared about it, I’m not sure it’s worth my fiscal angst.) The mandates bother me in the sense that I’m not sure I like the idea of being required by the government to buy a private sector product. (I’ll happily leave the constitutionality of that to the lawyers.) I still haven’t gotten over the public bailout of the financial firms that got us into the latest recession, and can’t figure out why once again we’re going to channel more federal dollars to those same insurance companies many blame for being the root of the problem.

But do these objections outweigh the moral correctness of insuring that everyone in this nation has access to health care? Absolutely not. And I wholeheartedly reject the argument that everyone already has access to health care because they can always go to the ED. Having lived my clinical life there, what you get is a screening for emergency conditions and sent on your way. You do not get primary care, preventive care, or anything even vaguely resembling comprehensive care. False statements such as these are used to “cover” for a system that is irrevocably broken. There are any number of fair objections to the way health care reform has evolved. But they do not overtake the basic need for access to care.

I’m also bothered by the failure of nearly everyone…and this is truly bipartisan...to recognize the inherent contradictions in play. Insurance companies are part of the problem, but we’re going to give people public funds to buy their products. Health care access is the goal, but there’s nothing to encourage doctors to see more patients. Cost control is critical, but there are no brakes placed on the runaway train. Improving the health of the nation is the goal, but those measures which can have the most impact on health are ignored. Opponents of the bill were simply that, and offered nothing concrete as an alternative for debate.

But I think the heart of my discomfort lies in the recognition that the new law really isn’t about health. Health is defined by the World Health Organization as "a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.” By way of contrast, health care refers to system of delivery of medical treatments (doctors and hospitals), while health coverage refers one view of how such services are mediated between patients, physicians, and external payors (public and private insurance plans). This distinction is critical to understanding the true impact of the current bill.

Let’s be clear about what has happened. We have started to address the problem of health care coverage. We have not yet begun to address issues of health care quality, health care costs, health care financing, or health care access. The final bill holds provision for panels to study a host of issues, but no definitive statements or policies designed to remedy these problems. For all its volume, the bill is actually quite limited in scope. And any evidence of its effect on health itself is considerably muted.

Supporters of the bill would say that coverage enhances health by insuring access to care. But history has shown us that the biggest factors in improving health, at least in the physical sense that we think of in the United States, is not the existence of an advanced and aggressive health care system. Health is most improved by those measures that fundamentally change the landscape and facilitate healthy behaviors. Updated and enhanced immunizations laws, clear indoor air statutes, the provision of physical education in schools, environmental regulation, mandatory seat belt and motorcycle helmet laws, and cultural change will do far more to promote health than any manipulation of insurance plans.

One of the tasks of the health care community is to help policy makers understand the difference between health, health care, and coverage. Monitoring health outcomes such as life expectancy and infant mortality rates are measures just as key to evaluating our efforts as are persons covered and costs for care.

So in the end, the new law is a significant step forward. (I’m purposefully avoiding the term “Great Leap” because I don’t want to be enmeshed with Maoism or the whole “Obamacare as Socialism” argument which, for the record, it’s not.) I’ve still got some questions. Nonetheless, I support the legislation because it’s the right thing to do. And I look forward to the day our nation recognizes that in the end, health is what really matters. Unfortunately, we’re not there yet.

Hopefully, we can all keep in mind that health care reform is a work in progress. I don’t know about you, but I’m looking forward to the next round.