Sunday, November 15, 2009
Three weeks ago, 35 to 40 people gathered at Off the Beaten Path Bookstore for a conversation about health care reform. I want to thank all who participated for frank, thoughtful, respectful conversation, and to apologize to the many people who came but could not find a seat or were unable to hear. I also want to thank Sue Birch, Carol Milligan, Brian Harrington, Todd Hagenbuch and Jay Fetcher for their informed perspectives as members of the panel.
Today, I want to break from the spirit of impartiality in which I tried to moderate the fireside chat and offer some comments about the pending health care reform legislation. In the three short weeks since our conversation, the House has passed its bill, and the Senate is poised to reconcile bills that have emerged from its two committees and begin its debate. Decision time is near.
There is much to like in these bills. They provide for nearly universal health insurance. They eliminate the most egregious health insurance practices: denial of coverage for pre-existing illness and rescission of coverage. They limit annual out-of-pocket expenses, eliminate annual and lifetime limitations on coverage and guarantee portability of insurance. They eliminate insurance rating based on gender and illness. Through a variety of approaches, they seek to reduce administrative costs.
Still, there is much to be concerned about. It is encouraging that some of the bills provide incentives for reducing liability costs but discouraging that none tackles tort reform head-on. It is not clear to me that these bills will increase competition among health insurance providers, a critical component of cost reduction. The bills rely on several laudable but largely unproven methods for achieving cost savings: accountable care organizations to provide better coordinated care and various payment schemes with incentives based on quality outcomes.
Much of the discourse in the coming weeks will be about the “public option.” We should remember that the purpose of the public option is to provide insurance primarily for those who do or will not have employer-provided insurance — estimates are that only 5 million to 10 million citizens will choose it — and to create competition in an insurance market where there is none today. The co-operative alternative will be expensive to deploy and historically has been unable to attract sufficient participation to be an effective market competitor. In my view, the public option is the preferred vehicle for achieving market competition — a component of cost containment — but it should not be allowed to defeat overall reform.
On balance, we ought to take these reforms if we can get them. Universal coverage with fewer of the fiendish, inequitable and unfair insurance practices will go a ways toward improving our health care system. But we need to know that delivering lower cost and better health outcomes will take many years, innovation in the methods of delivery and kinds of health care, and a sustained effort by all those with a stake: providers, payers, insurers and, of course, all of us.