I fear Americans have unrealistic expectations for what health care reform can accomplish. We seem to expect that we can quickly achieve universal coverage, for almost no additional cost to the taxpayers or businesses, no limits on the choice of physicians, no limits on patients' ability to sue doctors or institutions that make medical mistakes, no limits on care and no rationing -- that 80-year-olds will be able to receive kidney dialysis or open-heart surgery, and there will be no waiting times for any procedures. Liberals want an immediate shift to a single-payer system like Canada and England have; conservatives want health insurance reform governed by the free market.
We are all setting ourselves up to be disappointed. I can already anticipate complaints and grievances in the midterm 2010 elections: Obama either failed to achieve universal coverage; or failed to control costs. Our personal health care costs are still rising, people might say. "We're facing limits on care. We were promised no limits on which physicians we can see, but indeed there are limits."
"My doctor (health care institution) made a terrible mistake -- my loved one died when he shouldn't have; I ought to have the right to sue the beejeesus out of them, but with this new health care reform I can't," I can imagine people saying. Or conversely, doctors and health care institutions will be complaining that they still have to practice self-protective medicine and order a lot of unnecessary tests in order to protect themselves from malpractice lawsuits.
"My loved one needs kidney dialysis, but the new Obama health care reform won't pay for it,"I bet some will say.
"I had to wait three hours to be seen by the doctor -- guess that's the result of Obama care."
"Obama passed a law saying I have to purchase health insurance, but I'm healthy, I don't need it and I can't afford the insurance."
I was one of those who believed that mandates -- requiring everyone to have health insurance just as we require everyone to have auto insurance -- was necessary to finance universal coverage. But I recently read that despite the requirement that everyone have auto insurance, the percentage of people who don't have it is likely to rise to one in six or 16 percent by 2010, according to the Insurance Research Council, due to the worsening economic climate. That's not much better than the percentage of people who do not have health insurance (18 percent).
Obama is urging supporters not to use the word "rationing" and instead promote "evidence-based medicine." While it's true that health care guidelines for physicians based on actual research can reduce health care costs, physicans do not want to be penalized financially for being willing to try unconventional approaches. There is a danger that "evidenced-based medicine" can lead to straight-jacket medicine, in which innovation is discouraged.
Some opponents of health care reform fear that it will lead to long waiting periods for care. Truth is that there are considerable waiting times for certain procedures now. When I called to schedule a colonoscopy, for example, the first available appointment was three months later. Americans wait as long or longer for routine care than patients in countries with universal insurance programs. And in rural areas, due to doctor and nursing shortages, there are already long waits for routine care.
To control health care costs, I have believed that creating a public health care plan is essential, because private, for-profit, investor-owned health care institutions generally charge almost 20 percent more. But if a public plan does not require physicians and other providers to participate -- if many physicians refuse to take public plan enrollees because the reimbursement rates are significantly lower than private plan(s) -- the public plan could become financially unsustainable. It could become a dumping ground for the poorest, oldest and sickest patients, and "adverse selection" could occur, while private plans cherry-pick healthy patients and are therefore able to offer cheaper premiums. As Ruth Marcus pointed out in a Washington Post column, it might make more sense to jettison the public plan and strictly regulate private plans.
Either decision -- requiring providers to participate in a public plan or strictly regulating private insurance -- is likely to infuriate doctors and/or private insurers.
Competion between public and private health care plans may lead to even greater consolidation in the health care industry (already quite consolidated and concentrated), shrinkage of the private health care industry, and even a reduction in the number of private health care jobs, for which there will be bitter complaints. Jobs in public health care would increase, but the salaries and bonuses probably wouldn't be as high. Certain highly-compensated private health care employees won't be happy about that.
Even without a public option, or any federal action on reform, the pressure on health insurance companies and providers to contain costs and wring more efficiencies from the cost of care are almost inevitably going to lead to complaints. One question is whether Obama's opponents will be able to associate him in the public mind with the inevitable, increasing frustration over health care.
Perhaps it isn't politically advantageous right now for politicians to tell us the trade-offs we're going to have to make regarding health care in this country, but sooner or later we will need to know.
Let's face it. If real health care reform passes in 2009 or 2010, some constituencies -- those who are likely to lose high-paying jobs, those whose health care costs are likely to rise and those whose care is likely to be restricted -- are going to be upset, and may take out their anger on the politicians who vote for reform. But real leadership means a willingness to endure these slings and arrows and vote for advances that are better for the country as a whole in the long run.
With a filibuster-proof majority in the Senate and a sizable majority in the House, it is inevitable that Democrats are going to get the blame or the credit for health care reform, and will have to run on their health care record in the 2010 midterm elections. Worse than angering some constituents will be if they are unable to reach consensus and pass anything significant -- that will anger everyone.
It's also reasonable to assume that Democrats are at the high point of their congressional power -- they will likely lose votes in 2010, as the dominant political party almost always does in off-year elections. So, it's now or never for real health care reform.
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