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The next big health reform debate is all about costs, not expanding coverage

The next big health reform debate is all about costs, not expanding coverage

Picture of Trudy  Lieberman
(Photo by Drew Angerer/Getty Images)
(Photo by Drew Angerer/Getty Images)

What does the public really want when it comes to health care?

In 2017, I thought the country had turned a corner. Perhaps Americans were ready to embrace deep changes in their health insurance arrangements when angry people flooded Congressional town halls that spring, demanding that people with preexisting conditions have the right to buy health insurance. And when Congress later that year narrowly refused to repeal the Affordable Care Act, which extended coverage to millions more over the past decade, health care as a basic right seemed poised to become a universal value.

The national conversation now appears to be shifting again. The raucous Democratic primary debates and ads from big money groups suggest the country is still stuck at the same intersection where special interests and the public interest collide.

The big questions remains: Does the public believe everyone should have guaranteed health care for life — and are we willing to pay for it?

The Democratic primary debates taken as a whole didn’t answer the question. Instead, they melted into a discussion of the specifics of legislation rather than a continued focus on the larger question. We got the candidates’ takes on whether private insurance would become obsolete under a “Medicare for All” plan — an unpalatable solution for some of the candidates. We heard about a public option dusted off the shelf from the Obamacare wars. That was also popular with some candidates. We also learned that some Americans like their health insurance from private carriers like Aetna, Cigna, and UnitedHealthcare, an observation that has become a common talking point in the current discussion.

Setting aside Medicare for All, these are the details of bill crafting and compromise and probably flew over the heads of many listeners. They don’t directly address the larger question of whether every American should have a guaranteed right to coverage.  

TV ads from special interest groups are beginning to address that larger question and subtly or not, they are undermining the notion of health insurance for everyone.

In a $4 million ad campaign, a dark money interest group with ties to Republicans is doing just that by attacking single-payer plans and implying Americans aren’t keen on giving up their private health insurance. The ad disparages the national health systems of other countries and raises the specter of “socialized medicine.”

The ads show people with signs indicating wait times in countries with national health systems: 10 weeks for heart surgery, 26 weeks for brain surgery, 11 weeks for an MRI. That’s scary stuff, but with no source or attribution for these claims, viewers are misled. “Medicare for All would eliminate private insurance for 180 million people — you and every American waiting in the same government-run plan,” the ad goes on. The ad implies a brutal tradeoff: If everyone gets coverage, you might not get care or have to wait a long time for it.

“The actual debate won’t be about access. It will be about cost containment for all people.” —Dr. Robert Blendon, Harvard

What does the public want right now as we approach the third round of health reform in the past 25 years? I rang up Dr. Robert Blendon, senior associate dean at the T.H. Chan School of Public Health at Harvard and a veteran health care pollster. “People are unsure about what the alternatives would do for them,” he told me. “It’s status quo bias.” Their current arrangements may not be ideal, he explained, but they are leery of changing to something new when their insurance is mostly working.

That said, Blendon told me, health care will loom large in the general election, but the focus won’t be coverage this time. “The actual debate won’t be about access. It will be about cost containment for all people,” he said, adding that big plans to expand coverage like Medicare for All, or a Medicare buy-in plan, or a public option, won’t be the theme of the 2020 election.

A new “Perspective” piece in the New England Journal of Medicine by Blendon and colleagues noted that about three-quarters of the public thinks that Americans are paying too much for most of their care relative to its quality, and a majority believes that health insurance premiums are increasing mostly to boost the profits of insurers or accommodate high prices for care.

Blendon said the public’s view on controlling health care costs is at odds with that of policy makers. The experts say we have to contain costs, he explained, but the average American wants to spend more money on things like mental health and long-term care. As he and his colleagues recently wrote, “Americans are not particularly concerned about aggregate health spending either overall or on the part of the government.” They see the issue of health costs as mostly a price problem for them, not one of overutilization, a favorite theme of the wonk community.

If Blendon is right, the cost of hospital services and the price of prescription drugs will loom larger in the public’s mind in the coming election than plans to expand coverage, whether that be a public option, Medicare buy-in or some other health insurance system that covers everyone.

It may be that covering all Americans will be a dream deferred yet again.

Veteran health care journalist Trudy Lieberman is a contributing editor at the Center for Health Journalism Digital and a regular contributor to the Remaking Health Care blog.


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Nobody would argue that the Public Health Service is un-American. Congress founded it in 1789. What people forget is that it used to take care of people. In 1921, after WWI, it loaned 57 hospitals to the VA to take care of the veterans from that war. It's time to return the loan, with appropriate interest, all paid for by tax-payers. Let the reconstituted PHS care for anybody who wants to leave the private insurance market, or who has no insurance at all. This neatly solves the otherwise insoluble problems of quality, access and cost, as follows:
1. Competition between a private sector covering 85% of people and a robust public sector covering 15% of people would improve quality. Right now the VA covers only 9 million Americans or 9/330 = 3% of the country. Few women and no children are seen by the VA. The VA does excellent research, but its budget is tiny and its scope limited to men. If expanded to cover the entire population, the VA/PHS could easily be ordered to solve all common diseases, and its research would have significance. The private sector would have to adopt the VA/PHS's research findings, or risk losing patients who wanted better outcomes. At the moment there is absolutely no business incentive to innovate or prevent disease, and every incentive not to, in both the VA and the private sector. Academics want to study the same topic their entire careers, and the private sector loses money every time a disease disappears.
2. Cost: without spending an extra dime, the VA/PHS could take care of all the un-/under-insured simply by working a little bit harder. The average patient load for a VA physician is 200, ten times less than the average doctor in private practice. So increasing from 9M to 90M patients would be feasible paying physicians their current salary.

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