Missing: A robust, honest discussion about health care costs, financing

Published on
September 20, 2017

Republicans may have misjudged the public when they embarked on their seven-year crusade to repeal and replace the Affordable Care Act. Even though the last few months have shown they had no viable plan to achieve that, they may have had another, more long-range goal in mind – to portray Obamacare with its government mandates, inevitably rising costs for policyholders, and modest regulations on doctors and hospitals in the worst possible way. Were they trying to push the discourse about U.S. health insurance arrangements further to the right and foreclose the possibility of Medicare for All that would bring an even bigger government role? The Cassidy-Graham bill up for grabs in Congress would certainly do that. 

If that was their goal, it has backfired. Instead of poisoning the notion of national health insurance, the opposite seems to be happening. A Gallup poll last December found that in 2016 43 percent of Americans favored a system run by the government. That’s up from 34 percent who felt the same way in 2010. During that same timeframe the number of Americans supporting a system mostly based on private health insurance fell from 61 percent to 53 percent. Harvard pollster Dr. Robert Blendon told me “there’s a growing interest in universal coverage as a principle,” but we’re still a long way from translating that into policy. And there’s a difference between saying that everyone is entitled to health insurance and a plan to make that possible. 

The conversation about a greater government role moved forward last week when Vermont Sen. Bernie Sanders announced his Medicare for All legislation. Media reaction to Sanders’ bill was swift and largely negative. Some outlets treated the bill as a bad policy that needed to be squelched while a number of them reported that chances for passage were zero.

Bill Scher, writing for Politico, said the bill was a “big mistake” setting Democrats up for “years more of a treacherous health care debate.” NPR’s politics blog tried to tell readers what’s in the bill. One expert it quoted from the Urban Institute predicted, “people’s taxes are likely to go up substantially.” She added, though, how much they’d rise would depend on family income but that financing details were not yet part of Sanders’ proposal. The New York Times tried a fact check and reported that “Republicans are fighting back with familiar critiques of such a single-payer system.” Times health policy reporter Margot Sanger-Katz presented a list of negatives – “substantial disruptions in the current health care system, upending the insurance arrangements of the 156 million Americans who get their coverage from work, changing the way doctors, hospitals and drug companies are paid, and shifting more health care spending onto the government ledger. Such a proposal would reshuffle the winners and losers in our current system.”

She acknowledged, though, details do matter.

Absent from the media stories last week was perhaps the biggest detail of all - how would health care costs be contained and whose ox would be gored in the process. The government’s ability to control costs is the real reason why discussions of national health insurance don’t reach the detail stage. Yet controlling costs is a big reason for the success of universal systems in other countries. In the U.S., drug companies, doctors, hospitals, and other providers of care don’t want to lose income, and have argued against national health insurance whenever it has come up.  Supporters haven’t been keen on talking about it either. “Neither side wants to confront costs,” says Blendon, because politically they’d have to challenge powerful stakeholders like drug companies and hospitals that make large campaign contributions and carry great clout in local communities. 

If we need proof of how vociferously those special interests will fight back, consider what has happened to recent government efforts to control spending by changing the way hospitals are paid for joint replacement procedures and cardiac services. The Obama administration had proposed paying hospitals bundled payments for those services - high ticket items - that would include the procedure and care needed afterward. The idea was to move away from fee-for-service payments that reward volume not outcomes. Both rules were supposed to take effect last February, but the Trump administration delayed implementation. Many providers objected, and in August, HHS Secretary Tom Price, an orthopedic surgeon himself, cancelled both programs although small and rural hospitals can still opt for bundled payments for joint replacements.

That’s not to say that opponents of Medicare for All are against cost containment. Their solution to limiting cost growth is to limit the number of people who get subsidies - the focus of the current fight in Congress. Proponents don’t want to do that, but, they, too, avoid talk of cost containment in their drive for a fairer, more inclusive health care system. 

Cost containment isn’t the only big question.  Paying for the new program, especially during the transition period, is closely related. The tax increases necessary to fund health care for everyone helped doom the single-payer efforts in Colorado and Vermont. Once bill drafters decide on a way to pay for a universal system, how will the rising costs of new technology, new services, and provider fees be managed? That’s a huge question that at some point must be answered. 

Blendon predicts Medicare for All will be very popular with voters in the Democratic primaries next year, and there will be a lot of young, liberal voters casting ballots. While they still may vote based on the principle of care and coverage for everyone, some may be ready to consider how principle can be turned into policy. The public doesn’t need more stories reciting old, familiar reasons why a Medicare for All system wouldn’t work here. The polls indicate that large numbers of people have moved on from that frame. They need a robust and honest discussion of how such a plan would be financed in the short and long run and how costs going forward will be managed and kept in check. Explaining all this is the challenge for the press.

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.

[Photo by Hamza Butt via Flickr.]