Q&A with The American Prospect's Paul Starr, Part 1: Making health reform's fine print legible

The American Prospect has done health reporters everywhere a huge service.

It has taken the mess that was the health reform debate and tidied it up into a package of stories that will make you feel smarter and much better equipped to cover the reform battles and policy rollouts that lie ahead. In a special report on newsstands this month and available online here, the magazine deconstructs the health reform fight and forecasts the legal and legislative skirmishes to come. The work was funded by The California Endowment (which funds ReportingonHealth), the Missouri Foundation for Health and Universal Health Care Foundation of Connecticut.

A talented team of Prospect writers and academics – including Jonathan Cohn, Jacob S. Hacker, Joanne Kenen, Keith Wailoo and Paul Starr, the Prospect's co-editor – examines health reform from multiple angles and provides countless story ideas for health writers across the country.

Antidote wanted to hear from Starr about what sparked the special report and what they hope readers will do with the information. The first part of our conversation is below. The second part will run next week.

I reached him at his office in New Jersey. The interview has been edited for space and clarity.

Q: What was it about the debate surrounding health care reform and the media coverage of the debate that drove the creation of this special report in your magazine?

A: What drove the special issue was the recognition that the battle is not over. The opponents are continuing to resist the program, fighting it in every venue that is available, in the courts, in the state legislatures and in the congressional elections in the fall. There is still an open question as to whether this legislation will be carried out.

Q: How much do you think opposition to health reform stems from the lack of understanding most people have about their own health plans?

A:I do think that many people are unclear about the true costs of their care. Most employers do not tell employees how much the employer contribution is. So people don't know what the total bill for their insurance is. They don't understand that there is a government subsidy worth up to 40% of their contribution. They think of themselves as having earned the health insurance they have and think that other people ought to earn it just the same way. As a result, they resent the idea of paying taxes to underwrite other people's coverage. I don't think you would have seen health care costs in the United States rise to their present levels if people had to make a lump sum payment every month for the full cost of their health insurance. So there are deep misunderstandings of how much health care costs and what the relationships are. The federal government is paying more for the benefits for mostly middle class people than it pays for Medicaid.

Q: People might see the deduction from their paychecks, but the bulk of the costs are seen as somebody else's problem.

A: Many think they are getting health care largely for free by their employer. When they evaluate health care reform, they are doing it from a perspective that has been shielded from the full reality of the situation. Reform looks like a bad idea to them. We're trying with health care reform to protect people who don't have good insurance from the brunt of health care costs. But the people who have good insurance and have been so well protected are really scared of any change. That's been a major source of the difficulty in passing reform.

Q: This came up during the Clinton reform effort, too.

A: The whole effort this time with reform was to work around that anxiety by saying, "If you like your health insurance, you are going to be able to keep it." Most people who have insurance today will not be affected by reform. There are some provisions that will affect them, but on the whole the reform tried to leave them undisturbed. If you work for a big company and have a good health plan, this legislation will not have a big effect on you. Other groups as well, (such as) the people who use the Veterans Administration, will see no effect. Most seniors will see no reduction in Medicare benefits. One group that will be affected are those people in private Medicare Advantage plans.

Q: Isn't that a legitimate concern, then? Seniors who felt like they had to pay more to get the coverage they needed will now lose coverage?

A: There is a lot of evidence that those plans were overpaid. Reducing those excessive subsidies was the correct policy. There is no question that some seniors are opposed to this reform because of what they have been hearing from their private Medicare plan. The elderly are now the only age group who, according to Gallup and other polls, have a negative view of health care reform as a group. There are a number of reasons for that. There is a lot of misinformation among the elderly about health care reform. The most recent Kaiser survey showed that a third of them still believe there are death panels.

Q: On the flip side, if you don't have insurance and don't want insurance, why should you be forced by the government to buy insurance?

A: The individual mandate did not generate that much controversy during the congressional debate. It's only since the law has passed and been challenged on constitutional grounds that there has been a focus on the mandate. I proposed an alternative to the mandate in the late stages of the debate and was unable to get people interested. Here's the rationale for the mandate: If you guarantee coverage of preexisting conditions, which is one of the major purposes of healthcare reform, and you don't require people to carry coverage, the rational thing for a healthy person to do would be to not buy insurance until they get sick. But if every healthy person did that, the whole system would break down. There needs to be a large pool of people paying into the system to cover the care for the people who need it, and there has to be a deterrent to opportunism. In order to have a system that provides protection for care of preexisting conditions, you have to have some kind of way to get healthy people to pay for insurance.

Q: It's interesting how foreign this concept seems to people when nearly everyone knows they have to buy car insurance in order to drive a car.

A: The most direct precedent here is Social Security, which was challenged on same basis. It's a compulsory form of insurance. And so is Medicare. The one difference here is that you don't have to take the insurance from the government. You can go to a private insurance company for coverage. Interestingly, Republicans wanted to introduce private options for Social Security, but the system would still have been compulsory. The Republicans then were calling for a mandate that is exactly the same as the health insurance mandate in this legislation. There is no question about the constitutionality of taxation. Congress can pass taxes. The only thing that makes this different is that this is a mandate for a payment to a private organization rather than a tax. And the penalty for someone not insuring themselves is to pay a tax penalty. So the whole thing is through the tax system. In fact, if the Republicans do win this case then there will be a constitutional ground for preventing privatization of Social Security in the future. They better watch out.

Q: Isn't it more than just worrying about paying more in taxes? Aren't people even more frightened by the idea that they will need a lifesaving treatment and it won't be covered under a restrictive government plan? Yet rationing occurs every day. If you are a middle-income person in Montana, you won't have access to the same level of care, the same access to advanced medical technology, the depth of expertise that you would in a place like Los Angeles, even with the same insurance. How can reporters better explain the interplay between costs, effectiveness and insurance coverage? 

A: Reporters can do a good job by telling stories that illustrate the fundamental patterns that exist in health care. I never use the word rationing, for one, because it conjures up images of rationing stamps as might exist in wartime when there's (only) so much gasoline to go around. There is evidence that there is a tremendous amount of unnecessary and inappropriate care in the health care system. We need more effective regulation and better research on the effectiveness of health care treatment in order to be able to reduce the unnecessary and inappropriate care. Because if we don't do that, we are going to end up with rationing. People are afraid that something they are going to need will be denied them. If we don't have systems to make sure that people are receiving appropriate care, we will have rationing.

Q: The decision by the federal Preventative Services Task Force to recommend fewer mammograms for women was seen by many as evidence of government rationing.

A: The conclusion of that committee was that the decision should be left to the doctor and patient, which is what the critics of the committee believe should be the case. But the critics weren't paying attention to what was really being said. They were just looking for a way to create a controversy.

Next: What reporters can do in their states to monitor reform