I don’t know how many of you linked over to Lawrence Brown’s perspective piece “The Amazing,
Non-Collapsing US Health Care System” in the January 24th issue of the New England Journal of Medicine
(buried in Mathew’s “Whisper it quietly. . .” post), but it’s the most useful piece of political analysis of the health reform conundrum I’ve seen in a long time.
What Brown argues, convincingly, is that we really have three healthcare systems: public and private health FINANCING systems (which operate in the lucrative fantasy land of “reimbursement”) and a public CARE system (the safety net urban hospitals, community health centers, public health clinics, the VA, etc.) that serve the rural and urban poor and uninsured.
Other than a few isolated outposts like Kaiser, the third health system that Brown discusses is the only place in the United States where population health is actually practiced. And, most important, it is also is the mysterious resource that prevents the 47 million uninsured, including a very large number of our 12 million undocumented people, from dying in our streets, and causing a huge political crisis. It is invisible to much of the voting public, but thank God we have a safety net healthcare system.
This latter system has been a political stepchild of state and federal governments, and lurches from financial crisis to financial crisis, living off the land. But it has successfully propped up the other two, and, I think, helped prevent a revolution. Precisely because it has succeeded in reaching its target populations and helping them, albeit “too late” in the disease process, it has drained both political urgency (and funding) from making the first two “reimbursement” systems universal.
It is also where most of the politically active health reformers,
like Lawrence Brown (and Ron Anderson and my old friend, Quentin
Young) work. They actually see and touch poor people. They go to their
own meetings. They rage appropriately against the hypocrisy, rhetoric
and waste they see in the rest of our so-called “healthcare system”.
They have their own political networks, and also a very impressive case
for continued funding. And they rarely communicate with their
prosperous colleagues in the other two systems, or the Executive Branch
and Congressional health policymakers who have their hands full feeding
the alligators through Medicare and Medicaid.
Closing the 47 million person funding gap by making the first two
systems “universal” has been the elusive Holy Grail of health reform.
What Brown is basically saying to the Holy Grail folks is, “Don’t Hold
Your Breath”. The left has historically advocated wiping out the
private side of the health financing system, (making Kaiser, Blue Cross
and United Healthcare disappear, basically) and controlling all payment
centrally (and politically). The right has historically advocated
making the public side disappear, by outsourcing it to private
insurers. I think this debate is tiresome because neither side is going
to disappear any time soon, and all the absolutist rhetoric does is
make people feel angry and hopeless, and turns off voters.
Both sides tend to behave as if this crucial third sector never
existed, and some believe that you wouldn’t need it if “coverage” was
universal (or perhaps that it would be paid more generously). There is
an important flaw in this argument. We will continue to need that third
sector because we will never make coverage universal. If, in our
current intolerant political climate, the Democrats, historic defenders
of the downtrodden, cannot give the 12 million undocumented folks we
depend on every day drivers licenses, they sure as hell aren’t going to
give them health insurance. And we aren’t going to send them all home
And, as the collapse of California’s health reform initiative
demonstrates, if you cannot make “coverage” affordable, you cannot
force people to purchase it. We’re all waiting for the Massachusetts
experiment to play out, but my prediction is that, due precisely to the
affordability problem, one third of the uninsured in Massachusetts will
still be uninsured five years from now. It is reasonable to forecast
that there are going to be a lot of clients of the “safety net” sector
into the indefinite future.
Moreover, millions of safety net “customers” are eligible for
Medicaid/SCHIP do not enroll, for a variety of reasons related to
privacy, dignity, paranoia, language or other cultural barriers,
administrative cumbersomeness or fiscal reluctance of state sponsors.
An estimated 25% of the uninsured are already eligible for public
programs and do not enroll.
Brown’s third sector also explains that mystery. They don’t have go
through all the humiliating hassle of enrolling in Medicaid or SCHIP
because they are getting free or nearly free care with at least some
measure of dignity from public sector providers. Though many of the
facilities are old and overtaxed, and the caregivers overworked, their
patients and the families they belong to feel at home in that public
system. It is also accessible to them because it is located where they
There are complicated issues surrounding the social efficiency of
having this third sector. They revolve around the untested belief that
if everyone had health insurance, they would be healthier because
they’d get care earlier. I am skeptical of this logic. True enough, the
uninsured have greater health risks for the same conditions than the
insured do, but how much of this is cultural and logistical, and how
much relates to the fact that they are not “insured” is an open
question. I’d like to see the data sorting out these multiple effects
on health status before concluding that the lack of insurance itself
was the cause of the large health disparities we presently see.
“Reimbursing” hospitals and doctors through private or public health
insurance to provide them care assumes not only that caregivers will do
the right thing, rather than the lucrative thing, and that families
will co-operate with them. To work, it also assumes that there is a
care system to pay near where the poor and uninsured live. It further
assumes that there are not important non-financial (e.g. cultural)
barriers to families getting care “earlier” even if people have
Practicing population health, as the safety net system attempts to
do, does not assume away those cultural barriers. I think we get way
more health improvement mileage out of our community health centers
than we do out of just about any other social investment. Do we fund
them more effectively by “insuring” their patients, or simply through
more generous grants or local government salary lines?
To simply assume that extending coverage to the 47 million uninsured
somehow assures access and, therefore, better health, requires multiple
leaps of faith. There are many physical, cultural and economic barriers
separating “coverage” from “access”. Rather than focusing on
unaffordable mandates and massive tax-based subsidies, extending
coverage should focus on affordability (vitally important for the more
than ten million younger uninsured) and ease of access to multiple
insurance options, including earlier access to Medicare for the ten
million uninsured boomers. If we could lower the number of uninsured by
twenty-five or thirty million, it would be a huge victory.
This is why any health reform legislation will contain one or more
titles increasing funding for safety net care providers. More generous
direct health funding for the safety net, with matching grants to
states and localities encouraging them to ramp up their efforts, rather
than continuing the elaborate system of largely hidden subsidies buried
in the Medicare program, is a vitally important adjunct to health
reform. Pragmatic health reform will incorporate reforming and
strengthening our healthcare safety net, and extending population
health initiatives that address the root causes of illness.