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Is Mandated Universal Coverage the Right Way to Achieve Health Reform? The Health Reform Debate We Haven’t Had Yet, by Jeff Goldsmith

Goldsmith_2I 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
either.

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
live.

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
coverage.   

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. 

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H. Green, MDGRBusby SEO ChallengejeremyPeter Recent comment authors
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H. Green, MD
Guest

Mandated Health Care is the right way to go provided you take advantage of economy of scale…. 9 Steps to Comprehensive Quality Health Care in America 1) Shut down the private health insurance corporations. 2) Enroll all Americans (including Veterans) and the 40 million uninsured citizens into the Medicare Health Insurance Corporation. Since the current functioning Medicare Insurance Company is already accepted by almost all physicians, Hospitals and clinics in the Country, hardly any infrastructure investments on the health care delivery end will be necessary. Have all private businesses pay a Medicare premium for their employees instead of private health… Read more »

H. Green, MD
Guest

Mandated Health Care is the right way to go provided you take advantage of economy of scale…. 9 Steps to Comprehensive Quality Health Care in America 1) Shut down the private health insurance corporations. 2) Enroll all Americans (including Veterans) and the 40 million uninsured citizens into the Medicare Health Insurance Corporation. Since the current functioning Medicare Insurance Company is already accepted by almost all physicians, Hospitals and clinics in the Country, hardly any infrastructure investments on the health care delivery end will be necessary. Have all private businesses pay a Medicare premium for their employees instead of private health… Read more »

GR
Guest
GR

Thank you, Mr. Goldsmith excellent article.
In addition health care, “fear”, can be used to implement change that has less to do with your health and more to do with control.
http://www.healthplan.9f.com/

Busby SEO Challenge
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good work

EdSmith
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EdSmith

I find this terribly sad. Jeff Goldsmith has this golly-gee resume and gets paid to speak to corporations on health care. Yet, he says we can’t have universal care because it has never worked before in the U.S. And, returning to the original subject, nothing is going to get fixed as long as we have the third sector of free clinics relieving pressure. Perhaps Jeff keeps busy by entertaining the swells with cracks like the one above about the podiatrist, chiropractic, and reiki lobbies. I can hear the yucks from the AMA/AHIP country club crowd already. Universal coverage can be… Read more »

EdSmith
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EdSmith

I find this terribly sad. Jeff Goldsmith has this golly-gee resume and gets paid to speak to corporations on health care. Yet, he says we can’t have universal care because it has never worked before in the U.S. And, returning to the original subject, nothing is going to get fixed as long as we have the third sector of free clinics relieving pressure. Perhaps Jeff keeps busy by entertaining the swells with cracks like the one above about the podiatrist, chiropractic, and reiki lobbies. I can hear the yucks from the AMA/AHIP country club crowd already. Universal coverage can be… Read more »

jeremy
Guest

Interesting comments.

Jeff Goldsmith
Guest
Jeff Goldsmith

What Ed is talking about is essentially what Uwe Reinhardt proposed years ago (First Class, Business Class, Economy Class coverage) which Ann Miller RN mentioned in the first comment. In Uwe’s scheme, unlimited access to elite institutions and no waiting was financed by the wealthy out-of-pocket. If we could restrain provider political interests from lobbying to have their services included in the basic coverage package (podiatrists, chiropractors, reiki practitioners, etc.) and focus on primary care/drugs/dental care and have catastrophic type coverage for most everything else, we could have an affordable basic package and lots of people would choose to be… Read more »

EdSmith
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EdSmith

I am still trying to get all this straight. If Jeff Goldsmith is arguing for stable funding for the third sector because it works well, or good enough, then can’t we reduce the question to how many of us should use this third sector? And, that begs the question of who funds and monitors this third sector. It seems so much of U.S. health care debate boils down to rich people, or the self-perceived rich, not wanting to run into their gardener in a waiting room. The well-to-do want assurance they get the best care, or at least better care… Read more »

Peter
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Peter

Does the third shelter system (homeless shelters) prevent revolution in housing? Does the third mental health system (jails) prevent revolution in mental health care? I guess they do if most people were forced to interact with these groups on a daily basis. But as EdSmith said very well, should that be how we justify their existence and prevent overhaul of a morally and financially bankrupt system. As costs continue to rise at unsustainable rates more and more people will find themselves depending on the third system – epecially in an economic downturn when the jobs with healthcare disappear. Maybe that’s… Read more »

Jeff Goldsmith
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Jeff Goldsmith

The Indian Health Service is laboring against huge cultural odds- poverty, massive adult unemployment, rampant alcohol abuse and a burgeoning meth epidemic, domestic violence, child neglect, third world diseases. I honestly don’t think more orthopedists and ENT specialists are going to make that big a difference. We ought to be ashamed of what we have done to our native American brothers. To repeat a point made in the post, I think there is more leverage in actually providing more generous direct funding of safety net providers, particularly at the community health center and neighborhood clinic level, than in providing heavily… Read more »

jd
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jd

My second to last sentence should have been something like:
This is an argument against trying to bring everyone into commercial insurance and Medicare, as they function now.

jd
Guest
jd

I’m trying to wrap my head around this. Is this the basic idea: of the 45+ million uninsured, we shouldn’t try to bring them all into the commercial system. We should instead aim to split this group into parts, some of which would become commercially insured, some of which would join a government-sponsored insurance program, and some of which would remain technically uninsured but have access to free or nearly free care through a loose system of community clinics and hospitals? Is that the proposal? I understand that community clinics are one of the most efficient parts of our system… Read more »

Lee Gugerty
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Lee Gugerty

Good idea to point out that increasing coverage does not necessarily increase access to care. Here is an example of where people have access (through your public care system) but not enough coverage — the Indian Health Service. That is, Native American users of the IHS have relatively easy access to health care (at least if they live near an IHS clinic); but they receive less comprehensive health care (e.g., no access to orthopedists and ENT specialists unless it’s an emergency; no access to some of the newer and more effective pharmacotherapies.) Political point: the US Senate is now considering… Read more »

EdSmith
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EdSmith

Reading Lawrence Brown’s piece, Jeff Goldsmith’s commentary, and a few posts make me feel like I’ve fallen down Alice’s rabbit hole. Let me in on the joke someone. These are Modest Proposals, right? Arguing that the third sector safety net relieves the pressure to improve U.S. health care, is like arguing we can let our highway system go because poor people can always walk or bum rides and there is more money made in selling airline tickets and SUV’s to drive around the potholes than in fixing roads. How do you define collapse? Is it when your neighbor dies because… Read more »