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Beyond the Beltway – How Most of America Sees Health Reform

What are people saying about health reform beyond the beltway and outside the health wonk debates?  I’ve been meeting with Rotary Clubs and local Chambers of Commerce during the last several months, and they’re talking about different issues than the ones being debated in Washington, DC.  When I talk with these groups about the prospects for national health reform, what are the top three questions they ask?

  • Is this going to lead to a single-payer system with rationing, just like they have in Canada?
  • Why isn’t the malpractice problem being addressed?
  • Will this include illegal immigrants?

These are not the top issues being debated on Capitol Hill.  If you just read Politico.com, the Washington Post, and the pundits’ blogs, you would think that the big issues are the public plan option, the employer mandate, and the cap on the tax exclusion of employer-paid benefits.  There are important, but they aren’t the issues that most small employers and consumers are worried about.

Let’s take each of these in turn.

  • The concern about rationing under a Canadian-style single-payer system shows that the messages from right-wing opponents of health reform are finding a receptive ear, at least among some people.  I heard this issue expressed at every meeting I attended – often using the exact language the Frank Luntz has recommended.  In response, I try to explain that the most likely reform legislation would preserve the multi-payer private employer-based system for most people, and it would rely on healthy competition rather than government price-setting and rationing to slow the growth in health care costs.  My response usually falls on deaf ears; many people are convinced that Obama and Kennedy are secretly pushing for a government-run plan.  It will take a lot of work to overcome the fear factor that is being stirred up by opponents of health reform.
  • Many people – especially those with family members who are doctors – are convinced that the malpractice problem is the single biggest driver of high costs.  In the words of one person at a meeting I attended recently, “The malpractice lawyers are raping the doctors”.   I respond by acknowledging that malpractice insurance and the use of defensive medicine do drive up costs, but these are relatively minor factors; the way physicians are paid has a much larger impact on driving unnecessary use of tests and medical care.  But there is a real issue here: why hasn’t malpractice reform been seen as an essential building block of reform?  The likely answer is political:  the trial lawyers have traditionally provided financial support to Democrats, while doctors have usually supported Republicans.  Since most of the current bills are being written by Democrats, it’s not surprising that they don’t focus on liability reform. Pres. Obama’s recent comments to the AMA provided a glimmer of hope that the issue will be addressed.  If there is any interest in building bi-partisan support for comprehensive health reform, this ought to be on the table.
  • The fear of illegal immigrants is a hot button issue for many people.  In the current economy – with many people losing their jobs, and many more worried sick about the danger of unemployment – it’s sad but not surprising that some people would see immigrants as a threat.  So far, the President and Congressional leaders have been successful in keeping this issue from getting out of hand, but Senators and Representatives will get an earful when they spend time in their districts during the July 4 and August recesses.  Unless we find a way to manage this issue, it could become a flash point in the final phases of debate on a comprehensive reform bill.

Bill Kramer is an independent health care consultant, focusing on health care management, finance and public policy. Bill served as a senior executive with Kaiser Permanente for over 20 years. Most recently, he served as Chief Financial Officer for Kaiser Permanente’s Northwest Region. More information about Bill may be found at www.kramerhealthcareconsulting.com.

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10 replies »

  1. Peter – I read the Gawande article the day it came out, but it is only one article, looking at one area of the country, and focused on one cost driver. It does not serve as a complete picture by any stretch of the imagination.

  2. The Canadian doctor waiting times are not as bad as one might suspect, especially in major cities. Wait times, especially for medicare and medicaid patients in the US, are long too.
    Malpractice is a bigger issue in the US than in Canada, though. Canadian doctors are surprised at how much overtesting occurs in the US, especially given for the most part, the doctor has no financial interest in the testing. As a physician who trained in Canada and now practice in the US, I practice defensive medicine much, much more here across the border than in the great white north. I was never threatened with a lawsuit while in Canada – it’s simply not part of the culture. Here, I get threatned with one whenever I disagree with a patient, especially if they want extra vicodin or percocet.
    I wonder how much of the malpractice problem is cultural, in that while other countries mediate disputes in a genteel way, Americans duke them out in court. Either way, at least this side of the border, defensive medicine is here to stay, and we all end up paying for it.

  3. “many people are convinced that Obama and Kennedy are secretly pushing for a government-run plan.”
    Would this maybe be becuase Ted Kennedy has been pushing for government ran plans for 35 years? He clearly said he wanted HMOs to take over healthcare becuase they are federally regualted. He has been pushing for government care for almost 4 decades and you expect the public to just ignore this?
    Obama has also said he wants government controlled healthcare.

  4. As an ER doc I can say that 98% of CT scans are defensive and 90% of chest pain admissions are defensive.
    The northeast is used to sponging off the rest of the country, so why should health insurance be any different.
    With this president the “illegals’ will not be illegal forever.
    Canada has different utilization of healthcare, so they will have different data than the US. Anyone moving to Canada for the healthcare?

  5. Bill – I disagree with your point that the payment model has a far bigger impact on overutilization than defensive medicine. You are assuming that a large percentage of physicians have financial incentives to order diagnostic tests. That’s definitely not the case in my local area and I can’t imagine it is in many other areas.

  6. I”m not in the heartland, but in a traditional liberal area of the Northeast US where the big issue is concern about losing employer-based health insurance due to affordability. The themes we’re hearing in Congress and from the Obama adminstration are very much music to our ears.

  7. Those of you screaming about potential tax increases to fund universal health care … wouldn’t you rather pay for that than some fat-cat’s bonus? The system has been broken for a long time and fixing it won’t be cheap. The engine light on the health care car has been ignored too long; after neglecting pay-as-you-go $25 oil changes, the motor either needs to be replaced or it’s time to buy a new car. Can’t afford it? Too bad. If you need transportation, you’ll just have to find a way to suck it up. If you keep your lemon and replace the parts piece by piece, over time, you will have invested at least double the original price of your car despite it’s depreciated value. Examine the health care systems of other countries, pick the top two and then decide. Money is a moot point- we either continue to strangle ourselves with higher premiums/out-of-pockets and pay higher taxes to cover those who are excluded, or pay the same in taxes to cover everyone. Get over it! If you’re one of the screamers, all you’re doing in the long-run is delaying the change and supporting on-going profits for the A.M.A., malpractice attorneys, drug companies, insurance companies, for profit hospitals….

  8. Regarding tort reform and health care reform, why is it that we always talk about the way providers are paid and how that drives up cost (which I agree) and we never talk about the way trial lawyers are paid (percentage of awards) and how that drives up the malpractice costs?

  9. I am going to state the obvious and point out that Rotary Clubs and local Chambers are not populated by and large by government workers, labor, or well anyone who is a Democrate. The R’s lost the election and so their issues are no longer on the top of the agenda.
    People on the other side of the aisle do discuss and discuss and discus the issues you raised but they aren’t trying to solve the problem they are just reacting from fear.
    Here are some more myth busters.
    Myth: Canada is a socialized health care system in which the government runs hospitals and where doctors work for the government.Princeton University health economist Uwe Reinhardt says single-payer systems are not “socialized medicine” but “social insurance” systems because doctors work in the private sector while their pay comes from a public source. Most physicians in Canada are self-employed. They are not employees of the government nor are they accountable to the government. Doctors are accountable to their patients only. More than 90 percent of physicians in Canada are paid on a fee-for-service basis. Claims are submitted to a single provincial health care plan for reimbursement, whereas in the U.S., claims are submitted to a multitude of insurance providers. Moreover, Canadian hospitals are controlled by private boards and/or regional health authorities rather than being part of or run by the government.
    Myth: There are no waits for care in the US. Try to get an appointment with a Dermatologist, (2 months) Orthopedic surgeon (if for back pain you won’t see one unless you go to the hospital owned by them) or cardiologist (3 months to get in to see one at Swedish Medical center) in Seattle. If you go through and ER it is often faster but not much if it a referral
    People think that in Canada there are long waits for care, which compromise access to care.There are no waits for urgent or primary care in Canada. There are reasonable waits for most specialists’ care, and much longer waits for elective surgery. . However, the wait has nothing to do with money per se, but everything to do with the lack of some specialists. radiation therapists.
    Despite such waits, however, it is noteworthy that Canada boasts lower incident and mortality rates than the U.S. for all cancers combined, according to the U.S. Cancer Statistics Working Group and the Canadian Cancer Society. Moreover, fewer Canadians (11.3 percent) than Americans (14.4 percent) admit unmet health care needs.

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