Let’s Not Lose Sight of the Goals

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I love Daniel Schorr.  I’ve never met him in person, but I love his voice and his insights about politics on NPR’s Weekend Edition.  But this morning I was disappointed.  After listening to his comments on the Olympics and Iran, I looked forward with anticipation to his thoughts about the Senate Finance Committee’s accomplishments earlier this week on health reform legislation.  When asked whether a “real health care bill” is likely to pass later this year, he said, “Well, it begins to look more [likely] . . . that there will be a bill.  The question is not whether there will be a bill . . . but what will be left in the bill, because so many things have been taken out.”  I could almost hear him sigh.  He went on to talk about the fact that the public option is not a part of the Senate Finance bill, although it might be restored in full or part (through a trigger mechanism or health cooperatives) as the bill moves through Congress. Let’s step back for a minute.  (This is what I usually rely on Schorr to do for us.)  Where were we a year ago?  Although advocates of health reform were encouraged that the health care crisis was getting a lot of attention in the Presidential election campaign, the outlook was not rosy. Obama and McCain were neck and neck, and McCain’s reform proposal was so weak as to be laughable.  The pundits and pollsters were predicting that the Democrats would get about 56 seats in the Senate – not enough to overcome a filibuster.  And there was serious concern that even if Obama were elected, health reform would be crowded out by other major crises – the threat of a serious economic depression, the banking collapse, Iraq/Afghanistan/Iran, energy and global climate change, and who knows what else.  In October 2008, the likelihood of serious comprehensive health reform was probably about 25%.

What has happened during the last 12 months?  Well, Obama was elected with a clear mandate to do something about health reform, and his proposal was pretty solid.  The Democrats surprisingly won 60 seats in the Senate, although it took months for the Minnesota recount to be completed.  The President and the Democratic leaders in Congress have made health reform a top priority and haven’t let other critical issues get in the way.  Obama selected a top-flight team of policy experts and – more importantly – politically savvy professionals to push health reform.  (Sen. Baucus and others on the Hill had started doing this a year earlier.)  Using the lessons from the defeat of the Clinton plan in the 1990s, Obama set the overall goals and framework for reform but let Congress take the lead in creating the specific legislation.  The administration worked closely with health care industry groups to get their support for reform, or at least reduce the likelihood they would torpedo it.  A strong consensus emerged about the basic shape of the reform package, and five Congressional Committees have passed very similar bills.  We’re on the verge of actually getting something done. What’s in the bills? Is it real reform or something watered down?  As the President reminded us in his September 9 address, we need to stay focused on the goals and not get tangled up in arguments about the ways we achieve those goals.  Reform advocates have been working for decades to improve access to health care for all Americans, improve the quality of health care, and reform the system in a financially responsible and sustainable way.  The bills in Congress would make major progress on all three of these goals, and we shouldn’t lose sight of that.  The bills can be improved, of course, but we must not let the perfect be the enemy of the good.  The inclusion of a public plan option should not be the litmus test of a good bill, despite what Howard Dean says; it’s only a means to an end, and there are other ways to get there.  We should focus instead on whether the final reform plan would make real progress on the three critical goals of access, quality and affordability.  In the end, it seems increasingly likely that we will pass the most important and far-reaching domestic legislation in many years – one that will help millions of people who cannot afford decent health care – and we should not lose sight of that. But I still love you, Daniel Schorr.  We all need a healthy perspective on the major issues of our day, and I’ll listen in again next weekend. 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 as Chief Financial Officer for Kaiser Permanente’s Northwest Region. More information about Bill may be found at his website. You can read more of his commentaries on health care management and policy at his blog, Now’s the Time, where this post first appeared.

10 replies »

  1. We just need to focus on the CAUSE– not the symptoms.
    This applies to your blog even tho it is also my Response to Bill HR676 (Single Payer Healthcare)
    Although this language appears to be much better than general insurance solutions I would have questions.
    1. Do this include citizen rights to any kinds of treatment they want?
    2. If not, who makes the decisions for me? For example, if I use Homeopathy or Chinese Medicine or Herbal or Vitimine Therapy or Visual Imaging, etc… will all of this be covered?
    (If any of this is denied then you will be driving legitimate practicitioners out of business. And it would be affecting my decisions by not allowing me to get equitible coverage for the way I choose to maintain my health.)
    3. The only solution to reduce healthcare costs is to let each citizen receive and pay for their medical care directly, like it used to be. Managed care was a very bad idea for people and a bonanza for insurance companies. (On the free market both regular and catestrophic insurance would still be available.)
    see more at

  2. Brian Klepper makes some very good points, and I don’t disagree with most of his criticisms of the Senate Finance Committee bill. Although it does include some cost containment elements – notably a stronger Medicare Commission and the excise tax on high cost insurance plans – the SFC’s proposal is unlikely to significantly bend the cost curve. In order to do that, we would need something like the CED proposal or Sen. Wyden’s Healthy Americans Act. I’m a great admirer of Alain Enthoven and Ron Wyden; from a policy perspective, I think these are great ideas. For better or worse, however, I think they are not viable politically.
    As Ezra Klein points out in a recent commentary (http://voices.washingtonpost.com/ezra-klein/2009/10/meet_the_new_health-care_syste.html), the Senate Finance Committee bill won’t affect most people. This is by design; the bill focuses on fixing the problems faced by three groups who suffer the most in the current system: the uninsured, those with individual coverage, and small employers. It has little direct effect on those who currently have coverage from Medicare, Medicaid, or large employers. The biggest political barrier to reform has always been the latent fear that reform will “take something away” from those who currently have coverage. Opponents of reform have exploited this in the past – successfully in 1993-94, less successfully so far in 2009 – so the Administration and Congressional leaders have made a political choice not to stir up this hornet’s nest.
    I think the debate about the merits of the Senate Finance Committee bill is largely a “half empty/half full” issue. In an earlier article about the first draft of the bill (http://voices.washingtonpost.com/ezra-klein/2009/06/the_finance_committees_compreh.html), Klein made a similar comment. He is more eloquent that I am, so his conclusion is worth quoting:
    “People frequently refer to the goal of health-care reform as “comprehensive reform.” But this is what I’d term “comprehensive incrementalism.” It makes everything a bit better. It is not radical. It is not root-and-branch reform. . . . It is one of the paradoxes of the legislative process that something that is substantively quite timid can also be quite bold. This version of health reform is far from what the country needs. It is far from what any health-care experts would develop left to their own devices. But it is still a monumental initiative and, if passed, it would be the most significant step forward since the creation of Medicare and Medicaid.”
    From one perspective, I am disappointed in the Senate Finance Committee bill, and I hope that it can be improved. But we shouldn’t lose sight that it would make things a lot better for those who suffer the most in our current dysfunctional health care system. If we withdraw our support for the bills currently under consideration in Congress because they aren’t “good enough”, we risk missing this precious window of opportunity to make some real progress.

  3. Based on the health propaganda numbers that we have been subjected to, why should we believe anything that passes for “debate” on current proposals.
    Uninsured: The 45 million “uninsured” number is bogus. The White House reduced it by the number of illegal aliens and the young/healthy to reduce the number to about 20 million. CNN quoted the number of “hardcore” uninsured at about 8 million. Can anyone tell me which walnut shell the pea is under?
    Cost: If the US spends $2.5 trillion annually on healthcare for 85% of the population (assuming that the 15% uninsured number is correct) then the full cost figure for universal healthcare (not universal insurance coverage) will be about $3.0 trillion. That’s a $500 billion per year add-on to current costs– which excess will be paid for by the 85%. This also amounts to $5 trillion dollar cost over the 10-year horizon used by policy makers to estimate costs of new legislation — which is $4 trillion more than the less than $1 trillion forecast by the current Administration.
    All of this in the face of the largest spending deficits ever faced by a human government.

  4. I strongly disagree. While current proposals offer modest extensions to entitlements and address a few problematic excesses that have plagued coverage (e.g., pre-existing conditions), they specifically avoid addressing the structural underpinnings of the system that have resulted in the cost crisis: fee-for-service reimbursement, a lack of transparency of cost and clinical outcomes, and a specialist-dominated system.
    These oversights are not accidental, but the result of intense lobbying by the industry, amounting to more than a half a billion dollars in campaign contributions to members of Congress. Dr. Enthoven recently inventoried (see http://www.kaiserhealthnews.org/Columns/2009/September/091009Enthoven.aspx) the deals cut with each major health care special interest group – the docs, hospitals, health plans, drug and device suppliers, unions, large employers – and the upshot is clear: the current round of “reforms” will solve little of our current woes, but allow the continuation and deepening of the crisis in ways that will force us to spend a great deal more and then quickly revisit a much greater problem. Thoughtful groups like the Committee for Economic Development and the Mayo Clinic have vehemently weighed in, making exactly this point.
    Mr. Kramer trivializes complaints like mine as seeking the perfect at the expense of the doable. But his analysis, such as it is, is foolishness. We’re not hearing anything from the industry right now because they appear to have won, co-opting Congress and consigning the American people to tremendous unnecessary cost for the foreseeable future.
    This is what Mr. Kramer thinks is success.

  5. I just don’t see any “comprehensive” reform other than insuring everyone – and I am not sure that my premiums in the non-employer-sponsored insurance market are not going to rise significantly as a result.
    Show me the quality and cost reforms; I don’t see them.
    Doctor penalties for performing too many tests? Blunt and ultimately self-destructive instrument. Effective physician/hospital payment reform? Don’t see it. Sorry.
    (ps I am retired so have no ax to grind, except as a patient.)

  6. What indeed is our goal and how are going to get their? I just posted on my blog some comments on this very topic based on reading the Senate Finance Committee bill and getting mired in double talk and conflicting objectives. Complex is an understatement of what we are creating, there is something in all of this for everyone to hate, abuse, misuse or whatever and it is very doubtful whether we have accomplished much except to add a few more million people to a flawed system.
    Take a look at some examples:

  7. “Well, Obama was elected with a clear mandate to do something about health reform, and his proposal was pretty solid. The Democrats surprisingly won 60 seats in the Senate….”
    That is exactly the problem. The bill should reflect this reality, and right now it does not.
    I was watching the Finance Committee deliberations on Senators Rockefeller and Schumer’s amendments the other day and I had this insane urge to smash the TV.
    Do these folks understand that they are there to REPRESENT the people?

  8. Bill Kramer says- we should focus …. on whether the final reform plan would make real progress on the three critical goals of access, quality and affordability.
    Thanks for “the re-boot”
    That said,a public option may not be a litmus test for a good bill, but a good bill is surely a litmus test for our nation’s basic character including a dedication to fairness and morality.
    Dr.Rick Lippin

  9. I guess the complaints are based on the fact that we DO have 60 Democrats in the Senate, which means we shouldn’t have to settle for a watered-down bill.
    In the end I think you’re right, though. As long as reform is successful, it paves the way for future reforms that get us the last 10%. If it’s not successful, it more firmly entrenched one of the most dysfunctional systems in the world without any benefit.

  10. Hi,
    This is nice article.The health care bill getting too much news nowadays due to its controversial content.You have suggested some notable points about this matter.