It’s always fun to see my friends beating each other up in public….and if you read down in the comments on the post published yesterday you’ll see a significant dispute between Maggie Mahar and the Klepper/Kibbe/Lazsweski/Enthoven team (who I’m calling the Four Horsemen from now on). But I think that right now we need to change what we’re talking about.
I’m with Maggie in that there is potentially more in terms of changing the payment system in the current bills than nothing, but it’s not that much more than nothing. However, pressure from the the Four Horsemen and their fellow travelers on payment reform may increase that section of the bill as it gets worked out on the floor and in the Congress conference committee. Their pressure will also serve notice that aware, sensible people are looking at the issues of payment and delivery reform.
And at the least, the proposals in the bill don’t make the current delivery system any worse (other than the exemption from taxes for self-insured groups which clearly discriminates against integrated systems and must go).
Instead lets focus on what most of the bill consists of which is insurance reforms:
- Yes, they take way too long to be implemented (They’re starting in 2013? Why not 2011 or even middle of 2010?).
- Yes, the subsidies are too low–and it would be better if we had one tax-based insurance pool
- Yes there should be national, highly regulated, insurance regulation with everyone (or many more people) having access to a real exchange
- And yes if there is a public plan lets have it available everywhere to keep the private guys honest (even if its just more access to Medicare as Jeff Goldsmith suggests).
But what we’re going to get from the bills in Congress now is clearly better for poor and lower income people with health problems, and for small employers, than the alternative. The alternative is nothing this year, and probably nothing for a good long while after that. And those are the people the current system discriminates against the most.
I appreciate that what may pass the Congress is not what any of us Obama fans and Democrats would want in an ideal world. Yes, all of us would like serious campaign finance reform. Yes, I think we’re all appalled by the behavior of the unions and the large employers in stopping meaningful tax reform on health benefits. (Jeez, I even agree with Mark Pauly about one way out of that!)
Rule 1 A health care reform bill needs to guarantee that no one should find themselves unable to get care simply because they cannot afford it. Neither should anyone find themselves financially compromised (or worse) because they have received care.
Rule 2 A health care reform bill needs to limit the amount of GDP that is going to health care to its current level, with an overall aim of reducing the share of health care going to GDP.
I think that the likely bill goes some long way towards the objectives in Rule 1. And makes a small start, albeit a very trivial, one towards the objectives of Rule 2–although I appreciate that it runs a substantial risk of breaking Rule 2. But I think that Rule 1 is more important than Rule 2–for now.
Maggie’s advocacy of the current bill fits Rule 1. The pressure from the Four Horsemen, Peter Orszag, Don Berwick, Zeke Emmanuel and others can hopefully make the Congress aware that on Rule 2 there’s lots of work to be done.
And I remind you all of perhaps the best post I ever wrote on THCB back in 2005. It was called “Why Hillarycare failed…and what we need to learn from that failure.” Here was my conlclusion:
The main lesson of HillaryCare is that when the right moment comes along politically we need to get whatever form of universal reform can be agreed on shoved quickly through the Congress. Make no mistake, universal insurance is a big bang and a necessary big bang. Getting it through will be a hell of a confluence of opportunity and tactics. Once we get it done, then we have a while to worry about sorting out the system to the purists’ satisfaction later.
So will you all still please stop arguing about what it should look like!
I know that the bill in Congress now isn’t universal insurance–but it’s as close as we’re going to get for now. So let’s stop arguing and instead get as much pressure as possible on getting the right stuff that we agree on into the bill. And when I say “we” I don’t mean a bipartisan 80% we, I mean the Dartmouth loving, primary-care loving, universal pool approving readers & authors of THCB. A group which includes both Maggie and the Four Horseman. And me.
Categories: Matthew Holt