Nope, it’s only 2010 – a new year to be sure, as evidenced by stabilizing home prices and normalizing presidential approval ratings. But you can stop holding your organization’s breath, slow down the conversion of that emergency room to a primary care clinic, and forget coming clean with your health insurer about your actual medical conditions. Health “reform” won’t be here until 2014, if the Senate bill – passed just as Santa Claus was loading up his own sled with presents – prevails in the legislative horse-trading that begins this week.
Or it could be here as early as 2013, if we give way to the reckless abandon of the House bill. In either case, fear not: full implementation of The Plan does not occur until well after the end of the world, according to the Mayan calendar. If this is a government take-over of health care, taking their sweet time may prove to be a brilliant poker strategy.
Where does The Plan stand in the first days of a New Decade? What happened while we were back in the real world, dealing with crowded malls, crappy weather, and airport security? Well, nothing really – except the Senate voted to pass, along predictable party lines, what amounts to the incredible shrinking health care reform bill. Don’t be fooled by page counts, which always grow during the legislative sausage-making process to add legal precision, accommodate technical arcana, and dole out the porcine one-offs for holdout votes; if this is the slippery slope to single-payer, as some have argued, it begins brilliantly, with uphill steps.
So for those stuck in mall traffic during the big Senate vote, the resulting bill – the one with process-momentum on its side – has been so stripped of government management options and control that it is best characterized as the exact opposite of a government takeover. Rather, the bill now on trajectory to become The Plan is – paradoxically – a privatization of the public health problem of the uninsured, a corporatization rather than nationalization of health care’s rotting safety net. As we enter 2010, the barely passable package churned out by the Senate will amount to nothing more elaborate than a shuttling of the uninsured, via new taxes-to-subsidies, into the commercial health insurance market.
This is hardly the government going into the complicated business of providing health insurance – of collecting premiums and trying to spend less than them while meeting the bottomless medical needs of a population – something the best health insurers themselves can barely do without enraging one or more among their round-robin of conflicting stakeholder groups. The chances of the American polity allowing the government even to attempt such a thing always approached nil, notwithstanding the perennial presence and rancor of the single-payer types.
With the exception of a marginal expansion of Medicaid, the bulk of The Plan detailed by the surviving Senate bill is the exact opposite of TARP II, ARRA, the auto industry bailout, and all those other suddenly quaint relics from 2009’s apogee of a traditionally non-interventionist government. Instead, the likeliest reform plan at the start of 2010 signifies the government going right back to the normative practices of our national religion – market capitalism.
Why else would people like Howard Dean be howling about the plan as a sellout to corporate America? Of course it is. Technically, it would be a sellout – if corporate America had not been bought in from the get-go, with seats at the table this time around. Maybe I’ve spent too much time listening to people from profitable health care organizations bash each other for bad faith, but I always thought the job of health care companies is to make money, not fix the problem of the uninsured; anyone who thinks otherwise should stop listening to what those companies say, and starting watching what they do. That’s been my little trade secret for years.
If you’re still bearish on The Plan ever passing in some form, bear in mind that all major health care business sectors are negotiating in public about the particulars of health reform, not lobbying in private to kill it. Business as usual, with 31 million new customers. The same goes for AARP, which is endorsing a bill funded, in part, with Medicare cuts – normally anathema for arguably the most powerful health care consumer organization. As one of the larger buying groups of individual insurance, perhaps the AARP sees a bigger pickup in new business for the under-65 crowd than it risks losing through one more threat to Medicare that will probably never happen. The fruit-fly length lifespan of the Medicare expansion option – wiped out within days by a grandstanding Joseph Lieberman (I-Ct) from the Great Insurance Headquarters of Connecticut – would certainly be incentive enough for their support.
I normally avoid anecdotes and soundbites as cheap sugar substitutes for actual data and analysis, but I overheard the perfect crystallization of the whole shebang at a party Saturday night: “If the insurance companies are behind whatever it is, it just means we’ll get screwed one more time.”
Live Screwed or Die
And thus, the lofty tabula rasa idea of “health care reform” mutates before our eyes – perhaps with utter predictability, at least from the fresh perspective of these first few days of post-freakout 2010 – into mundane market reform. This is certainly the case with a real tenet of actual reform, still in tact in both the House and Senate bills, in the form of a market fix that Americans of almost all political persuasions should realize we desperately need: the long overdue prohibition on the practice of medical underwriting by insurers, a.k.a., the systematic punishment of people for the misfortune of illness or accident.
Beyond this, the government is “taking over” health care precisely the way it has in the past. The last time, it was Medicare itself, a publicly funded program that has been administered and served entirely by private companies since its inception. Or the most significant expansion of Medicare – adding the long overdue drug benefit – also administered and served entirely by private companies, many of them subsidized by the government as a political nod to the right to prove the superior efficiency of the marketplace. So now we have The Plan, projected to move 31 million people out of the public safety net and into the commercial insurance market. The Faustian bargain that the insurance companies have made for these millions of new, subsidized customers involves a very simple thing: acceptance of the medical underwriting prohibition. Fair enough. And once again, this is actually a marketplace reform – one that the more enlightened in the industry itself recognize is good for its overall functioning, efficiency, and image.
The rest of what survives in The Plan on course for passage – the bulk of those legendary 2000 pages in the Senate bill – is lip-service to good ideas that have been around for years. In some cases, they’ve been around for decades. Quality measurement? Pay for performance? Hospital/physician financial risk-sharing? Let’s do a demonstration project! Beyond that, what is left – aside from the pork barrel pages – are still more virulent endorsements of the health care status quo. The Senate bill includes the creation of health insurance exchanges that will operate, like health insurance always has, at the state level. This of course will make their existence limited and redundant, preserve the oligopoly structure of most local insurance markets, and squander the opportunity for true interstate competition and real choices, a bigger and bolder market reform indeed – and still included in the House bill, which would create a national exchange. And both the Senate and House bills not only preserve the often meddling and occasionally bungling presence of employers in the system, but have set up tax-and-penalty incentives that will inevitably expand the one presence perceived – rightly or wrongly – as the greatest source of hypocrisy, mistrust, and fear in the system.
God forbid we use this historic moment to remove any of dozen or so ossified layers of our health care system, which for my tax money would constitute true reform. The Plan, like nearly every health care law ever passed by Congress, appears at this point ready simply to pile more layers of administration on top of a system already choking on paperwork and its own mind-numbing complexity.
The Net Effect of Conflicting Ideologies Approaches Zero
The oddest lesson about last year’s very odd trip to the brink of actual health reform – versus the market reform and privatization scheme now before us at the start of the new year – is how our health care system really has proven to be the dumping ground for our most vexing social and cultural problems. Go ahead and count them: abortion, immigration, euthanasia, fairness, responsibility for others, the hand of God versus the worship of technology, and of course a visceral, blinding hatred of anything related to the role of government. Third rails, every one of them, as it turns out; and each runs right through the middle of the health care railyard.
All of the competing and often compelling arguments brought to bear on these intractable social issues are steeped not in health care, medicine, epidemiology, economics, practicality, or common sense. Rather, they are broadcast to us across treacherous philosophical, emotional and spiritual terrain that will never be amenable to political compromise. And so, in short, the ideologues on both sides of each issue pounced; the issue was squeezed altogether from The Plan or flash-frozen in its current state of impasse (abortion being the perfect example); and what we’ve ended up with is a health care “reform” bill that re-paints all the old lines in the political pavement and promises to reform almost nothing structural or profound about health care in America.
Except now some of those lines have been built into permanent fences. The clearest example is the fate of the public option, a proxy for, if not cheap imitation of, the single-payer system that fills the dreams of some and nightmares of others. While there has always been a large and vocal single-payer crowd – armed with some strong arguments to support at least a two-tiered system with a government payer on the first tier – what are we to make of the rejection of even a whiff of a public option not just by Senate Republicans but by centrist Democrats, in a year characterized by government economic activism unprecedented since the 1930s? I’d say this is the coldest water yet on an idea cherished for decades by unreconstructed liberals, a surprisingly (or not?) large number of physicians, and many of medicine’s best and brightest. The public option – still hanging on in the House bill – will most likely follow the same route of the abortion debate. Many Democratic members of the House will eventually cave on something they believe in passionately, for a larger something they believe in even more passionately.
It is shame for them, and for their Senate colleagues who made the same calculus, that this “larger something” gets smaller with each screaming match in the media and in Congress, between people who have been using the health care reform stage to act out their bigger grievances, philosophical angst, and political frustrations. Say what you want about health care’s myriad problems, inefficiencies, and stupidities, but something as literally critical to all of our lives as our health care system – regardless of which way an eventual bill goes (including the remote but real possibility of it just going away) – deserves better than a face full of all that other mud.
Maybe by the time The Plan is actually enacted, in 2013 or 2014, the market will have straightened itself up in such dreaded anticipation of the effects of “reform,” that by the time reform actually gets here, no one will notice – except the 31 million newly insured and those happy to sell them insurance.
J.D. Kleinke is a medical economist, author, and health information industry pioneer. He has been instrumental in the creation of four health care information organizations; served on several public and privately-held health care information company boards; and written about health care business policy for The Wall Street Journal. His work has also appeared in JAMA, Barron’s, the British Medical Journal, Modern Healthcare, and numerous other publications. His books include Bleeding Edge: The Business of Health Care in the New Century (1998), Oxymorons: The Myth of a U.S. Health Care System (2001), and Catching Babies, a novel about the training of OB/GYNs, which will be published next year.