Saturday, January 20, 2007

With Health Care and Coverage For All

I no more have to take some time away, and suddenly news of insuring the uninsured is popping up all over. The governors of California and Pennsylvania have both released basic information about new plans. Both involve pulling together some state and federal resources with resources from employers and from the private insurance industry to expand coverage until all citizens are covered.

In addition, a new plan has been announced by an organization called Health Coverage Coalition for the Uninsured (not to be confused with the Coalition for Affordable Health Coverage, although there is some overlap in membership). This coalition includes a variety of constituencies, most notable of which is AARP, with it’s significant political clout (retired folks vote!), as well as America’s Health Insurance Plans (AHIP), the American Medical Association and the American Hospital Association (read the full list here).

I have written before of the Massachusetts experiment, and of a framework offered by AHIP, for covering more and more people. I have noted that the General Convention is on record as supporting universal access to health care. While it’s too soon to tell how well and what parts of these various plans will be enacted, we can support efforts to make sure more folks are covered.

At the same time, all of these plans are efforts to make more effective tools that are already in place. They still depend on government support only for those who can’t get insurance through employers (children, the unemployable, and those employed by the smallest businesses) or those who have retired from employment; and insurance through employers for most of us. They depend on the market to provide basic (read: minimal) insurance that may therefore be “affordable.”

What they don’t seem to do is to rethink completely how we provide and pay for health care. They don’t consider whether health care should be a civil right. They don’t address the limitations of the market, much less “the market” in health care (and, trust me: it doesn’t work as simply or as straightforwardly in health care as those college macroeconomics courses would suggest). They don’t reorient our delivery system toward prevention rather than pathology. They don’t address parity of reimbursement between mental health and physical health expenses. I have noted the Oregon Health Plan, and the proposal from Senator Wyden of Oregon for a national plan; but these stand out as significant exceptions. In general, these plans are about tweaking what we have rather than trying something new.

Back in 1992 or so, when we were discussing health care for the uninsured before, I was at a meeting of chaplains to listen to a health care economist. He spoke about the Clinton discussions on health care, and about all the difficulties it faced. Mostly, it faced difficulties because so many participants had such different interests. (In the ensuing fifteen years many of them have apparently seen that they had more in common than they then believed.) It also faced some difficulty because it was unclear how to connect universal coverage (anyone who needs health care gets it, and gets it paid for) with universal participation (everyone except perhaps the very poorest makes some financial contribution to the costs of health care), while managing rising costs. I asked a question: “Accepting that providers may only be reimbursed 70% of what they believe are their actual costs, what would be the effect on the health care economy of universal coverage? That is, what would be the effect of receiving only 70%, but knowing you’d receive it for every patient?” The economist answered, “No one knows. The numbers are just too great.” (Over the next couple of years, by the way, I had the opportunity to ask that question of several other economists. They all had basically the same answer.)

All these efforts to improve what we have without rethinking the basic framework suggests to me that the numbers are still too great. The variables of really rethinking the system are too frightening for many. At the same time, there are issues that simply won’t be addressed by tweaking the system we have. This is one more case on a grand scale of working to redress after the problem rather than working to prevent the problem in the first place. I have written before of one such suggestion as a “big Band-Aid.” There is certainly value in offering ever-bigger Band-Aids. At the same time, bigger Band-Aids will not really provide a solution.


Susan Palwick said...

Welcome back! I hope your recovery's going smoothly!

Marshall said...

Thanks! Things are coming along. I have flex to 90 degrees and extension to 175 or so- for those who know, that's big! I've discontinued opiates and am managing now with ibuprofen. So far, so good.