Duke Research Advantage

By Kevin Schulman, M.D.

The policy goals for health care reform are so clear it should be easy: 1) improve access to health care services — defined as access to insurance; 2) improve the quality of health care services — through health IT; and 3) reduce the cost of health care — through competition or structural changes in the system, such as reform of the small group market. From a policy standpoint, we can debate the intricacies of these various issues and use data or theory to support our arguments.

What is happening now in Washington is not health policy, but health politics. Politicians are searching for policies that would gain the most political support (or looking to offer promises to specific members to make the rest of the program more palatable to them). Negotiations are not with the public over the broad agenda, but with specific political interest groups that constitute the Washington lobby core. This is the legislative process of the US at its most transparent. The populist rhetoric has been lost in the tricky business of legislation, lobbying, and politics.

All of us have had our own ideas of where health care reform would take the country, and our opinions about the best way to proceed. We’ll see how this all turns out over the summer, but the one thing is certain — none of us can predict what might be the final proposal from Congress, assuming that there is a final legislative proposal coming forward (note there was not a proposal in 1994 despite a great effort by the Clinton administration to push health care reform).

Late last week, the Congressional Budget Office highlighted the obvious, that the program as currently outlined does not do enough to constrain the cost of health care in the US. Obviously, this is a very attractive proposition to the health care community (even the AMA has endorsed some of this legislation), but one would think that the beneficiaries of our massive health care system are the last community we’d want to be happy with this reform effort, if we really are going to change direction within the system.

You might notice a new story from Massachusetts calling for a reform in provider payments within that state. Massachusetts passed a health reform plan a few years ago which in many ways is a model for the current Federal legislation. To keep the program politically viable, they increased access without implementing major cost control mechanisms. The result was an acceleration of health care spending in the state. Now a special commission has recommended major changes to the payment systems for providers and incentives for providers to join networks as cost control mechanisms.

There appears to be a major concern within some segments of the Democratic Party over the cost of the current program and lack of attention to fiscal responsibility in the plan. President Obama’s campaign stated that people were uninsured because the cost of health care was too great. We’ll see if he returns to that rhetoric as the political process continues to move forward on health care reform.