On Health, Settling for Change We Can Agree On



By Rashi Fein

Published February 03, 2010, issue of February 12, 2010.
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We have reason to be angry.

After a year of effort, no comprehensive health reform legislation has reached the president’s desk. Nor have we created a grassroots movement for change. Tragically, we have failed to educate the public about the issues and the approaches embodied in the House and Senate bills or about reasonable alternatives.

Neither legislation nor education. Yet almost everyone, wherever they fall on the political spectrum, is convinced that our health care system is in trouble.

They are right. It is in trouble: 15% of our neighbors are not protected against the financial ravages of ill health; health expenditures, premiums and out-of-pocket costs continue to increase more rapidly than the economy and than our incomes; Medicare — unless we act decisively — faces insolvency within this decade; Medicaid budgets are straining the fiscal health of already impoverished states and localities; and private insurers have the power to affect clinical decisions by standing between patients and their physicians.

Nevertheless, the consensus that things need to change, and by more than a nip here and a tuck there, has not resulted in an agreement on solutions. So we are angry. But anger does not solve problems.

The real question is not how we apportion blame for the situation in which we find ourselves, but what we can do to move forward. What should we do in the face of constraints imposed upon us by the rules of the legislative process? What can we do given the reality that “coming together” is especially difficult in an election year, that we are running a surplus in the budget line labeled “lack of trust,” and that attention and energy must and will be riveted on jobs, jobs, jobs?

Some have suggested that the House should swallow hard, pass the Senate bill — which, though flawed, surely is better than nothing — and send it to the president for his signature. Others have suggested a reconciliation process in which health reform initiatives with budget implications are sent to the Senate floor where, as budget matters, they can be enacted with 51 votes, rather than the 60 required to stop a filibuster. It is doubtful that either approach would garner the necessary votes.

While it may be true that, if enacted, Americans would grow to love the Senate health reform initiative, they are not likely to be even mildly infatuated by the first Tuesday in November. The very complexity of the legislation inhibits understanding and convinces many Americans that this is “change you can’t believe in.” As a consequence, many legislators believe their political prospects would diminish if they were seen as “shoving something down America’s throats” or engaging in political “gimmickry.”

Still, we dare not do nothing. President Obama has stated that if we fail to act, it will be a generation before we try again. That very statement makes for a self-fulfilling prophecy. Having invested so much effort in his first year in office, it is difficult to imagine that he or others would soon support another attempt at comprehensive change. If we do nothing now, we are likely to do nothing for some years to come. And make no mistake: There is no status quo. The human and fiscal problems will grow worse.

I have long believed in and fought for a comprehensive “Medicare-for-all” approach rather than incremental legislation — after all, one doesn’t leap over a chasm in two jumps. So it is not easy for me to advocate enacting legislation that is less than comprehensive. But I have come to believe that this is what we need to do, as well as to begin the difficult but vital task of educating the public so that we can improve and build upon that legislation in the years ahead.

It’s worth remembering Ted Kennedy’s insistence that he would not hold hostage those people who can be helped today to the more elaborate and comprehensive proposals that, for the time being, are beyond our reach. There is no glory in having the uninsured remain uninsured and at risk so that we health-policy advocates (who most often have insurance) can bask in the warm feeling of having stayed true to our principles.

I believe there are useful initiatives that should and perhaps would be supported by a substantial number of Democrats and Republicans. Some deal with the egregious behavior of insurance companies, others would put in place measures that would begin to lower the rate of growth of health expenditures even as they enhance quality, and still others would expand (though in the short run only modestly) the number of people covered by Medicaid.

We should be clear: This would be a far cry from the comprehensive reform we need. Given current political realities, such a legislative compromise would be unlikely to improve prescription drug benefits, provide a ceiling on individual and family out-of-pocket expenditures, deal with annual and lifetime limits on benefits, or provide significant assistance to small businesses for the provision of employee health insurance. Most important, it would not produce the subsidies that would enable tens of millions of Americans to purchase health insurance. Absent agreement on new sources of revenue, we would not be able to tackle the major issues of health disparities and inequities. But things would be a little better.

I hope the president will convene Democratic and Republican leaders to identify areas where there is sufficient agreement to forge a mediated compromise and that he will make it difficult for anyone to refuse to participate in such an effort. Compromise does not mean surrender. Let presidential wrath fall upon those who want so much that they will not settle for less and upon those who prefer to act as if they were elected to obstruct.

No, that which we might achieve would not be universal health coverage. It would not be what many of us have dreamed about and fought for. But, properly designed, it could benefit many, many Americans in the short run and it would be a start toward something that could be improved upon over time. And if we educate and organize, that time will come.

Rashi Fein is an emeritus professor of the economics of medicine at Harvard Medical School and the author, most recently, of “Learning Lessons: Medicine, Economics, and Public Policy” (Transaction). He served on the staff of President Harry Truman’s Commission on the Health Needs of the Nation and on the senior staff of President John F. Kennedy’s Council of Economic Advisors.

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