Commentary--reform opinions.
Article Type: Interview
Subject: Health care reform (Political aspects)
Author: O'Rourke, Thomas
Pub Date: 06/22/2009
Publication: Name: American Journal of Health Studies Publisher: American Journal of Health Studies Audience: Professional Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2009 American Journal of Health Studies ISSN: 1090-0500
Issue: Date: Summer, 2009 Source Volume: 24 Source Issue: 3
Topic: Event Code: 290 Public affairs
Accession Number: 308743748
Full Text: Despite President Obama's pledge to oversee a major reform of the U.S. health-care system relatively soon, the effort appears to be stalled in Congress. Tom O'Rourke, a UI professor emeritus of community health, has studied health-care reform and systems outside the United States, and published on both topics. He shared his views on efforts to pass landmark health-care legislation in this country in an interview with News Bureau health sciences editor Melissa Mitchell.

With what appears to be zero-progress on reaching a consensus on health-care reform any time soon, what would happen if the U.S. Senate and House of Representatives ultimately fail to reach an agreement? In effect, if they do nothing?

Predicting the future is often difficult, but for health care it is pretty easy. Basically, we can expect more of the same that we have been having the past several decades. Premiums will rise several times faster than wages. Businesses will continue to reduce employee coverage and/or shift more costs to employees. Others will just stop providing coverage. Millions more will lose health insurance if they lose or change jobs. The ranks of the uninsured and underinsured will continue to swell. Those insured will have even more limited choices of both plans and providers.

Rising costs and employer inability to sustain cost increases will result in millions moving from full- to part-time work, thus reducing average income even further. Health care will be more expensive for those fortunate to have coverage, as providers shift cost to care for the uninsured, setting up a vicious cycle where even more people can't afford insurance. Others won't even be able to get insurance due to a pre-existing condition. Millions of Americans will continue to live one medical emergency away from bankruptcy. Using identical definitions in both years, the proportion of bankruptcies attributable to medical problems rose by 49.6% between 2001 and 2007. Illness and medical bills were linked to 62% of all personal bankruptcies in 2007. Most were middle class, had attended college, owned a home and were insured.

Health-care providers such as physicians and nurses will spend even more time dealing with insurers and health plans. An estimated 700 billion dollars or about one-third of total health care spending of 2 trillion-plus dollars will be spent on tests and treatments that cannot be shown to improve health. The relative health status of the U.S. population, already one of the poorest of industrial countries, will continue to deteriorate and fail to keep pace with gains in health outcomes achieved in other countries. Finally, the ability to curtail unnecessary and/or ineffective treatments will be diminished, thus adding to costs and impeding improved quality of care.

President Obama is now advocating a system that would allow people who already have health-care benefits to keep those plans, while those currently uninsured could opt into a so-called "public plan." Do you think that's a sound proposal?

That depends on what the final version of the public option looks like. The devil, as always, is in the details. And as it is proposed now, the public option is doomed to fail for a number of reasons. Most notably, hospitals and doctors would still need elaborate billing and cost-tracking systems. Overhead costs, even for an efficiently operated public option, would be far greater than that for traditional Medicare since, unlike Medicare, the public option would have to incur significant costs to compete in the marketplace. That's what makes Medicare relatively efficient--it doesn't have to compete. It automatically enrolls seniors at 65, deducts premiums through social security and incurs no costs for marketing or determining the costs for different risk pools. Unlike with private insurers, there is only one risk pool. This is in stark contrast, for instance, to the city of Chicago with its 17,000 different health plans, or more than 700 different insurance policies among 2,000 patients with depression in Seattle.

Is there competition among health insurers? Yes, but it is the wrong kind. Health insurers compete by not paying for care. Private insurers exert great skill and energy not to manage and pay for risk--the intended purpose of health insurance--but to target the risk and then avoid it. They seek to enroll the healthy and avoid the sick by not offering coverage, dropping coverage or pricing it out of reach, denying payment, and shifting cost to consumers, while lobbying against meaningful reform. By doing so, they defeat the intended purpose of what health insurance should be--spreading the risk and managing it over an entire group regardless of age or health status.

To compete successfully, a public-option plan would be forced to emulate private insurers. By doing so, it would be a race to the basement. If it didn't, it would soon be left with those shunned by the private insurers--the patients that are the sickest and costliest. That would quickly result in raising premiums to uncompetitive levels. In short order, the public option would inevitably fail without massive public subsidies and significant increases in total spending. In the process, the private insurers would cite the failed public option as the poster child for failed government intervention. So, to implement a public option, as presently conceived, would be tantamount to falling into the 'Surrender-in-Advance Trap' by continuing to support failed market-based policies due to political opposition.

And what about the notion of mandated coverage ... is that really feasible?

Feasible yes, but it depends on the merit of what is mandated. How would you like to be required to purchase an SUV using leaded gas that's prone to rollover--or a faulty smoke detector for every house or a shiny lead-painted toy for every child. As it stands now, Congress would make it a federal offense to not purchase faulty insurance. On top of that, some proposals threaten to tax health benefits to help keep private insurers in business. No plan out there today can make coverage universal, comprehensive and affordable not only for the poor and uninsured but also for the middle class who already are covered.

What will work? In other words, how do we effectively achieve real reform?

President Obama has previously stated that if we were starting from scratch, a single payer, publicly financed and privately operated system would be preferable. At his July 22 news conference he stated, "I want to cover everybody. Now, the truth is that unless you have a what's called a single-payer system in which everybody is automatically covered, then you're probably not going to reach every single individual." Unfortunately, the President has backed off due to provider and health industry, not patient or consumer, opposition. A single payer system could realize about $400 billion in annual savings --enough to cover the uninsured and improve the coverage for most Americans.

Short of a single payer, a public option could work if it contained the following:

* a pre-population with millions of people, representing a large pool to avoid the cost of marketing and contracting with thousands of providers (similar to Medicare). A large pool also is necessary to be attractive to providers, especially if they are asked to accept discounted fees, as is done now with Medicare. The present public option does not include a large pre-populated pool. The smaller the pool, the less likely the public option could exert any significant influence to restrain costs.

* substantial subsidies to individuals the public option. Subsidizing the private insurers would just perpetuate the status quo. Further, the public option and the subsidies need to be available to all non-elderly Americans, not just segments such as the uninsured or small businesses. Currently, large employers are not included.

* low overhead rates of reimbursement similar to current Medicare rates--about 20 percent lower than what private insurers command. To use the same rates as the private insurers would gain nothing.

Also, the insurance industry could not offer a stripped-down, inadequate coverage plan to undercut the public option. The insurance industry has to be required to offer the same minimum level of benefits as the public option. It could offer a higher level if it chose.

Ultimately, the issue is straightforward and not as complex as the health providers and politicians would like you to believe. Should health care be viewed as a for-profit commodity or a human service? Go with the first and you get what we have. Go with the second and you have what virtually every industrial country has achieved.

If you could pick a country (or countries) to serve as a model for the U.S., which would you suggest? Why?

While I certainly wouldn't advocate for the total adoption of any other country's system, I think that the commonalities of systems of industrial countries such as Germany, France and Japan to the U.S. may be informative and capable of being adapted for the U.S. While each has its own unique system, all three are similar to the U.S. in that most coverage is through the workplace, using private insurers with services provided by private practitioners receiving a fee for service. However, unlike the U.S., their governments ensure universal access, a comprehensive benefit package to all citizens with a uniform payment to physicians and hospitals, and play a role in restraining growth of expenditures to providers.

Thomas O'Rourke, PhD, CHES is affiliated with University of Illinois at Urbana Champaign. Please address all correspondence to Thomas O'Rourke, 1206 S. Fourth St., Rm. 127, University of Illinois, Champaign, IL 61820, Phone: 217-840-7036, Fax: 217-333-2766, E-mail: torourke@illinois.edu
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