Another Decade of Waste and Suffering

One of my colleagues in health system reform advocacy, Dr. Jonathan Ross, wrote an article before the election in 2008 which was published before the passage of the Affordable Care Act (http://ajph.aphapublications.org/doi/full/10.2105/AJPH.2008.148510). The whole article deserves a read, but here are some excerpts:

Theodore Roosevelt in 1912, political efforts to control health care costs and provide health care for all have resurfaced every 10 to 20 years in the United States, yet we have failed to achieve the universal national health care program so often recommended. . .Supposedly, competition in the face of market forces drives down costs, maintains quality, and makes insurance more affordable. However, market forces have not significantly moderated health care costs and lack of insurance. Health insurance premium increases at double the inflation rate have remained the rule for most businesses that provide health insurance. Out-of-pocket costs to working people have jumped substantially because of decreased coverage and increased copayments. Fewer patients than ever have free choice of doctor or hospital. . .If market forces were an experimental drug in a trial to cure the dual problems of health care costs and lack of universal insurance coverage, the experiment would be terminated early as a dismal failure.

During a century of intermittent attempts to enact a national health program, federal health care reform legislation has mostly been incremental. This is not surprising. A significant majority of both houses (60 votes in the Senate) and enthusiastic presidential support are needed to pass sweeping social reform, and this kind of consensus is rare. The chance that broad support will materialize in at least 1 state is significantly higher.

History suggests that reforms are more likely to be adopted by the federal government if they first succeed at the state level. Examples include women's suffrage, child labor laws, unemployment insurance, social security, civil rights and antidiscrimination laws, environmental laws, and family and medical leave. All passed in states before federal action was taken. Successful state-based health care reform programs can be models for the nation.

Federal support for state-based universal coverage and cost control efforts should have bipartisan appeal. Presumably, conservatives would like to see more privatization and market reforms in their home states, and progressives would like to see expanded public programs and public accountability in theirs.

In addition to more resources, enabling legislation will be needed to grant flexibility in areas such as the Employee Retirement Income Security Act, tax policy (e.g., the extent that health insurance premiums are deductible), and some federal program regulations that inhibit states from attempting more comprehensive reform because of conflicts between state and federal authority.

What should be the balance of political power between insurers, suppliers, providers, and patients? Who should shape health care policy and determine health care spending? Not everyone is a conservative or a progressive, an insurance bureaucrat or a health care provider, but everyone will likely be a patient someday.

If the lessons of history hold true, the enactment of universal health insurance at the national level will most likely follow enactment of a successful model at the state level. Federal support for state efforts could move the process forward and should be a priority. Untimely or inadequate efforts at the federal level could result in failure and another decade of waste, deterioration, and suffering.

For evidence that the Affordable Care Act is causing the nation to waste time at the very moment when action to reform the health system is needed, consider this article (http://trib.com/news/state-and-regional/article_0ddacf05-3986-50df-b45c-...) recently published in the Wyoming Star-Tribune. Excerpts:

Wyoming’s two major health care projects are either on hold or have been discontinued. . .The Healthy Frontiers health coverage program folded earlier this year after the state Legislature refused to authorize spending $1 million already in the budget to keep the pilot project going.
The project was hampered by a slow start and a participant rate far short of the 500-client target. . .More recently, the health care insurance exchange steering committee on March 28 voted to suspend its work until the U.S. Supreme Court decides whether all or part of the federal Affordable Care Act, also known as Obamacare, is constitutional.

Hoy noted that opponents of the ACA say the government shouldn’t be involved in health care. But the government is already involved in health care.
The state pays $560 million from the general fund every two-year biennium for the Medicaid program for low-income people, Hoy pointed out. The state dollars are matched by the federal government.
“It’s not like these are problems we can ignore,” Hoy said.

State Sen. Don Dockstader, R-Afton, a co-chairmain of the steering committee, said he made the motion to put activities on hold and not proceed with federal money.
“It makes no sense until we know where we stand,” he said. In addition to the Supreme Court case, the November election for president could change the nation’s and the state’s direction in health care reform.

My comment:

What Dr. Ross predicted in 2008 has come true. The passage of the Affordable Care Act, which was a step backward away from comprehensive, sustainable health system reform, has placed the entire national debate about health system reform in limbo, as witnessed by the reporting from Wyoming. What Congress should have done in 2010 instead of the Affordable Care Act, and what it can do now, is pass the States' Right to Innovate in Health Care Act (find a draft of this legislation on the Utah Healthcare Initiative website by clicking on the 'Solutions' tab). In the US, major social changes usually begin at the state level, as Dr. Ross has indicated. Yet Congress has passed a number of measures over the years which effectively keep states from comprehensively addressing health system problems. 2012 is an election year. Now is the time to induce candidates for federal office to promise to sponsor legislation that will make comprehensive and sustainable state-based health system reform possible.

Dr. Joe Jarvis