Marcia Angell: Opposing "Health Insurance Reform", Supporting Reforming Health Care
Marcia Angell, former Editor-in-Chief of the New England Journal of Medicine, doesn't like where health insurance reform is going. She claims the current reforms being discussed by the White House and Democrats in Congress(clearly, Republicans are too busy creating Obama's Waterloo moment to worry about the rapidly rising cost of health care, much less the plight of the uninsured and underinsured) amount to "throwing good money after the bad". Angell makes a strong argument for reforms by targetting what doesn't work, and building on what does. She lays out the argument opposing current proposals for health insurance reform from the left of the left of the left.
Via Huffington Post:
It's not just the right-wing crazies who oppose health reform. In addition, there are many sane Americans who worry about committing a trillion dollars to it. They have a point. We already spend more than twice as much per person on health care as other advanced countries, and our costs are rising faster. How much is enough?
Make no mistake, sky-high and rapidly rising costs are the core problem. If money were no object, it would be easy to provide full care for everyone. But even a perfectly designed system will fail if it is unaffordable, or rapidly becomes so.
So why is our system so unfathomably expensive? Angell follows the money:
...we have the only health system in the world based on avoiding sick people. Insurers cream 15 to 25 percent off the top of the premium dollar for profits and overhead (mainly underwriting) before paying providers.
Providers themselves have high billing and collecting expenses to deal with the Byzantine requirements of multiple insurers. The innumerable health facilities, both for-profit and nonprofit, also have high overhead expenses to cover their business costs, executive salaries, and the promotion of their profitable services...
...Most doctors are paid on a piecework basis -- that is, fee-for-service -- which gives them a similar incentive to provide too many services for the well-insured. That is particularly true of specialists who receive very high fees for expensive tests and procedures (like cardiac angiography and MRI's).
Can the reforms being debated in Congress fix our health finance and delivery system? Angell says they can't:
In sum, the answer to the question, "Where is all that money going?" is that much of it is diverted to profits and overhead, and to exorbitantly priced and medically unnecessary tests and procedures. Any reform that has a prayer of containing costs, hence being sustainable, must deal with these two massive drains.
Yet, most reform proposals would leave the present profit-driven and inflationary system essentially unchanged, and simply pour more money into it.
What about Massachusetts? We have near universal health insurance here. Doesn't that support the initiatives in Congress? Angell says no:
That's what is happening in Massachusetts, where we have nearly universal health insurance, but costs are growing so rapidly that its long-term prospects are bleak unless we drastically cut benefits and greatly increase deductibles and co-payments, or change the system. We're learning that health insurance is not the same thing as health care; it may be too limited in what it covers or too expensive to actually use.
Can't we lower costs with good preventaive care? Angell says no:
To control costs, the President is pinning a lot on electronic records, disease management, preventive care, and comparative effectiveness studies. But while these initiatives may improve care, they're unlikely to save much money because they don't deal with the underlying problem -- a system based on maximizing income, not maximizing health. Promises by for-profit insurers and providers to mend their ways voluntarily are simply not credible. Regulation of the present system is also unlikely to modify profit-seeking behavior very much, without a bureaucracy so large that it would create more problems than it solves.
But aren't the reforms being debated in Congress akin to other countries that have private insurance? Angell says no:
Nearly every other advanced country has a largely nonprofit national health system that guarantees universal care. Even countries with private insurers, like Switzerland and the Netherlands, require uniform prices and benefits and limit profits. Not only are expenditures much lower in other advanced countries, but health outcomes are generally better. Moreover, contrary to popular belief, they offer on average more basic services, not fewer -- more doctor visits and longer hospital stays, and they have more doctors and nurses and hospital beds. But they don't do nearly as many tests and procedures, because there is little financial incentive to do so.
Does Angell just oppose health insurance reform, then? Is her answer to do nothing? Nope:
I believe our best bet now would be to extend Medicare gradually to the rest of the population. We could begin by lowering the eligibility age from 65 to 55, then after a few years, drop it to 45, and so on. Medicare is the most popular part of our health system; unlike private insurers, it offers free choice of doctors, it covers all eligible beneficiaries for a uniform package of benefits, regardless of medical history or how much care is needed, and it cannot be taken away by job loss or illness.
Angel doesn't stop there. We still have to deal with the profit maximizing incentives on the provider side that are inflating health care costs and lowering quality:
If Medicare were extended to everyone, it should be in a nonprofit delivery system. In addition, fees would have to be adjusted to reward primary care doctors more and specialists less, or better yet, doctors should be salaried.
Is there even any discussion in Congress for implementing these changes to our health care system? Angell says there is:
There is now a bill in Congress that calls for exactly that -- H.R. 676 ("Expanded and Improved Medicare for All"), which was introduced by Rep. John Conyers of Michigan and has many co-sponsors. Unfortunately, given the power of the health industry lobbies, it's unlikely to make it out of committee without strong public pressure.
But isn't there something to be said for not making the perfect the enemy of the good? Angell doesn't think so:
One thing is certain: We need a complete overhaul of our health system. Tinkering at the edges won't do it. Expanding coverage through government subsidies and mandates, as advocated by the president, won't either. Besides being a windfall for insurers and drug companies, that approach will just add to our soaring costs and be a temporary fix, at best. In my opinion, it makes no sense to throw good money after bad.
Marcia Angell is no Rush Limbaugh. She isn't trying to derail health insurance reform to humiliate the Democrats. She's assessed the policy and finds it isn't the right approach. She's offering a way forward, and it's a policy I am very comfortable supporting and advocating for. Health insurance reform is not an an either/or. Nothing is written in stone yet. We do not have to settle for throwing good money after the bad. As democrats, we can advocate for a good policy, and if we do, whatever comes out of Congress will be better than what they are now debating.