American health care reform has been historically difficult to achieve, both for structural and political reasons. Many of you have heard of, or are advocates of, HR 676, the The United States National Health Insurance Act, a single-payer national health program. Maybe you heard about a Senate universal health care proposal, The Healthy Americans Act, cosponsored by 12 Senators. Perhaps you've been wondering what its chances are for passage. Perhaps you've been mulling over the health plans from Clinton, McCain and Obama (and Edwards), trying to do some comparison shopping. Or, perhaps you just want to know what to expect with a new President in the White House. This review of health reform data will hopefully help put the difficulties of enacting reform in perspective.
For starters, let's look at the political side via this tutorial from Kaiseredu.org. It's important to note that while health care remains an important issue that matters in the upcoming election (along with Iraq and the economy), Republicans, Independents and Democrats do not agree on the issues or the relative importance of health care as an election issue. Those with insurance are satisfied with their own health care coverage (83% to 93% depending on the question), but fear paying more for care (41%) or losing coverage altogether (29%). That >80% satisfaction is a key finding, because people satisfied with what they have a) don't want to give it up and b) are less likely to push for change. And when asked to rank health care along with other important issues facing Americans, Democrats tend to rate health care as more important than either independents or Republicans, so the push for health reform is not unanimous by any means.
Another important difference is that Republicans are more worried about cost-containment and Democrats more interested in expanding coverage. This leads to the following caveat; while much of the public agrees with the goal of increased coverage, there is no agreement about the best solution to get there. In fact, when all solutions are considered, single payer is way down on the list of "best solution", coming in at an anemic 37% (see slide). Needless to say, that doesn't make bills like HR 676 any easier to pass. By the way, the uninsured are substantially less likely to vote (in 2002, 30% of the uninsured under 65 voted compared to 49% of the insured under 65).
See also the ambivalence about government vs private insurance in providing medical coverage (government better - 21, private better - 60 if you are a Republican, government better than private 41 to 36 for Democrats. A fifth of the country thinks they are the same or does not know).
By the way, another reason to suggest a lack of political pressure is to look at the habits of voters. As seen in the slide, half the voters vote on issues, the other half vote on character, values, experience, leadership etc. Given that split, it's tough to make a case that the public is driving change, or that 2008 will be the year health care reform is going to decide the election all by itself.
Well, that's public opinion and public opinion can change. So what do the academics say about the likelihood of health reform and changes in health care financing (i.e. the structural side)? Eh, maybe chances are not so high, at least right away. Echoing the theme of non-agreement of what to do, an article in Health Affairs by Victor Fuchs (the Henry J.Kaiser Jr. Professor Emeritus at Stanford University and a research associate at the National Bureau of Economic Research) writes
Enduring reform must cover the uninsured, reduce inefficiency in funding and delivery of care, improve quality, and tame but not destroy the development of new medical technologies. Obstacles to reform include "special interests," especially as they exploit the U.S. political system; Machiavelli’s Law of Reform, which favors the status quo; and the inability of reformers to agree on a common approach. Short-term prospects for enduring comprehensive reform are virtually nil. Over five to ten years, prospects are fifty-fifty unless there were a major economic, political, social, or public health crisis. In the long run, major reform is inevitable.
So what is Machiavelli's Law of Reform? From The Prince:
He who desires or attempts to reform the government of a state... must at least retain the semblance of the old forms, so that it may seem to the people that there has been no change in the institutions, even though they are in fact entirely different from the old ones.
Still, a major asset to reform hopes is the possibility of same-party control in DC. That has to improve chances of reform but as noted, also in Health Affairs, by William L Roper (dean of the University of North Carolina at Chapel Hill (UNC) School of Medicine and chief executive officer of the UNC Health Care System):
The 2008 election will focus renewed attention on fundamental health care reform. Lessons from past politically driven reform efforts show that although fundamental reforms may make for good politics, a systemic shift in how health care is financed and delivered is unlikely to occur. Calls for fundamental reform over the past twenty-five years have prompted incremental changes that have had a major impact on the U.S. health care system. Many of these changes were driven from outside the political system. The forecast based on past experience is not radical change; it is more of the same.
That resistance to change is something we've covered here. It's partly a function of the resiliency of the health care system, and partly a function of a lack of political pressure to make changes.
Nonetheless, change is in the air. Single party rule in DC is possible (more so for Democrats than Republicans, and Democrats rate health care a higher issue than Republicans do). Costs are driving business and consumers alike to consider health reform. The NY Times this month:
The American carmakers’ problems underscore the need for a government-backed system of universal health care, which would relieve some of the costs that have made competing so much harder.
Who knows? With a Democratic victory in November, and a leader in the White House, a recession in the economy and business pushing to reduce costs, we may just get the perfect storm of events that'll move the ball down the field.
Friday, Feb 29, 2008
A new poll on health care from NPR, the Kaiser Family Foundation and the Harvard School of Public Health finds that a majority of Americans are backing key elements in the health reform proposals of Democratic presidential candidates Hillary Clinton and Barack Obama.
But even if that happens, check the conclusion from the NEJM authors:
Looking forward, the ranking of health care as a top issue in the primaries and plans for serious health care reform proposed by both Democrats and Republicans are major steps toward a larger debate in the 2008 general election and beyond. However, the intensity of the debate, and whether it engages the nation the way the last great health care debate did in the early 1990s, remains to be seen. In addition, the prospects for actual health care reform are tempered by two factors: the wide differences in the two parties' views of what health care reform should look like and the current level of satisfaction that majorities of both parties have with their own health care situations.
Reform needs to happen. Just don't expect it to all happen at once (childrens' coverage has more consensus than adult), or at the expense of what people already have, or even to necessarily look radically different (see Machiavelli), whatever anyone promises.
This is a follow up on Daily Kos posts here (Medical Crisis: The Shape Of Things To Come), here (Perspective on Health Care Reform), here (What's The Effect Of Recession On The Health Care Safety Net?), and here (Health Stories: HR 5449). The posts use public opinion polling from Kaiser, here with a summary tutorial, narrative supplied by Claudia Deane (formerly of the Washington Post polling unit). Further elaboration appears here in more academic form published in the January 24 New England Journal of Medicine with co-authors from the Harvard School of Public Health and John F Kennedy School of Government). The latest poll from NPR/Kaiser/HSPH is dated 2/28/08, and available here.