Health reform gone too far?

November 16, 2009

I was having a debate the other day about whether the health reform bill going through Congress was a good or bad thing and whether it went too far or not far enough. This dialog is occurring with my friends and colleagues who are strong European model supporters – let’s put all docs on capitation/salary – and my friends who are fearful that the public option will be the end of private insurance as we know it. The perspective from these discussions is interesting because on one hand, those on the “fear” side of the equation are saying that they believe the legislation will be too dramatic and those on the “disappointed” side feel that the proposed legislation isn’t dramatic enough. In fact, I think it’s probably about where it needs to be. While there are certainly quite a few specifics that I would change, overall I think what is being proposed is good and meaningful and will make substantive change.

For my friends and colleagues who think the legislation doesn’t go far enough, I would simply say that the political process is unlikely to produce a bill that does what anyone who has spent years in the trenches believes needs to actually get done to substantially reduce health care spending or even the rate of increase in health care spending. But, I don’t think that is so important – this time around. What is more important is to have a structure and foundation for making policy decisions around health reform. Both the Senate and the House bills include such structures and simply having most Americans covered by some kind of insurance allows for that policy intervention to occur.

For those who think that because the House included a public option, the health insurance market is doomed, take heart. What has really been proposed in these bills is unlikely to make a major impact in the market, one way of the other. As proposed in the House bill, this public entity is not like Medicare and Medicaid, which have the leverage to all but require participation. Rather, this entity will have to negotiate contracts with providers of care as a new entrant in the market place, with a fairly limited primary market that won’t give it huge leverage in provider negotiations. And, it will take some time for the public entity to get up and running, so the private market will have an opportunity to adjust to new insurance regulations and the like before that happens. So, while many on the more liberal end of the debate feel strongly there must be a public option in the final bill, the reality is that this piece of the legislation is probably going to have a modest effect, if any. All the attention being paid to the public option really misses the far more significant changes that the legislation will really produce on rating and underwriting practices.

So, to all my friends who are passionate about health care reform, it’s time to be happy. After years of pessimism that any substantive change is possible, it looks like we have a chance that this time around, something really will happen. And, while it will have lots of warts rather than being that perfectly formed jewel, it will move us forward greatly from where we are now. And, if that isn’t enough to make you happy, just think – health reform will undoubtedly produce full and long term employment for those of us who are true health care junkies…