The Politics of Holding on to Health Care Reformby George Vradenburg
The Contrarian article in the September/October 2009 issue argued that "the perfect should not be the enemy of the good" in adopting health care reform and that "one can only hope that Congress will have the will to embrace a process of continuing improvements in the years ahead."
And that is where Congress has come out. A dramatic and positive step toward a fairer and more just society has emerged. Yet, the substance and politics of reforming health care in America is only just beginning.
The substantive goals of health care reform were threefold: extend access, improve quality, and reduce costs.
The Patient Protection and Affordable Care Act clearly satisfies the first goal, since it extends health care insurance/access to most uninsured Americans. Indeed, for roughly 40 percent of Americans, health care will now actually be provided through government-managed Medicare, Medicaid, or Veterans Administration programs. For the remainder of American citizens, health care insurance is now mandated by law either through individual policies available through newly formed health care exchanges or employer-provided policies. For those earning less than 400 percent of federal poverty guidelines (roughly $88,000), the costs of that insurance will be subsidized by the government. The costs of those subsidies are, in the view of the neutral Congressional Budget Office, "paid for" by reducing Medicare costs and by increasing taxes on the wealthy. That assumes, importantly, that Congress sticks to its commitments regarding taxes and expenses (as to that, more below).
The law makes an attempt at achieving the second goal by, among other things, mandating that the costs of health care prevention be 100 percent covered by insurance, by changing reimbursement practices to reward health outcomes rather than more-fees-for-more-services, and by the very act of extending access to health care insurance. Having said that, ongoing congressional oversight that tracks health outcomes and adjusts incentives or other interventions is essential to assure that improved health outcomes actually occur.
And the law is weakest in attacking health care costs. While a number of pilots and demonstrations are authorized for tort reform (to reduce malpractice insurance costs), for coordinated care (to reduce unnecessary tests, hospitalizations, and institutional care) and for "effectiveness" research (to minimize costs on treatments not "comparatively" effective), there is no clear path to overall health care cost reduction. This is so even if one believes that the costs of extending access is "paid for" by Medicare cost reductions and by increases in taxes on the wealthy.
So, true comprehensive health care reform is just beginning.
The first test of Congress' willingness to execute on the promises it made in this bill will come this year (before the November midyear elections), when Congress is faced with the question of whether to adhere to a planned reduction of 20+ percent in Medicare physician reimbursements. If Congress blinks, the entire "pay for" for this bill may vanish.
And in coming years, Congress will have to be urged to revisit a number of the cost-containment provisions of this bill: the dramatic increase in taxes for those making over $250,000; the partial elimination of the tax benefits for employer-sponsored health plans; and the rationing of treatments not considered "comparatively effective." The recent political reaction to the determination that mammograms for women under fifty were not "comparatively effective" gives little confidence that Congress will adhere to its commitments.
Because of likely congressional backsliding on cost containment and the inexorable growth in health care costs, there is serious risk that the escalating deficits generated by Medicare and Medicaid will create overwhelming political pressure to pull back on comprehensive health care reform.
The Left has been left whimpering that health care reform did not go far enough, that we should adopt "Medicare for All." But the claim that this bill is middle-of-the-road or too pragmatic has not found any significant public sentiment and fails in the face of the financial pressure on government. Those pressures are being created not only by Medicare and Medicaid themselves, but also by the TARP stabilization of the financial system; investments in the auto, energy, and education sectors; the weak performance of the economy; two wars; and a dramatic increase in government debt (increasingly held by foreign nations).
The political threat to the sustainability of this health care reform will thus come from the right. To sustain the momentum for health care reform, Obama cannot and should not move to the left but must rather stay in the center. He must demonstrate a continuing firm commitment to fiscal discipline and economic growth. Movement to the left will threaten the historic steps toward health care reform that have been achieved after so much effort.
George Vradenburg is the publisher of Tikkun, and he often disagrees with our editorial opinions.
Vradenburg, George. 2010. The politics of holding on to health care reform. Tikkun 25(3): 6