The ACP Advocate Blog
by Bob Doherty
Monday, October 5, 2009
The interconnectedness of health reform
One of the problems with reforming the health care system is it's so darn complicated. Critics have made a point of the House bill being over 1000 pages in length, and polls show that the public continues to be confused about key details.
It would be nice if there was a simple way of fixing the health care system that would take only a few pages of legislation and could readily be explained to the public. The reality, though, is that health care itself is so complicated that there are no simple fixes or easy explanations, and any effort to fix one part of the system will create multiple connections to other issues.
Remember the children's rhyme - "the toe bone connected to the foot bone, and the foot bone connected to the ankle bone, and the ankle bone connected to the leg bone ..." - well, the health care system is something like that. A policy that deals with one particular aspect will almost always be linked to another.
Take the popular idea of prohibiting insurance companies from excluding people with pre-existing conditions. It is hard to see such a requirement working though, without a requirement that people buy coverage (otherwise known as an insurance mandate). Otherwise, some people would just decide to go without insurance coverage until they get sick, knowing that insurance companies could no longer turn them down. This would screw up the whole concept of pooling risk. If you are in favor of requiring insurance companies to accept people with pre-existing conditions, you pretty much have to support a requirement that people buy coverage, because one won't work without the other. Yet many of those who support a ban on pre-existing condition exclusion are opposed to an individual mandate.
Similarly, take the idea of requiring large employers to provide coverage to their employees. Many of conservative critics who object to an employer mandate oppose expansion of government-funded health care. But when a company that can afford to provide coverage, but chooses not to, their employees will likely end up getting coverage from ... you guessed it ... Medicare, the SCHIP program, or private coverage subsidized by taxpayers. So the best way to limit the number of people covered under taxpayer-funded public or private plans, if that is your goal, is to link it to a requirement that large employers provide coverage to their employees.
Or, take the idea of expanding Medicaid to the poor. The Washington Post reports today that the governors of many states are concerned that the federal government will not provide them with enough money to pay for enrolling up to 11 million people in Medicaid. Also, the article notes that any expansion of Medicaid may not ensure access to care if the payment rates are so low that physicians refuse to treat Medicaid enrollees. The House bill has a provision to raise Medicaid rates for primary care until they equal the applicable Medicare rates but the Senate Finance bill lacks such a provision. Unless Congress provides states with the money needed to increase payments to physicians at the same time as it demands expanded coverage, the likely result will be that many of the newly covered won't be able to find a physician.
It is because of these many linkages that ACP has taken the view that incremental reforms that deal with only one part of the puzzle won't be effective. If we are going to subsidize coverage for the poor through Medicaid, then we will need to increase Medicaid payments to physicians. If we are going to prohibit insurers from excluding people with pre-existing conditions, then we will need to require people to buy coverage. If taxpayers are going to subsidize coverage for those who can't otherwise afford it, then we need to require that large employers - if they can afford it - provide coverage to their employees, or pay back taxpayers for shifting the cost onto the rest of us. And if we are going to provide everyone with access to an affordable health insurance plan, then we also need policies to ensure that there are enough physicians, particularly primary care doctors, to take care of them.
Today's questions: Do you agree that a ban on pre-existing condition exclusions needs to be linked to an individual mandate to buy coverage? That subsidies to help people afford coverage need to be linked to a requirement that large employers provide coverage? That expansion of Medicaid and other health insurance programs needs to be linked to increased payments to primary care physicians?
About the Author
Bob Doherty is Senior Vice President, American College of Physicians Government Affairs and Public Policy; Author of the ACP Advocate Blog
Email Bob Doherty: TheACPAdvocateblog@acponline.org.Follow @BobDohertyACP
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