Monday, January 25, 2010

Will Congress throw the uninsured under the bus?

The Wall Street Journal reports that the Democrats may put aside the party's goal of providing health insurance coverage to (almost all) legal residents. Instead, they might push for more scaled-back reforms including, "modest coverage for the uninsured, perhaps aid for small businesses, new rules for insurance companies and some policy changes to control federal health spending." To be clear, as the WSJ points out, no decisions have been made, and likely won't be, until after President Obama's state of the union address Wednesday.

I understand the political reasons why some members of Congress may want to put aside the goal of achieving near-universal coverage. Most voters have health insurance, and polls show that voters with health insurance increasingly are concerned that the health reform bills will increase their costs and reduce the quality of care they receive. So the political calculation appears to be: why pass something that is disfavored by a good proportion of the 85% of your constituents that have health insurance, so as to provide coverage to the 15% who don't, many of whom don't vote? Especially since most of the almost trillion dollar cost of the proposed bills is to fund programs to expand coverage.

We've seen this before. In 1995, when President Bill Clinton's efforts to reform health care collapsed, 40.6 million people in the United States, or 15.4% of the population, were without health insurance coverage during the entire year, according to the Census Bureau. In 2008, the exact same proportion of the population -15.4% - went without health insurance, but because of population growth, the total number of uninsured persons reached 46.3 million. The uninsured rate would be much higher, if it were not for enactment and reauthorization of the State Children's Health Insurance Program, which in 2008 provided coverage to 7.4 million low-income kids. The best one can say is 15 years after Clinton's health reform initiative collapsed, we have made absolutely no progress in reducing the percentage of the population without health insurance.

One big difference now is that both the House of Representatives and the Senate have passed bills that would cover between 94-96% of legal U.S. residents - the farthest this has ever advanced in the legislative process. Yet Congress and maybe President Obama may be on verge of deciding that the politics make it too hard to get the bills over the finish line.

I understand that the bills are controversial, and that people are troubled by the deal-making that went into getting the necessary votes. I appreciate that people are concerned that the U.S. can't afford to take this on now, even though the CBO says that the legislation will reduce the federal budget deficit. I "get it" that many people don't trust the government to deliver on the promise of better care at lower cost. I know that changes will need to be made in the bills to increase public support, such as elimination of some of the special deals made in the Senate. What I don't get is the apparent willingness of politicians to again throw the uninsured under the bus.

I don't know if providing everyone access to health coverage is a right, but I do believe that it is the right thing to do. I continue to have some hope that President Obama and Congress will find a way to ensure that "the U.S. health care delivery system provides access, best quality care and health insurance coverage for 100%" of Americans, as called for by ACP's vision of a desired future for U.S. health care. Tomorrow's state of the union address should at least tell us where the President stands.

Today's question: Do you think Congress and the President should throw in the towel in providing affordable health insurance coverage to all?


james gaulte said...

What members of Congress are willing to do is whatever it takes to increase their likelihood of reelection.Staying in office is job one and fear of losing it will motivate them more than some version of what is thought to "be right"

Rich Neubauer MD said...

I have a number of thoughts:

1) Despite what detractors say, Canadians are generally proud of their health care system. Why? Because everyone is covered and they are proud of that fact and what it means for their brethren.
2) I firmly believe that unless we take the step of covering everyone or nearly everyone, special interests representing their subgroups will thwart any further reforms that might include cost controls and making rational decisions about how to use scarce resources.
3) Not covering the uninsured is a form of rationing, and it is the cruelest and most shameful form of rationing imaginable. It is a major source of disparity and a blot on our nation. At some point, the downtrodden rise up. At the very least, this form of rationing has consequences for all of us.
4) In a real sense, health care reform is important for our economy to flourish. As in point #2, I am very doubtful that we can start to reign in health care costs without first having universal or near universal coverage.
5) Despite the fact that politicians like to keep their jobs by attracting votes, they have an obligation to govern. Furthermore, the democratic party will not shine if all the work of the last year dies with a sorry gasp when the going got tough. If all that emerges from this is a few tidbits of minor insurance reform, I think a resurgence of conservative rule is likely as a backlash.
If logic prevails, the best alternative I’ve heard so far would be for the house to pass the Senate bill. At this point, despite the imperfections of that bill, at least we would have a chance of moving ahead as a nation with our heads held high instead of our tail between our legs.