Monday, March 15, 2010

March Madness

While most normal red-blooded Americans are focusing on the NCAA basketball tournament, Washington is paying attention to another "sudden death" tournament going on in the nation's capital.

As early as Thursday, the House of Representatives will cast its votes on whether to approve the December 24 bill passed by the Senate and a side-car "corrections" package, using the "majority rules" reconciliation process.

If the vote fails to get a majority in the House, health reform is dead. Or at least the type of reform that would make a dent in reducing the numbers of uninsured. While Congress might extend some existing health programs that are set to expire, and probably do something to stop the next round of Medicare pay cuts, that's about it. I see no chance that they would "start over" and pass reforms to cover more people or ban insurance companies from turning down people with pre-existing conditions.

Like basketball fans rooting for or against a particular team, I know that some readers of this blog fervently hope that the legislation will fail, while others feel just as strongly that it should pass. (Later this week, I will have more to say about how ACP is approaching the final votes.) Yesterday, Health Affairs published a fascinating new study that helps explain why we Americans are so divided on health reform

The researchers looked at polling from 1999 to today that shows that a person's views on health reform are related to two factors: (1) their partisan and ideological leanings and (2) how much they think the uninsured already get decent care. The first factor - that someone's political views are a major influence on how they view health reform - isn't particularly surprising. One would expect Republicans to be more opposed to using government to expand coverage, and Democrats more in support.

More interesting is that people differ in their perceptions of the care available to the uninsured. Overall, the authors' write, "In 2009 a majority of survey respondents (56 percent) still perceived that the uninsured are able to get necessary medical care." Support for health reform "was significantly more popular among people who perceived that the uninsured are unable to get care (72 percent) or able to get care with great difficulty (75 percent) than it was among those who perceived that it is not too difficult (38 percent) or not at all difficult (31 percent) for the uninsured to get care ... These associations persisted even after political party and demographic characteristics."

And who were the people most, and least, likely to believe the uninsured get needed care? "Democrats are far more likely than Republicans to believe that the uninsured have difficulty gaining access to care. Senior citizens are less aware than others of the problems faced by the uninsured. Even among those Americans who perceive that the uninsured have poor access to care, Republicans are significantly less likely than Democrats to support reform."

The fact that large swaths of the American electorate believe that the uninsured are getting the care they need flies in the face of evidence - such as the study that I blogged about on Friday - that people without coverage are more likely to die prematurely than those who have insurance.

Because of this continued divide, the author's state that "even if President Barack Obama signs health reform into law, its future political support could be uncertain. A shift from Democratic to Republican control of either congressional body could mean the reduction or elimination of funding for insurance subsidies. Subsidies are essential to a coverage expansion that these critical constituencies ultimately deem unnecessary." Republicans already are making it clear that they will seek repeal if the bill passes Congress and is signed into law, even though that is not likely to happen as long as President Obama is in the White House.

In this sense, this week's elimination round vote, as crucial as it is, will not settle the long-standing divide in the electorate on the role of government in subsidizing care for the uninsured, or even on the basis question of whether the uninsured already get the care they need.

Today's question: Why do you think most Americans believe that the uninsured can get the care that they need, when studies show otherwise? And why does a person's view on this question tend to track with their partisan leanings?


Rich Neubauer MD said...

It is my fervent hope that we as a country will take a step forward in the coming days and decide affirmatively on the current bill that, while flawed, does start us on a pathway for reform.

It is my belief that extending coverage to (nearly) all is a key part of the legislation and indeed the glue that holds its loose patchwork together as being more than just a collection of random bits of change.

Having seen in one form or another in my years of practice, the tragedy that is wrought by being uninsured or underinsured, it is hard for me to understand turning a blind eye to that part of our "system".

I think that some of the public inattention to this is the result of fear. Fear that the coverage they have will be diminished when the "doors are open" to those who have been denied.

I can only say that if reform happens, the changes made, and those that will need to follow, will be carefully managed, and will erase the fears, make Americans proud of their health care systems, and move us to a better future.

PCP said...

I was a health care wise democrat ideas leaning Doctor until I worked in a CHC and saw what I saw.
Gov't run/heavily influenced health care is inefficient, unaccountable, limited in scope and access, inconvenient, poorly funded, poorly delivered and leaves the Physician, not in charge, but heavily interfered with by administrator. You become an employee and start to think and act like one.
That is something I have found out by experience. This is why I now feel, middle America will be sorely disappointed with what they get should this bill become law.

Jay Larson MD said...

Americans believe that the uninsured can get the health care that they need because most Americans don't have chronic illness (yet). Until a person has to have access to our health care system for a major medical condition, they don't have much in site to the problem.

If a person does not have direct knowledge of the system, they have to rely on other people's experiences or belief systems.

Those of us on the front lines of chronic illness management know how problematic our system is. We know how expensive medications, hospitalizations, and diagnostics can be.

We also know that the front line physicians are diminishing. No matter what a person believes or hopes for health care reform, the future is not pretty for chronic disease management.

Steve Lucas said...

The role of government goes back to the founding of our country and the debate between Rousseau and Locke. Currently this debate does have a Republican versus Democrat tone.

No matter what the outcome of the vote my hope is this issue will be resolved, and we will continue to improve how medicine is delivered in this country. Certainly no one can defend the policies of our health insurance industry. Preexisting conditions, slow payments to providers, limits to care, are but the tip of the iceberg of issues regarding this industry.

We also have to look deeper at hospitals and the drug/device juggernaut. With many doctors offices affiliated, or owned by hospitals, we find that there is a drive to support the system by maximizing insurance income to the system. These test, and the resulting prescriptions, are supported as necessary by the drug/device industry whose own financial interest out weigh any patient concerns.

Doctors see a never ending parade of patients in need on a daily basis. We as a society have forced them into practicing insurance, not medicine. While it is easy to view the issue from that perspective, thought must be given to the societal changes this bill will bring and the resulting cost.

Steve Lucas

Harrison said...

In your question you ask basically why is it that Americans listen to the opinions they like and side with like minded people.
Well, that's part of the problem with our current political environment.
Our representatives don't have to worry about the middle, they often only have to worry about winning a primary election, safe in the knowledge that their party will carry them through a general election.
The insurgency of the tea party movement speaks to some of this. Politicians with extreme views and no interest in compromise are gaining on politicians who are moderate and able to find common ground.
On the left it is absurd that Dennis Kucinich is not a supporter of the health care reform bill. But in the fall he will tell his supporters that he was a staunch defender of a single payer system, and he didn't compromise. And by so doing he jeopardizes a move forward on this issue.
On the right, there is Senator DeMint, and Representative Cantor. The extreme views on the right cause moderates to back away from compromise.

But politicians need money to run campaigns. They are in debt to donors who have views and who expect results. Increasingly those donors have extreme views and don't want to see their views compromised.
They donate to politicians who carry those views and those zealous positions.

And we don't get a dialogue.
We instead get loud statements, espousing a point of view.
And we get vows to vote in a certain way, stated in such a way that it would be political suicide to compromise.

And unfortunately, none of them really want to serve and run the risk of being voted out of office.
They want to advance their political careers and acquire more power.

And the media feeds all of this.
There is an MSNBC camp, and a Fox News camp.
Real news is hard to come by.
Opinions abound.
News as opinion and entertaining argument has become big business -- and we all support it by tuning in.

On the bright side, our country has seen much worse.
And not only survived but thrived.
We will again.
That is what we do.