Several people have asked me in the past few days for my perspective on what's happening to health reform in Washington.
For what it's worth, here goes
Congress is in recess until Labor Day, and they are back home having lots of meetings with their constituents. President Obama is also hosting events almost daily to discuss health reform with the American people.
We have a governmental system that is chaotic and messy at times and this is surely one of them. Remember the quote about making laws is like making sausage ¦
Several points I'd make
1. Although President Obama won handily (53 percent to McCain's 47 percent), there are a lot of Americans who did not vote for him. So it should be no surprise that many of them are showing up at events and town hall meetings and voicing their opposition to whatever the Democrats and the Obama Administration are working toward. The fact that politics has intruded is shocking to some people, I know, but that's the American way.
2. We still badly need to reform the American health care system and as hard as this public policy and political process is, we need to press ahead as a nation.
3. As we deal with the all too familiar problems of the cost of health care, the lack of access due to uninsurance, and the quality and safety of health care in America, a lot is up for grabs. A few weeks ago it seemed like the Congressional leadership were just going to steamroll the process and enact thoroughgoing reform of the entire system. Now the sheer magnitude of all this is scaring a lot of people, especially at a time of such great economic uncertainty.
4. Proposed reform that does not take seriously the need to constrain cost growth should not itself be taken seriously. And as much as I support prevention (and I do, I put Prevention in the name of the CDC), it likely will not reduce health care expenditures though it will make us all healthier. And as much as I support Health Information Technology (and I do, very much), it is likely to add to costs for the foreseeable future, not save.
5. We need to have a serious discussion as a nation about end of life care and we are beginning that conversation now. We waste (yes, that's the right word) a huge amount of resources there. But we as a nation don't want the government making these decisions like taking your mother off the respirator. My sister and brothers and I had some tough decisions to make as our mother and father were gravely ill, and we made them. But not the government.
6. But critics of the President are crassly scaring the American public with this issue and we need to counter their fears with an honest conversation about the limits of medical care, and help patients and families with those tough decisions.
7. There are some things the government does right and the Medicare program is one of them. We should be proud of it. And I am proud to say that for several years in the 1980s I was responsible for administering it. But it is not a model for the rest of the health care system it is outmoded and frozen in time, tied to a payment system of fee for service that does not make sense for doctors or patients.
8. That is one of the risks of the public plan option that is being debated right now can a government plan innovate and be creative over time?
9. Also, Medicare pays rates to doctors and hospitals that are below the actual costs of delivering that care. A new public plan, if linked to Medicare, would have tremendous clout in the market place institutions like ours would almost certainly have to take whatever rates they offered, even if greatly below our costs, which would surely worsen the crazy quilt of cross subsidization that we now have in health care finance in our country.
10. One of the ironies right now is that many in Congress are insisting on the public plan option because of their faith in the government's ability to run the program, yet many of the same Members are urging that a new independent body MedPAC enhanced be set up to make decisions and oversee the entire system, because they don't trust the regular governmental agencies (like HHS and CMS) and processes (like the Congress) to manage things well.
11. So ¦ where are we? I think the Senate Finance Committee proposal, which is yet to be completed, will be the plan that ultimately holds sway. Yes, there will be some who say it is too conservative, and others will say that it is too liberal (whatever those words mean in this complicated area). But I believe it is likely to pass this fall, surely amended many times. The political stakes are just too high for the President and the Congress they cannot allow failure.
12. So I'd suggest you keep your eye on Senator Baucus and his colleagues on the Senate Finance Committee, and try not to get too distracted by the sound and fury around the whole process.
13. Will such legislation be good for the country? I very much believe so. But this is woefully complicated and it needs to be done right. So taking a little more time is not a bad thing.
14. And what will such legislation mean for UNC Health Care? It's way too soon to answer that question with any finality, but given our huge problems with the uninsured, we would have to be better off, at least in the short and medium term, if those now uninsured are covered. The longer run is harder to predict because the risk is as costs rise, and they inevitably will, will our payments be cut so much that we end up worse off? Time will tell.
15. And in the meantime, we have recently launched an effort to redesign how we deliver care, so that we can be one of the places that people point to as an institution that delivers top quality care in an efficient manner, with lower overall costs. I very much believe that is do-able, but it won't be easy. It will stretch us as an institution, requiring our doctors and hospitals and others to work together in creative ways that we haven't even begun to try yet. But we must I want us to be a part of the solution, not a part of the problem.
More to come ¦ stay tuned.