May 13 2008
Despite the prominent role that health care reform is playing in the 2008 presidential election, leading Republican and Democratic pollsters agree that deep partisan divides among voters -- combined with a worsening economy -- may permit only incremental, rather than sweeping, changes to the health care system. The perspectives of political pollsters William McInturff and Celinda Lake are featured in a far-reaching thematic issue on health reform in the May/June 2008 issue of the journal Health Affairs.
The journal will be highlighted at a May 13 briefing that will include presentations from health advisers for the three presidential candidates. The issue and briefing are supported by a grant from the Robert Wood Johnson Foundation.
Republican pollster McInturff and colleague Lori Weigel analyze data from multiple national public opinion surveys to show how lingering perceptual barriers that doomed previous major reform efforts may do the same this round. Those barriers include an unwillingness on the part of the American public to accept certain trade-offs in return for universal coverage, as well the desire to fix other problems in the health care system before overhauling it entirely, they write.
Nevertheless, the pollsters identify two factors that could differentiate this effort from the last major health reform push during the Clinton administration. First, small-business owners hit by rising premiums are calling for major reform. Second, people see health care reform as an essential and affordable priority for government spending in the wake of ballooning costs of the military efforts overseas. "Health care will continue to be on the agenda no matter who wins in November. How much the next president addresses and overcomes the persisting barriers from the last health care debate will likely determine the fate of reform these fifteen years hence," McInturff and Weigel conclude.
Democratic pollsters Celinda Lake, Robert Crittenden, and David Mermin present key opportunities and drawbacks for health care reform. Although the 2008 election could "set the stage for the most significant reform of the U.S. health care system since Medicare," Lake and colleagues warn that the political system is slow to act and that a well-funded opposition will work hard to prevent major change. "The next president will have to campaign actively and vocally on health care reform and move quickly in his or her first year in office to be successful," they write. What is unique this year, they add, is that "the core ideas and rhetoric embedded in the leading health care proposals are more in tune with the experience and values of voters than they have been in previous reform battles."
Separately, a series of papers in the issue examines the failure of the Clinton reforms in the 1990s and looks at lessons learned for the future. In separate pieces, authors Joseph Antos; Christine Ferguson, Elizabeth Fowler, and Len Nichols; and Jacob Hacker look at the politics and policy of the Clinton plan's demise.
Sens. Ron Wyden (D-Ore.) and Bob Bennett (R-Utah) also write in the journal that their Healthy Americans Act reflects what they see as important bipartisan movement to seek consensus on an approach to reform. They join a host of other health care experts from various sectors of the health care industry who offer various positions on the role of taxes, the federal budget, and other building blocks that could improve access, temper costs, and improve quality.
Other highlights in this issue:
Taxes And Budgets. Achieving almost any new major federal budget priority will be nearly impossible if health costs continue to soar, write Eugene Steuerle and Randall Bovbjerg of the Urban Institute. If current trends persist, sometime between 2016 and 2020 existing federal revenues will cover only health entitlements, Social Security, debt service, and a smaller defense budget, leaving nothing for anything else, including the environment, education, or new health initiatives. The researchers warn that budget-driven reforms in health policy must aim to end automatic year-to-year budget growth and push Congress to formally recognize when it chooses health cost increases over other priorities. Steuerle and Bovbjerg warn policymakers against getting derailed by the search for one grand reform; instead, they suggest a host of reforms that would empower government, providers, insurers, and citizens alike to choose a better and more efficient health care delivery system, and one with much better coverage to boot.
Jason Furman, a senior fellow at the Brookings Institution, analyzes a range of proposals to change health care through tax reforms. He suggests that the best option would be replacing the current tax preference for employer-sponsored insurance with an income-related, refundable tax credit. Although this approach by itself would involve considerable risks, Furman says that it has the potential to increase coverage and reduce inefficient health spending at no net federal cost. "Current tax expenditures for health care provide a pool of $200 billion that could be used to finance expanded or even universal coverage, with additional resources potentially left over for debt reduction or tax cuts," he writes.
Formulas For Compromise. A compromise model of health care reform that draws on past reform experiences may expand coverage and focus spending on high-value care, explains Katherine Baicker, a professor of health economics at the Harvard School of Public Health. Financial strains on both public and private budgets -- such as Medicare's current financial woes, the possibility of tax reform, and pressure on private stakeholders -- might foster such a compromise. "Reforms should aim not just to expand insurance coverage today but also to put in place a system that would allocate health resources more efficiently so that we would be able to afford the coverage tomorrow," Baicker writes.
Karen Davis, Cathy Schoen, and Sara Collins of The Commonwealth Fund offer a method to provide universal coverage with minimal net increases in national health spending. Their "Building Blocks" approach includes a Medicare-like option for people under age 65, along with a choice of private plans offered to small businesses, the self-employed, and everyone without large-employer insurance or Medicare. Other features include an individual mandate, required employer contributions, Medicaid/State Children's Health Insurance Program (SCHIP) expansion, and tax credits to assure affordability.
In the event that the new president should put forward a universal coverage proposal, the CEO of Blue Shield of California, Bruce G. Bodaken, writes that the president's ability to attract support from the insurance industry will be successful if he or she keeps the following criteria in mind: respect the industry's economics, understand the competitive dynamic, think through the transition, rely on the expertise of the insurance industry, demand shared responsibility, and stop portraying health plans as the adversary.
Improving Quality And Accountability. In addition to expanding coverage, other authors say that a new system must address quality and cost. Margaret O'Kane, president of the National Committee for Quality Assurance; Janet Corrigan, president and CEO of the National Quality Forum; and a distinguished panel of colleagues identify five fundamental steps for the public and private sectors to take to move toward a high-performance health system. The authors' recommendations includes creating a national center to support effectiveness research; promoting coordinated care; rewarding high-value care; creating a national system for measuring performance; and developing a strategy for improving population health.
The Role Of States. Henry Aaron of the Brookings Institution and Stuart Butler of the Heritage Foundation advocate the importance of giving states more leeway to enact their own reform solutions to lay the foundation for national action. The role of the federal government would be to define adequate coverage for residents, ensure that state plans are sufficient to meet the objective, and design the process for approval of such plans.
Alan Weil, executive director of the National Academy for State Health Policy, argues that state-based health reform should occur in the context of a national strategy. He says that congressional proposals to encourage state action cover too narrow a span of state health policy, do not provide states with sufficient authority to tackle major health policy challenges, and supply insufficient funding.
Health Affairs, published by Project HOPE, is the leading journal of health policy. The peer-reviewed journal appears bimonthly in print with additional online-only papers published weekly as Health Affairs Web Exclusives at www.healthaffairs.org.
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