Monday, October 26, 2009

The Endgame of Act I of Health Care Reform

Remember back to the President’s big health care speech? He declared in it that he would be the last President to deal with health care. That was an exaggeration, and only really has a chance of being true if he wins a second term (which of course we should devoutly hope). But it’s worth, for that reason, not merely thinking about what’s right and wrong about this bill, but also what would be the best way to set up a second-term bill.

Paul Krugman, in his op-ed today, touched upon this when noting the costs and benefits of the Massachusetts health care plan. Pro? Only 2.6% of Bay Staters are uninsured. A focus group found: “Health reform enabled many of these individuals to take care of their medical needs, to start seeing a doctor, and in some cases to regain their health and control over their lives.” Con? Well, it hasn’t exactly touched the cost control part of the issue, which Krugman delicately understates and continues that Massachusetts is enthusiastic for more health care reform, addressing costs this year by that old standby, a special commission.

But there’s some reason to believe that Krugman was understating matters. The National Journal came out with a review of Massachusetts’ health care plan in July, with this damning graf:
The price of the four insurance plans offered under Commonwealth Care rose 9.4 percent in 2009, according to the report done for the Physicians for a National Health Program. The study's authors said that the law has done nothing to stem the overuse of high-tech care and the "underdevelopment" of primary care. "Indeed, one little-known provision of the reform actually shifted resources away from primary care by lowering Medicaid payment rates for such services, while raising them for high-tech, tertiary-care services," they said.

[emphasis mine, because this is an issue that Gawande focuses on in his McAllen, Texas New Yorker article].

Now, the various Democratic politicians emphasize in the article that putting the good stuff, the stuff people like, the stuff to cover people, is what ought to be done first, before getting to the cost control part (i.e. Act II of Health Care Reform), and this may be true.

The problem was that it is incredibly difficult to engage people’s attentions for any sustained period of time in this day and age. People’s impatience, furthermore, might doom any bill before we’re ready to get to the tough choices part of the deal (i.e. the part where people lose money, and blameless people lose jobs for the good of everyone, etc.).

As it turns out, Sen. Harry Reid’s compromise just might have saved the day. As Ezra Klein points out, the bill is an extraordinarily conservative, tentative reform: the opt-out public option will only available to people who can use the exchanges, which is the uninsured and the small-business-employed (I believe. Unless the details have changed.). The point is, if these things are good—and there’s no reason to believe they’re not (well, there is, but chances are if you’ve read this far, you agree)—then the public will clamor for them. And there will be no good excuse—why is a health insurance exchange where I can shop for different options only available to a limited subset? Why can’t everyone use it? (I have been exposed to too much Dylan Ratigan, maybe.) Well, there’s no good answer to that question. Which is why those programs will eventually be extended.

The key is to make it sooner rather than later. Every year that it’s delayed, health care cost inflation will eat another person’s raise, a raise that could have been put to better use. However, Reid’s bill contains an excellent method of sustaining attention: the opt-out’s deadline, state-by-state is 2014. We know, from interviews with Senators Schumer, Durbin and Brown that progressive public pressure was critical to their being any sort of public option in the bill at all. Well, from now until 2014 (that’s three election cycles that the public option, and therefore health care generally, will be a central issue!), that intense public pressure may be able to bubble and froth over until we’re ready for Act II: The Final Countdown.

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