File photo by Rose Lincoln/Harvard News Office


Economy shaping health care reform effort

5 min read

Paying for plan is a major issue

Political and philosophical differences aside, it’s the economic crisis that’s driving the current national health care reform debate.

“Every day the president gets an envelope [that] says, ‘Whoa! Bigger [deficit] this day than yesterday,’” noted Robert J. Blendon, professor of health policy and management, speaking at the Harvard School of Public Health on Tuesday.

Couple the worst economy since the 1930s, with the reality that President Obama “does not have the statutory power to enact health care reform,” and the reform effort is headed for major reformation, contends Blendon.

The structural and economic realities simply cannot be ignored, he said, pointing out that the structure of the U.S. government requires House, Senate, and the president to negotiate major issues as though they were “coalition partners.” But in the case of health care reform, they aren’t doing that, he added.

Blendon, who is also a professor of political analysis at Harvard’s John F. Kennedy School of Government, said that what is being debated now is not a real restructuring of the American health care system, but a “[proposed] law that says ‘everybody who works at Dunkin’ Donuts has to have insurance.’

“It turns out millions of people work full time, but they get no [health] benefits. Cost and the [state] of the economy are the problems,” Blendon said. People across the country can be heard crying, ‘I can’t afford to pay. Do whatever you want—just don’t ask me to pay.’”

The tax issue presents a perfect example of why it’s not really up to the president to decide what health care reform will look like. In fact, Blendon said, “the discussions about Obama’s health plan are actually, politically fictitious” because Congress controls the power to tax and “in a deep recession you have people saying ‘I can’t pay more taxes. I can’t even pay for my kids to go to college,’” Blendon said.

“So this is no small issue at any level,” he continued. “A lot of people are saying, ‘Of course I want reform. I want coverage, but somebody else has to pay for this,’” he said. “… And every time that happens, Obama turns to [his director of the National Economic Council] Larry Summers and says, ‘Take it out of Medicare.’ Summers gets it out of Medicare, and then Mom and Dad start firing off e-mails [to the White House] about it” and the fight starts all over again.

It may be that everyone has agreed that providing universal health care coverage is the socially right thing to do, but then comes the reality of the proposed law, said Blendon. And a number of realities trump principle, he added.

Blendon explained that when most people think of health care reform, a national health insurance plan of some sort, they envision everyone having something like a national insurance card, “mostly paid for by tax payers ahead of time. But the U.S. model is not going to work that way,” Blendon said. “People are going to be asked to pay thousands of dollars for a subsidized policy unless their income is very low. And a lot of young people who are healthy,” and don’t think they need insurance, and the “‘I hate the government’ types are not going to buy it.”

Despite the endless discussion on talk radio and in the blogosphere, none of the major players in the current health care debate is pushing for an all-government, “socialized medicine” form of health care, Blendon told his audience. In reality, all the proposals are solidly anchored “in the existing system, which is an employer-based insurance for people who work, a public insurance plan, like Medicare, for the retiree, and some kind of insurance for the unemployed or those working only part time.” There is a new government portion to Obama’s plan, which proposes to mandate employer coverage, creating a public insurance option that will compete with private insurance companies, a government body to regulate cost, and a guarantee of insurance for all Americans, Blendon said.

Here, defining the role of government becomes significant. “The public wants much more involvement with the government in decisions about insurance companies through hospitals, and doctors … in quality and in cost. They want to share it. But when you push them, [people] all say the same thing: ‘I don’t want the government running the system,’” Blendon said. “The issue in the American debate right now is: ‘I want Obama to do more, but I don’t want him to end up running it.’”

In fact, Blendon said, special interest groups—such as the insurance and pharmaceutical industries, and the American Medical Association—are playing to people’s fears of a government take-over of the health care system, and are themselves in a position to shape the plan that ultimately emerges.

The reason the special interests are so powerful is obvious, Blendon said: “If I have to run every two years (for a seat in the House) there are two things in the United States political system that I need, and that’s voters and money to run,” and the special interests provide some of the former and a lot of the latter.

However rough — and complex — the debate is, Blendon is convinced that a very significant, yet not as broad piece of legislation, will get produced by the first of the year. “It possibly won’t solve as many problems as people expected when they started the debate. But we’ll have a reform that will be a compromise bill.”

This bill, when enacted in its final form, will probably be a compromise. In Blendon’s opinion, it will move the discussion forward with a lot of improvements, but rather than say “health care solved” it will raise a lot of issues that will continue to be very important for both experts at Harvard and people across the country.