Expanding the universe

There's a shared sense of urgency to enact comprehensive healthcare reform this year, but views vary on how to get there, according to the latest Commonwealth Fund/Modern Healthcare Opinion Leaders survey.

Don Kempner

Opinions differed on how to fund the massive overhaul of healthcare—and extend coverage to tens of millions of uninsured, with the majority coming out opposed to a wealth tax included in the House reform bill introduced earlier this month.

“This survey is a great example that people from every sector agree that what we are doing right now isn't working,” says Bruce Bagley, medical director for quality improvement at the American Academy of Family Physicians, who participated in the survey.

Overall, 68% of those surveyed say it is urgent to enact comprehensive healthcare reform this year, while 21% say Washington should make a “down payment” on health reform this year and just 6% say reform should be postponed because of the poor economy.

Support is high, too, for a public health insurance option, with 69% of opinion leaders saying they support the creation of a public insurance plan to compete with private insurance. Another 20% say they support reform where there are only private plans, and 7% say only public plans should offer insurance in the new scheme.

The survey, called “Priorities for Expanding Healthcare Coverage,” was conducted from June 8 to July 8 by Harris Interactive. A total of 208 people participated. This was the 19th in a series of surveys designed to highlight the perspectives of leaders in health policy, delivery and finance.

Among the respondents, 50% are at academic and research institutions; 23% work in healthcare delivery, including hospitals and medical societies; 26% work in health insurance, pharmaceutical and related industries; and 9% are in government, labor or consumer advocacy.

Karen Davis, president of the Commonwealth Fund, says she found the participants to be extremely thoughtful on the subject.

“There's a lot of nuanced variation in the responses,” Davis says. “There's a lot of variation on which way to turn.”

Support for a public plan option was high even among the 55 respondents who work in the insurance or other healthcare industries, with 45% supporting both public and private insurance choices. Another 40% say only private health plans should be able to compete for consumers. “That's a pretty ringing endorsement,” Davis says.

Support was strong for payment reform. Some 65% of respondents say new payment methods should be deployed in the public plan option that incorporate global fees for care over time or acute episodes of care rather than fee-for-service payments. Only 13% say payments should be based on Medicare's current methods and tweaks to the current system, and another 13% say payments should reflect those used by private plans.

William Sage, vice provost for health affairs at the University of Texas at Austin Law School, a survey participant, is worried about costs.

“I'm nervous about proposals that expand coverage without making changes to healthcare costs,” says Sage, who is also a physician. “I would like to see a much more honest appraisal of healthcare costs.”

Davis says the House bill is addressing costs because it permits the HHS secretary to test new payment methods, and includes an amendment that would allow a public plan to also use innovative payment methods. “I think people are not yet quite aware of the details of the bill,” she says.

Although support of a public plan option in the survey was high, that could deteriorate depending on the details.

Donald Kemper, chairman and CEO of Healthwise, a not-for-profit healthcare content provider in Boise, Idaho, says he has reservations about the idea.

“I'm worried about doing a public plan because of the cost,” Kemper says. “If you just tried to create a plan like Medicare and extend it to a new population, you would bust the system. I'm not in favor of doing a public plan without serious payment restructuring.”

As far as a “trigger” option—where a public plan would be created only when private plans fail to meet certain expenditure targets—that idea got support from just 38% of total respondents.

How to finance the system? Here, survey participants seem to be out of sync with some congressional proposals. Some 79% say they support or strongly support so-called “sin” or “sugar” taxes in the form of higher excise taxes on alcohol, cigarettes and sugar-sweetened drinks—a component of health reform that appears to have fallen out of favor in Congress.

But 77% say they support or strongly support an employer mandate, requiring employers to either offer coverage to workers or pay a percentage of their payroll to finance extended coverage. An employer mandate also has significant congressional support.

Other revenue generators got less support in the survey. Some 58% say that they support or strongly support capping the amount of employer-financed premiums exempt from federal income taxes for workers. Thirty-eight percent say they support a luxury sales tax, and 30% are in favor of an income tax surcharge.

And 46% say they approve of a so-called “wealth tax”—higher taxes for household incomes above $250,000. A wealth tax is included in the House healthcare reform bill.

Sage says he disagrees with a wealth tax for healthcare reform. “I do think our tax system isn't as progressive as it should be,” Sage says. “I don't think a small segment of our society can bear the costs of a very large and uncontrollable aspect of healthcare.”

Those surveyed seem to want strong oversight of a national insurance exchange—where private and perhaps a public plan would compete for customers.

A quarter of the respondents say the exchange should just be a clearinghouse, with state insurance commissioners holding authority over rate-setting and other issues.

Participants interviewed say there should be clear rules about benefit packages. “One of the inherent costs of the system is the complexity of the benefits packages,” Bagley says.

Meanwhile, there's not enough talk about the patient's role in all this, such as encouraging the use of online health tools for patients and other ways to pull people toward wellness, prevention and disease management, say respondents interviewed for this story. Kemper says a patient-centered medical home is a crucial goal. And health insurance choices should remain—even those that are politically unpopular today, he says.

Regardless of the details, the respondents' message is clear, as Sage sums up: “The longer we wait to change things, the worse it gets.”

What do you think?
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