Most of the healthcare opinion leaders who responded to the Commonwealth Fund/Modern Healthcare survey agreed that Congress should target the uninsured as a top priority in the next five years, but some are doubtful that the issue will get much traction on Capitol Hill in the near term.
The 289 respondents to this edition of the Healthcare Opinion Leaders Survey represent key stakeholder groups in health policy, delivery and finance. A majority of respondents from each of the sectors agree that expanding coverage for uninsured should be the No. 1 healthcare priority for Congress, says Commonwealth Fund President Karen Davis. The issue was considered a top priority for 63% in academic/research institutions, 59% in the healthcare-delivery field, 57% in government/labor/consumer advocacy, and 47% of those in the business/insurance sector.
Respondents cited other issues that Congress should address, such as Medicare reform, expanding the State Childrens Health Insurance Program, the rising costs of healthcare, and the increasing use of information technology (See chart, next page).
Healthcare leaders may be in agreement that the uninsured is the issue to pursue this year, but its notable that there are no real proposals on Capitol Hill to address the uninsured, Davis says. The concrete plans for legislating this year are all about setting prices for prescription drugs and reauthorizing SCHIP, she adds.
John Rother, policy director for the AARP and one of the survey respondents, says theres not a lack of interest in Congress to fix the uninsured problem, but rather a lack of funds to pay for it. We have an administration thats going to resist any kind of new revenues to fix a quandary as big as the uninsured. So theres the standoff.
The issue may not be completely off the table, however. Sen. Ron Wyden (D-Ore.) at the end of the year announced a plan to introduce broad healthcare reform legislation this year under which all Americans would be required to buy health insurance, and the current system of employer-based coverage would cease to exist.
Additionally, a senior aide to Rep. John Dingell (D-Mich.), the House Energy and Commerce Committees new chairman, says the uninsured would be on the table for the panels work this year. I know there will be a gazillion flowers blooming among the members of the Democratic party who have had all this pent up desire for the uninsured, so we will be trying to determine which ones of those deserve hearings and meet with the budgetary targets well be able to move forward, the aide said at an Alliance for Health Reform briefing in December 2006.
If Congress does anything, Its likely to be an incremental rather than a sweeping change, says William Jessee, president and chief executive officer of the Medical Group Management Association, another survey respondent.
Several bills in Congress have proposed funding for innovative state programs, which is where progress may ultimately be made in reducing uninsured figures, Davis says. Massachusetts, for example, is one state that has figured out how to work across a broad political spectrum to provide universal coverage. The plan requires individuals to buy health insurance and encourages state and federal subsidies to provide coverage for low-income individuals. It also reallocates existing monies to finance coverage, she says.
The Commonwealth Fund is currently funding an evaluation of Maines Dirigo universal health plan, another public/private strategy to reduce the numbers of uninsured, Davis says. Dirigo is a voluntary plan, however, and doesnt require employers to buy coverage.
Letting the states run their own healthcare experiments may be a more viable approach than a sweeping healthcare bill to implement something like a single payer system, which would have so many vested interests and require a complete overhaul of the healthcare system, Jessee says. I think Massachusetts is going to be closely watched by policymakers.
Rother believes that expanding coverage to the uninsured will get more attention in the 2008 presidential election cycle, after lawmakers have had time over the next two years to build a platform for action through hearings, policy analyses and debates over proposals to address the problem. The last couple of election cycles have been dominated by terrorism and Iraq, and healthcare hasnt gotten enough attention.
The survey found differing views among the healthcare sectors on how this expansion of coverage should be achieved.
Academia and research institutions tended to favor a single payer insurance system run by the federal government (66%) and covering everyone under Medicare (63%), whereas the healthcare provider sector respondents leaned toward other alternatives, such as requiring individuals to buy coverage (62%) and providing subsidies and pooled mechanisms for the uninsured to purchase affordable insurance (57%).
Both of these groups thought that providing federal matching funds for coverage through the Medicaid/SCHIP to cover low-income adults and children would be an effective method for expanding coverage.
Its true that academia tends to lean toward expanding public programs, whereas those in the private sector are more comfortable with a mixed public-private strategymandating that working families buy private coverage and setting up pools to offer insurance plans, while expanding Medicaid and SCHIP for low-income families, Davis says.
Among the respondents in the government/labor/consumer advocacy sector, 62% cited employer contributions to funds to pay for coverage as an effective option, followed by the single payer idea and then universal Medicare coverage.
When presented with a list of approaches to control rising healthcare costs and improving quality of care, most respondents (75%) thought that reducing inappropriate care would be an effective approach, followed by the usage of evidence-based guidelines (70%) to determine whether a test or procedure should be done.
The support for evidence-based guidelines as a tool to control costs is one of the more surprising findings of the study, Davis says. In the past, theres been some resistance in the provider world to establishing any kind of guidelines. More surprisingly, within the healthcare-delivery segment of the respondents, 69% backed the use of such guidelines in determining whether to administer a clinical test or procedure.