The events of this year have only reinforced the harsh lessons of the past about the gargantuan task of reforming the U.S. healthcare system. As readers undoubtedly know, the evidence about the need for reform has never been stronger, as healthcare costs continue to rise faster than inflation and reports come out almost daily about the failures of the system to improve quality and safety of care. And yet, despite the fact that healthcare has dominated the domestic policy landscape in the presidential campaign and taken center stage in Congress, the goals of universal coverage and a remade care-delivery system seem to be getting no closer.
The most recent evidence of this is found in the debate over the State Childrens Health Insurance Program. You have to question what is going to happen with the larger picture of covering all of the uninsured when the two parties cant even agree on how best to cover children of lower-income families.
In fact, the SCHIP debate represents the first salvo of the 2009 reform war. Any plan that expands government health coverage one iota is going to be labeled socialist by the right, even as the same people profess support for Medicare, Medicaid and veterans healthcare, each a prime example of government-sponsored care and each having been expanded in recent years without the socialist tag. Likewise, some on the left have savaged Hillary Rodham Clintons healthcare plan for continuing a significant reliance on private health plans, even though it contains market reforms such as ending the exclusions for pre-existing conditions.
The SCHIP debacle shows that unless the Democrats win the White House and a supermajority of the Senate (and retain control of the House), the chances of expanding health insurance coverage seem dim indeed. Republicans are transfixed by the notion of market-based coverage, but are unwilling to do much to help those who cant afford the markets entry fee.
What also doesnt help is the current mania for reform proposals. I count at least 37 major health reform plans out there, running the gamut from single payer to ending employer-sponsored care and tossing everyone into an unreformed individual insurance market. All this has done is to hopelessly muddy the waters of real change.
I asked one of the proponents of a reform plan why he didnt just jump on one of the other bandwagons out there and why nobody in the industry was trying to rally people to work together on a single plan. He said it was a great idea, but first his organization had to get a plan out there; everybody else had one, after all, and his members had wondered why theirs did not.
The other major stumbling block to reform is the fact that any plan worth its salt will offend any number of current healthcare stakeholders. An individual mandate will anger people earning just enough not to get subsidized care. Physicians wont like ideas for changing how they practice medicine and forcing them to buy information systems (most reform plans include such changes). Hospitals will fight any changes to the way they get paid, even if it makes sense in the long haul. Drug companies will fight price controls on their products. And health plans will fight to the death to avoid having to cover even one more sick person.
Anyone remember Harry and Louise? In 2009, it will be Harry and Louise on steroids.
There has been more talk about reform this year than at any time since the earlier Clinton reform effort in 1992-93. Thats good, to an extent. The big question now is whether we are primed for a repeat of that earlier debacle or whether the planets and stars will align so that we can begin to fix whats wrong with healthcare.