The Obama Administration’s announcement that it will delay the employer mandate for one year brought the rhetoric surrounding the Affordable Care Act (ACA) to a fever pitch.
Republicans see this development as proof that the entire concept is doomed to failure and promptly introduced a House bill to delay the individual mandate. Representative Louise Slaughter (D-NY) decried the bill as "the height of irresponsibility and nihilistic obstruction." Her party is quick to play up the delay as a temporary setback, an opportunity to iron out inevitable kinks in ACA implementation.
As I watch this spectacle unfold, I can’t help but feel a little pessimistic about the fate of healthcare reform. I fear that the intense partisanship surrounding the ACA (and everything else in Washington) is interfering with our ability to make difficult but necessary choices. It also begs a fundamental issue: Is healthcare in our country a right or a benefit?
There’s a lot riding on these reform efforts. Our economy, for one thing. The United States spends twice as much per capita on healthcare than other Western countries without achieving proportionate public health outcomes. Twenty years ago, I remember saying that we’d never be able to afford it when healthcare spending reached 15 percent of the GNP. Now we’re pushing 20 percent. It’s inevitably going to hinder our ability to compete in the world market.
Then there’s the societal cost. Being uninsured impacts earnings, educational attainment, and ultimately, mortality. The uninsured receive less preventative care and tend to be diagnosed at a later, more costly stage of illness. The high price of their care is shifted to hospitals, providers and individuals. It’s not surprising that medical bills are the number one cause of individual bankruptcies.
So what needs to be done? For one thing, both sides need to step back and see the big picture. The ACA may have its faults, but in my opinion, it’s a step toward rationality. And to effect meaningful reform, policymakers will need to drop the rhetoric and come together to tackle some thorny issues.
For one, we need to take a hard-nosed look at the practice of defensive medicine. Malpractice insurance and legal costs account for billions in healthcare spending each year. They also create issues around waste and efficiency. Physicians put a lot of effort into making sure they don’t miss that one case in a thousand that could land them in court.
Most developed countries have effectively curbed the costs associated with medical liability. The Canadian legal system, for example, caps medical tort awards, and the standard of proof in such cases is high. California’s Medical Injury Compensation Reform Act represents a partial homegrown solution to the problem.
Another hurdle that requires a bipartisan solution is administrative simplification. At present, 15 to 20 percent of U.S. healthcare spending goes not to the professionals delivering care, but to those managing behind the scenes.
At a seminar this weekend, I had dinner with Canadian friends. They were talking about their system — how they don’t have to go through all these crazy rules and regulations to get care for their patients. Their workflow is far more streamlined and costs much less.
And finally, there’s the conundrum of stewarding our finite resources. "Rationing" may be a harsh word, but the truth is we simply don’t have the resources to give every patient all the care they (or their families) request. A poignant example: nearly a third of Medicare spending is for patients in the last six months of life. Expanding early access to palliative and hospice care could ease these costs and relieve stress on patients and their families.
None of these issues has a simple, obvious, or universally popular solution. Successful resolution will require support and cooperation from both parties. But given the level of rhetoric we’ve seen around healthcare reform, can it ever happen?
I think the long-term answer is yes. But it will be a slow process. Things may have to get much worse before policymakers are willing to look beyond party lines and address complex issues that don’t lend themselves to sound bites.