Will Rogers once famously remarked, “I don't belong to any organized political party. I'm a Democrat.” He must be smiling now.
With the Democrats firmly in control of the Executive and Congress, and, with the personal popularity of President Obama, just a short time ago major health care reform seemed like a slam dunk. The president's three goals were clear: 1) universal health care coverage, including a “public option,” 2) budget neutrality for 10 years, 3) congressional approval before the August recess.
Mindful of the failure of the Clinton Health Plan in 1993, all 1,366 pages of it, which had been written more or less in secret by a small group and presented to Congress in toto, the president informed Congress of his goals and then left it to the House and Senate to construct the actual bill. That's when the wheels came off.
The three committees responsible for writing the plan (two in the House and one in the Senate) responded by constructing labyrinthine drafts of over 1,000 pages, with hundreds of special “entitlements,” by congressmen eager to court their constituents. One description was that it looked like a “pork barrel Christmas tree.”
The result was multiple splits of the Democratic Party itself (Liberals versus Blue Dogs) and a public increasingly alarmed that its health insurance would be taken away or that its health care would be controlled by the government.
Anxiety centered around particular epicenters. Many citizens were concerned about increased taxes. Seniors were especially alarmed because part of the proposal would pay for the plan with cuts in Medicare. Additional concerns centered around the effects of these cuts on “end of life care.”
The public option provision was designed to provide insurance by the government for those who were not otherwise insured. The fears here were that private insurance companies would be driven out of business and employers would begin to phase out employer-based health insurance. Others felt that this was a covert end run to achieve a single payer system over time.
The tremendous confusion in Congress seems to have led to an outpouring of anxiety, concern, and anger by the general public unmatched in my experience since the Vietnam protests. Understandably, congressmen began to become fearful for their own political lives. A series of town hall meetings, were held all over the country with politicians facing intense questioning.
Finally, the president himself took to the campaign trail, where he has been so effective in the past.
The bills make much of “comparative effectiveness research” (CER), overseen by an “independent commission” charged with developing “quality measurement and performance standards.” This has created concern about possible arbitrary denials of care based on government standards rather than medical judgment, i.e., camouflaged health care rationing.
Much of this debate is centered on end of life care. Studies have shown that 10 percent of Medicare patients generate 60 percent of the costs while the bottom 50 percent account for 4 percent of the costs. The current concern is that individuals generating the most cost will be at greatest risk for denial of care. Recent studies have shown that properly done, home health care cuts costs by 25-60 percent while providing better care. Ironically, what these results require is actual house calls by physicians who can use computers from the home to coordinate care.
As psychoanalysts, we might wonder about the intensity of emotions produced in these debates. Some feel that this might be “the end of the world as we know it.” Others feel that the more likely outcome will be “more of the world we know and already don't like it much.” However, the fears stirred by questions of health and death and dying touch the deepest core of all of us and our need to protect the very lives of ourselves and our families. Roughly put, much of the debate seems to rest on the polarization between those who trust the government and those who don't.
Our Association has been in the thick of this struggle to ensure that we can continue to provide quality care for our patients. Our goals have been that of ensuring that private practice is protected and that the privacy of health care information is safeguarded. So far we have been remarkably successful on both counts, most recently getting strong privacy protections into the stimulus package.
This is a very fast moving debate with developments and changes every day. Clearly, by the time this article reaches you, we will have moved far beyond the points that I am describing here. However, I did want to convey some flavor of this remarkable process.
My best guess and hope for a successful outcome of this struggle would be for the president to show the vision and leadership that he has in the past. Having heard the concerns of the American people, the president is in an ideal position to generate a simple plan to improve access to health care in America while preserving those aspects of the current system which Americans value.
Editor's Note: For up to the minute information on the national health care debate visit the Association Web site and click on Advocacy/health care reform or scroll down the home page to The President's Corner.
Bob Pyles, M.D., is chair of the Committee on Government Relations and Insurance.