The Implications of the 2000 Election

This message is about a very subtle yet crucially important topic. It is long because it cannot be stated in a few words. I saved it for Saturday, since some will have time during the weekend to read it.

The New England Journal of Medicine
March 1, 2001
"Health Policy 2001"
by R.J. Blendon, D.E. Altman, J.M. Benson, and M. Brodie

Quote from article, with footnotes:

"We believe there is a reasonable chance that legislation representing a compromise between the Bush and Gore positions can be enacted that will help 4 million to 10 million of the nation's 43 million uninsured
persons receive coverage. Such legislation might make it possible for some employed but uninsured persons to obtain coverage through tax credits that would pay for part of the cost of private health insurance
policies. The availability of medical savings accounts might also be increased. In addition, self-employed persons might receive tax incentives to encourage them to purchase insurance. Complementing these
private-sector approaches would be an increase in funds for states to expand Medicaid coverage and the State Children's Health Insurance Program for persons with low incomes. The states could be given greater
discretion in determining how these two federal-state programs would be structured and administered."

Comment: No footnotes? What gives? This description af a political agenda for our health care system does not really need to be referenced with footnotes as long as it begins with, "We believe that..."

This quote is from the New England Journal of Medicine, a publication noted for its academic purity. The lead authors are Robert Blendon, Sc.D., Professor at the Harvard School of Public Health, and Drew Altman, Ph.D., President and CEO of the Kaiser Family Foundation, two of the most ethical and highly respected individuals that help to bring light on the problems inherent in our health care system. Let me state up front that in no way do I question the integrity of these icons for whom I have the most profound respect. I believe that the problem that I address is a very subtle one that has received very little consideration.

What is this that they state they believe? They believe that the leading proposals have a significant chance of enactment. They base their belief on scientifically valid surveys of the American public and on the opinion of those that now control the agenda by virtue of having been elected to office. These are very reasonable conclusions.

Robert Blendon and his colleagues have a well deserved reputation for capably assessing the opinions of the public on matters of applications of health policy. They and others have shown that Americans express
greater distrust in the ability of the government to meet our social needs, and that private solutions have increasing support. But Americans do believe that the government can have a significant role in meeting the needs of the more vulnerable members of our society.

With this background, what are the current proposed solutions? Any form of universal, comprehensive reform is totally off the table. It is nowhere in sight. Supporters of universal coverage such as Ron Pollack and Jim McDermott are now seeking solutions that are compatible with the background laid down by the studies of Blendon, et al. Ron Pollack of Families USA has joined with Chip Kahn of the Health Insurance Association of America to propose the Medicaid and S-CHIP expansions, along with tax credits, as mentioned in the "We believe" statement above. Democrat Jim McDermott and Republican Jim McCrery are proposing refundable tax credits as a compromise that might increase coverage of the uninsured.

There are serious problems with the proposals under consideration. Tax deductions and tax credits are not really health care legislation but really are tax proposals. Most of the benefit would accrue to those that already have health care coverage. Low income individuals do not benefit unless they are given a refundable tax credit that approximates the cost of health care coverage, an extremely unlikely prospect in the current political climate. Medical savings accounts are a favorite of conservatives since they benefit the healthy and wealthy, leaving out the sick and poor. Medicaid has been chronically underfunded and the S-CHIP program has Spartan benefits. Expanding these programs for low income individuals perpetuates muti-tiered health care. Legislation expanding the role of private health plans perpetuates the administrative waste and flawed health policy characteristic of these plans. Even if all of these proposals were adopted, at best we would still be leaving over three-fourths of the uninsured without coverage.

Every informed person agrees that we have enough resources to provide comprehensive care for everyone. A publicly administered, universal program would correct most of the defects in funding and allocating
health care In America. So why has this concept been totally rejected and kept out of public forums and press coverage of health care reform?

Simply, those that have control the agenda, whether the media, public forums, legislative hearings, or whatever, repeatedly cite the studies that show that Americans do not want the government involved in their
health care. Innumerable presentations in print, at forums, or wherever, specifically cite the Harvard University/Kaiser Family Foundation/Washington Post studies that confirm that concept. This perception is so pervasive that even Al Gore said, "We don't want one-size-fits-all," and Sen. Clinton supports the "small steps" of incrementalism. Consequently, all current proposals are limited to incremental expansions.

Although these polls demonstrate that anti-government rhetoric has permeated and molded the opinions of our society, do they show an accurate picture? Do Americans really want government out of their health care system? I often ask audiences, "How many here would like to see Medicare abolished and not replaced with any other program?" Rarely do any hands go up. If Medicare had been established as a universal program, I sincerely believe that the support would be the same, considering the great resources that we have that would be available to everyone.

When issues are carefully explained, then individuals make decisions based on their values rather than on the rhetoric. Unfortunately, the nation is poorly informed on the real issues involved. For instance the NEJM article contained the statement, "Two thirds or more of both Republicans and Democrats favor the use of tax credits to help the uninsured buy private health insurance." This response is expected. It really sounds like a good idea. But suppose, before you ask that question, you explain the issue. You point out that a tax credit proposal will have to be a bipartisan compromise. The Democrats will prevail in seeing that the tax credit is refundable so that it will provide cash to the low income individual to enable the purchase of health care coverage. The Republicans will prevail in insisting that the amount of the credit will be modest because "we cannot afford to pay for" a generous tax credit. Studies have confirmed that such a proposal will not be adequate to make coverage affordable for most of the uninsured, but it will provide a tax subsidy for the more affluent who already have insurance. Now, let's ask a more accurate question. Instead of asking, "Do you favor the use of tax credits to help the uninsured buy private health insurance?", let's ask, "Do you favor the
use of tax credits for purchasing private health insurance, a proposal that would provide a generous tax subsidy for the more affluent, and might allow a very limited number of lower income individuals to
purchase insurance?" I believe that the results would have been dramatically different. A very important question that we should ask ourselves is whether we should consider the opinions of Americans when
we make policy decisions, if those decisions are going to be based on perceptions of rhetoric rather than on a clear understanding of the fundamental issues involved.

The concept that I want to make clear is that these studies do not only show us where Americans believe they stand on health care reform, but they are also driving the political agenda for reform. I emphasize that
that these are opinions on where Americans believe they stand, but they are not opinions on where they would stand if they understood the full implications of the policy behind the rhetoric. The rhetoric is even influencing the pollsters. They are asking questions about private versus government. Is Medicare private or government? It is a publicly funded program that uses the private and public health care delivery
system. Such dual choice questions are frequently inappropriate.

The Harvard/Kaiser/WP poll asks, "Do you favor a national health plan, financed by taxpayers, in which all Americans would get their insurance from a single government plan?". There are many problems with the
phrasing of this inquiry, but the term "government" assures a negative response, based on reflexive rejection of the rhetorical implications, but not based on a comprehensive knowledge of the policy issues involved. Indeed, this one question has been used repeatedly to support the position that Americans do not want national health insurance (even though they do support Medicare.) It is being used to keep the consideration of comprehensive reform off of every agenda.

Polls could be designed that would ferret out the true values of Americans. Those are the polls that should be used to establish policy. The current polls, which are based more on rhetoric, are being used by each interest to further their own political agendas. In the case of health care, they are being used to dismiss, without
consideration, a rational, ethical approach to reform: a publicly administered, universal risk pool. In reforming health care, we need to understand the position of Americans, but their position on their values, not on their rhetoric.

Don McCanne