CEO SUMMARY: It appears that a determined effort to reshape and restructure the entire American healthcare system is unfolding in Congress. Missing in public discourse about this vital topic is informed, intelligent discussion about the types of alternative healthcare delivery models and options that might successfully address problems in the current U.S. healthcare system, without a total makeover of healthcare as it exists today. This is a big stakes issue for the entire laboratory testing industry.
IT IS LIKELY THAT MOST AMERICANS will look back on 2009 as a momentous year in our nation’s history. We are in the midst of the deepest recession since 1981-82. There has been an unprecedented meltdown in the banking, mortgage, and auto industries. And… to top off all of that: a major restructuring of healthcare in the United States is widely predicted to happen.
Now that both houses of Congress are in their August recess, there will be a month of highly-polarized debate by both sides of the political spectrum as they speak to their constituencies about different aspects of healthcare restructuring. It may be a nasty time in our nation’s public discourse, since changing the American healthcare system touches deep emotions for many Americans.
I know this is a topic of keen interest for pathologists, executives, and lab managers. That’s because, at the offices of THE DARK REPORT and in my travels, I am regularly asked for my opinions and predictions about the shape and form of healthcare restructuring that is likely to emerge from the wrangling in Congress.
My honest answer to these questions is “how can anyone accurately predict what will emerge from all the back room politics, shaped by the intense lobbying of a myriad of powerful interests?” On the other hand, THE DARK REPORT would be derelict in its responsibility to provide informed strategic assessments of the situation as it relates to the clinical laboratory and anatomic pathology profession.
With that preface, I will wade into this most difficult of topics. The goal of this commentary is to provide objective observations and insights about what has been made public about healthcare restructuring proposals.
Reform Versus Restructure
My first point is to address the issue of healthcare reform versus healthcare restructuring. In this commentary, the use of “healthcare restructuring” is intentional. My interpretation of what is known publicly about the house and senate bills moving through committees is that these are comprehensive make-overs of the entire U.S. health system—not sincere attempts to reform core problems without overturning the entire existing scheme of care in this nation.
Thus, I recommend that pathologists and lab directors assess the implications of proposed legislation through the strategic lens of “total makeover.” Congress appears to be moving down the path of a massive, one-shot redo of healthcare. What parts they get wrong are likely to be irreversible a few years down the road.
The second point is to address the private choice versus single-payer issue. At this time, the privately-insured middle class (about 185 million Americans) and Medicare beneficiaries (about 45 million Americans) have a fair amount of freedom to choose both their health insurance plans and their providers.
Remember HMOs of 1990s?
Media sources seldom address how the proposed legislation is likely to restrict patient choice. Were a single-payer system to evolve and result from this current round of healthcare restructuring, these 230 million Americans will find themselves confronting a familiar nightmare. Remember the closed panel, gatekeeper model HMOs of the 1990s, so emphatically rejected by middle class Americans? A single-payer system administered by government bureaucrats will be even more daunting for patients to challenge than the irascible HMOs run by Aetna/U.S.Healthcare, Pacificare, and others in the mid-1990s.
Clinical laboratories and pathology groups can expect that the same HMO exclusionary network contracting practices will be employed by a single-payer, government-run system. After all, squeezing down price with little consideration of quality has been a characteristic regularly displayed by Medicare and Medicaid program administrators.
Point number three involves the remarkable lack of public discussion, evaluation, and debate about different options and approaches to true reforms of existing flaws in our healthcare system. I’ll bet not one of you readers has seen a side-by-side analysis of how the proposed changes in pending bills compares with credible reform ideas of recognized experts. By itself this is a remarkable fact. Congress is about to restructure almost 20% of the U.S. economy and rank and file Americans have precious little information about which options might best meet their needs while solving recognized problems in today’s healthcare system.
Health Vouchers Not Offered
For example, what about healthcare vouchers? Were a system of health insurance vouchers to be developed, might this be successful? In one approach, uninsured people just over the poverty level could get a government health insurance voucher that allows them to buy basic coverage from any qualified insurance plan.
In another approach, maybe vouchers for Medicare beneficiaries is a way to control year-to-year increases in Medicare program costs. The voucher would be enough to purchase the accepted level of health insurance coverage. Medicare beneficaries who want additional or premium care would be free to purchase such additional coverage on their own.
The central idea here is none of us have seen an informed public comparison of the health voucher concept against what Congress is actively working to pass. Nor have we seen a public comparison of any other reform approach to fixing problems in the current health system versus what Congressional nabobs are working to pass.
Point number four is the search for ideas, inspiration, and relevant experience from health systems in other developed countries. It would seem common sense that policymakers in Congress would want to mine the experience of other countries for the best ideas to apply here in the United States.
Other Countries’ Successes
Yet few in the American public have seen a credible, well-researched study that identifies the best successes of other healthcare systems. For example, Australia has a universal coverage requirement, funded by income tax collections. Australian citizens who want to obtain more extensive health benefits can purchase this coverage from private plans. In Singapore, health savings accounts (HSAs) have played an important role in their health system since the 1980s.
It is likely some of these approaches could solve problems in this country. It is a “best practices” study that can allow the United States to avoid “reinventing the wheel.” But at this point, Congress seems to have shut the door to this source of proven innovation.
Point number five focuses on the cornerstone of science: multiple experiments. No political leader is suggesting that one way to improve the flaws in the American health system is to enable different states to experiment with various approaches to healthcare coverage. Yet, in science, it is the ability to perform experiments which guides the researchers to a more accurate understanding of the natural world.
We have the capability to run these experiments. Examples are the Oregon Health Plan of the 1990s, Tennessee’s TennCare Medicaid plan of the 1990s, and, most recently, the Massachussetts plan for universal coverage which launched in 2006.
In the private sector, Kaiser Permanente, Mayo Clinic, and Geisinger Health are regularly hailed by policymakers as examples of the type of healthcare deliv- ery models that are patient-friendly and are not plagued by many of the problems seen in the general fee-for-service health system that predominates in this country. Will Congress cast aside these greatly-admired health organizations in the final bill it passes? Alternatively, why does Congress seem unwilling, as of this moment, to incorporate these types of care delivery alternatives into the proposed bills so as to encourage wider use of these successful healthcare delivery models?
These five points represent objective observations about the current direction of healthcare restructuring as I see it as of this moment. Of course, as events unfold in coming weeks, lots of things are likely to change with the specifics of the senate and house bills currently under consideration.
A Major Overhaul Bill
Something big is likely to emerge from this effort to restructure healthcare in the United States. That’s because a single party controls both houses of Congress and the presidency—a situation which doesn’t happen regularly in American politics.
My theme in this analysis is that the public discourse about how healthcare in this country should be restructured fails to identify valid and reasonable alternatives that could help solve existing problems. That means both elected officials and the electorate at large are not informed about the full menu of options and alternative ways to improve the delivery and cost of care.
This does not bode well for the final bill that may eventually wind through Congress and reach the desk of the president for his signature. It would be a tragedy if the best aspects of this nation’s healthcare were undermined because the nation at large was not able to consider and debate all the best ideas for improving healthcare.