By Bernadine Healy, M.D.
One thing that's clear from the political winds blowing at both ends of Pennsylvania Avenue is that the perceived secret to getting health reform done is to keep the details away from pesky critics until it's almost too late to say no. On this, President Obama and a select group in Congress have emerged as a phenomenal tag team. Obama is the frontman, speaking in great generalities and making pledges that are almost too good to be true, while those in Congress, emboldened by a nearly filibuster-proof Democratic majority, are at work behind closed doors on the nuts and bolts. The promise is that all Americans will soon be guaranteed affordable, high-quality healthcare and the freedom to choose whatever doctor or health plan they want, all at a savings of some $2,500 per family. This comes with an even broader assurance: the very salvation of our economy, which Obama preaches is doomed without the cost-tightening of health reform. But slow down here. We need to look critically at this sales pitch, because reform comes with a price that is only gradually being revealed.
At the moment, committees in the House and Senate are penning their sweeping legislation on a timetable that will not allow for a public viewing before mid-June. Passage is expected in July, in time for a presidential-congressional victory lap by summer's end. The reason for this breathtaking pace? A big one is the fear that if it doesn't happen fast, it won't happen—and that many of those who lived through the Clinton health plan debacle in 1994 believe that the devil in the revealed details of that plan sank it.
In the interest of time, the Senate Finance Committee headed by Sen. Max Baucus has made a heroic effort to pull together the many committees with a stake in health reform and craft a bill that most in the majority will buy into. Just in the past three weeks, his committee has begun to let the public in on some of its handiwork by issuing three white papers on policy options that might or might not make it into the final bill. At first glance, some of the ideas look awfully good. Mandating that every American has coverage, ensuring that those who really can't afford it will be helped, and providing that affordable insurance will be there from an employer or through a national purchasing exchange in which insurers are obliged to participate without discrimination based on a person's health status. This adds up to universal coverage.
But it may be hard to swallow many of the other changes included in comprehensive health reform, particularly without a deeper understanding of just how they will be implemented. The creation of an electronic medical record is a priority, but making it a national database accessible in real time to a wide array of people, including government bureaucrats and researchers removed from the care of the individual patient, raises concerns about privacy and the risk of mishaps and misuse. Similarly, investing in expanded comparative effectiveness studies that balance benefits of treatments with their costs in order to come up with more-standardized care can readily fall into the trap of rationing and one-size-fits-all guidelines. And with monitoring of each keystroke of doctors and hospitals made possible through computer networks, one could imagine imposing penalties on caregivers who don't always toe the line.
Look at colon cancer prevention. Medicare decided recently not to pay for virtual colonoscopy, an approved and useful imaging test. Sure, it may not be as accurate as invasive colonoscopy, but it may be all certain people will do. Also, doctors have advised some patients with totally normal colonoscopies to have the easier and less expensive virtual procedure at the next five-year mark and another full exam at 10 years. The need for examination at the five-year point is controversial and opinions vary among doctors, but studies have shown that at least one precancerous polyp is detected in 17 percent of such patients and more advanced cancers in 1.3 percent at that five-year point. The virtual option should be a doctor-patient decision but would be eliminated if Medicare is paying the bill.
Also being considered is an institute dedicated to comparative cost-benefit studies, like the National Institute for Clinical Excellence in Great Britain. NICE has made some famously unpopular rationing decisions that have prevented or delayed patients' access to lifesaving cancer drugs. Before it was embarrassed in the press, NICE restricted access to a new drug that prevents blindness until patients had lost sight in one eye. Obviously, implementation is everything.
A highly controversial proposal featured in one of the white papers released this month calls for a new public health insurance option, amounting to Medicare for those under 65 years old, that would compete with private insurance plans. But as both referee and player, the government could easily obliterate private insurance, achieving what some have wanted but the public has not widely endorsed: a single-payer healthcare system. If that is the intended goal, let's discuss it.
Perhaps the most provocative of the white papers, released Wednesday, describes ways to pay for comprehensive health reform. The report acknowledges that savings from within the current system will not generate dollars up to this task in the near future. Thus, more than the rich will have to dig into their pockets and pay extra in taxes.
Income-tax breaks geared to encourage healthcare coverage are high on the list for reduction or elimination. That includes taxing employer-paid premiums and doing away with the deduction that's currently available to the elderly for their Medicare A, B, and D premiums. Retired military and their families would lose their similar tax deductions.
On the chopping block as well are deductions that individuals and families can take for major out-of-pocket medical expenses, as well as a portion of the tax benefit of funding health savings accounts. Charitable contributions to health organizations and even tax-free bonds for private nonprofit hospitals are potentially on the phaseout list. Beyond income taxes, lifestyle penalties seem popular, such as taxes on alcohol and soft drinks charged to the miscreants.
These are but a few of the numerous options that will be unveiled next month. Many will create unintended or unconsidered consequences. With the popularity of the president and the dominance of his party in Congress, comprehensive healthcare reform may easily pass, but the victory will be pyrrhic if questions concerning regulation and taxation, rationing and government intrusions into medical practice, and the real taxpayer cost are not taken up ahead of time.
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