Some Health Reform Questions for The President

In David Brooks' op-ed column in The New York Times last Friday, he pointed out that, by telling people they could keep their current insurance plan, President Obama--and candidate Obama during the election campaign--had unintentionally pulled the rug out from under healthcare reform. While reassuring people who are worried about losing what they have, Brooks said,

"Obama's promise has sent the reform effort off the rails. It meant that efforts to expand coverage marched ahead, but efforts to fundamentally reform the system got watered down. Instead of true reform, we got a series of bills that essentially cement the present system in place. The proposals do not fundamentally challenge the fee-for-service system. They don't make Americans more accountable for their own health care spending. They don't reduce costs. They just add more people into the mess we've got."

I don't always agree with Brooks, but this time he got it exactly right. If all Obama does in his upcoming address to Congress is tell the public that he's determined to achieve universal coverage and cut costs, we're in a lot of trouble--and so is the President. Because if he lets Congress keep going in its current direction, the reform bill it produces will essentially be the status quo as far as the industry is concerned. While an individual mandate to buy insurance will increase the financial burden on consumers, the legislation will contain little or no cost control measures.

We need some new ideas, and we need them fast. Brooks praises a recent Brookings Institution report that makes several concrete proposals to cut spending growth, as well as the Wyden-Bennett bill that has been languishing since the election. The Brookings paper was written by a bipartisan group of health-policy experts, and Wyden-Bennett, according to the CBO, would achieve universal coverage without increasing the deficit. There are many other good ideas waiting in the wings, among which is the modest proposal I made in my own book, Rx For Healthcare Reform.

While I won't bore you with the details of that plan, I do have a few questions that I'd like to ask President Obama:

  • Do you still believe that employers above a certain size should pay their fair share of healthcare costs?
  • If individuals were required to buy insurance, and the government subsidized only those whose incomes fell below 300 percent of the federal poverty level, as the Senate Finance Committee suggests, is it reasonable to expect those with incomes from 300 to 400 percent of the FPL to spend up to 13 percent of their income on health insurance?
  • Would this approach lead to millions of people buying skimpy plans and having little access to care?
  • Should every middling town in the United States have multiple MRI, CT and PET scanners, or should we limit the availability of these profit-producing machines to keep down costs, as they do in Canada?
  • Should we restore the regional health planning agencies that were launched in the '70s to prevent hospitals and physician entrepreneurs from building unneeded facilities that generate more business, whether or not it contributes to the health of patients?
  • If we pursue payment reform to eliminate perverse provider incentives, should we start with Medicare or do we have to include the entire system to make it work?
  • Assuming that you and your allies in Congress have the guts to take on the healthcare industry, a lot of jobs would be eliminated, generating massive public opposition. Should we gradually phase in structural reform and if so, should we combine it with industrial policies that would generate new jobs to replace those that are lost?
These are just a few of the issues that need to be considered in healthcare reform that is worthy of the name. Anything less is just tinkering at the margins, and we can't afford that now.