By Marcia Angell, M.D. for Huffington Post

Well, the House health reform bill — known to Republicans as the Government Takeover — finally passed after one of Congress’s longer, less enlightening debates. Two stalwarts of the single-payer movement split their votes; John Conyers voted for it; Dennis Kucinich against. Kucinich was right.

Conservative rhetoric notwithstanding, the House bill is not a “government takeover.” I wish it were. Instead, it enshrines and subsidizes the “takeover” by the investor-owned insurance industry that occurred after the failure of the Clinton reform effort in 1994. To be sure, the bill has a few good provisions (expansion of Medicaid, for example), but they are marginal. It also provides for some regulation of the industry (no denial of coverage because of pre-existing conditions, for example), but since it doesn’t regulate premiums, the industry can respond to any regulation that threatens its profits by simply raising its rates. The bill also does very little to curb the perverse incentives that lead doctors to over-treat the well-insured. And quite apart from its content, the bill is so complicated and convoluted that it would take a staggering apparatus to administer it and try to enforce its regulations.

What does the insurance industry get out of it? Tens of millions of new customers, courtesy of the mandate and taxpayer subsidies. And not just any kind of customer, but the youngest, healthiest customers — those least likely to use their insurance. The bill permits insurers to charge twice as much for older people as for younger ones. So older under-65’s will be more likely to go without insurance, even if they have to pay fines. That’s OK with the industry, since these would be among their sickest customers. (Shouldn’t age be considered a pre-existing condition?)

Insurers also won’t have to cover those younger people most likely to get sick, because they will tend to use the public option (which is not an “option” at all, but a program projected to cover only 6 million uninsured Americans). So instead of the public option providing competition for the insurance industry, as originally envisioned, it’s been turned into a dumping ground for a small number of people whom private insurers would rather not have to cover anyway.

If a similar bill emerges from the Senate and the reconciliation process, and is ultimately passed, what will happen?

First, health costs will continue to skyrocket, even faster than they are now, as taxpayer dollars are pumped into the private sector. The response of payers — government and employers — will be to shrink benefits and increase deductibles and co-payments. Yes, more people will have insurance, but it will cover less and less, and be more expensive to use.

But, you say, the Congressional Budget Office has said the House bill will be a little better than budget-neutral over ten years. That may be, although the assumptions are arguable. Note, though, that the CBO is not concerned with total health costs, only with costs to the government. And it is particularly concerned with Medicare, the biggest contributor to federal deficits. The House bill would take money out of Medicare, and divert it to the private sector and, to some extent, to Medicaid. The remaining costs of the legislation would be paid for by taxes on the wealthy. But although the bill might pay for itself, it does nothing to solve the problem of runaway inflation in the system as a whole. It’s a shell game in which money is moved from one part of our fragmented system to another.

Here is my program for real reform:

Recommendation #1: Drop the Medicare eligibility age from 65 to 55. This should be an expansion of traditional Medicare, not a new program. Gradually, over several years, drop the age decade by decade, until everyone is covered by Medicare. Costs: Obviously, this would increase Medicare costs, but it would help decrease costs to the health system as a whole, because Medicare is so much more efficient (overhead of about 3% vs. 20% for private insurance). And it’s a better program, because it ensures that everyone has access to a uniform package of benefits.

Recommendation #2: Increase Medicare fees for primary care doctors and reduce them for procedure-oriented specialists. Specialists such as cardiologists and gastroenterologists are now excessively rewarded for doing tests and procedures, many of which, in the opinion of experts, are not medically indicated. Not surprisingly, we have too many specialists, and they perform too many tests and procedures. Costs: This would greatly reduce costs to Medicare, and the reform would almost certainly be adopted throughout the wider health system.

Recommendation #3: Medicare should monitor doctors’ practice patterns for evidence of excess, and gradually reduce fees of doctors who habitually order significantly more tests and procedures than the average for the specialty. Costs: Again, this would greatly reduce costs, and probably be widely adopted.

Recommendation #4: Provide generous subsidies to medical students entering primary care, with higher subsidies for those who practice in underserved areas of the country for at least two years. Costs: This initial, rather modest investment in ending our shortage of primary care doctors would have long-term benefits, in terms of both costs and quality of care.

Recommendation #5: Repeal the provision of the Medicare drug benefit that prohibits Medicare from negotiating with drug companies for lower prices. (The House bill calls for this.) That prohibition has been a bonanza for the pharmaceutical industry. For negotiations to be meaningful, there must be a list (formulary) of drugs deemed cost-effective. This is how the Veterans Affairs System obtains some of the lowest drug prices of any insurer in the country. Costs: If Medicare paid the same prices as the Veterans Affairs System, its expenditures on brand-name drugs would be a small fraction of what they are now.

Is the House bill better than nothing? I don’t think so. It simply throws more money into a dysfunctional and unsustainable system, with only a few improvements at the edges, and it augments the central role of the investor-owned insurance industry. The danger is that as costs continue to rise and coverage becomes less comprehensive, people will conclude that we’ve tried health reform and it didn’t work. But the real problem will be that we didn’t really try it. I would rather see us do nothing now, and have a better chance of trying again later and then doing it right.

By Marcia Angell, M.D. for Huffington Post.

10 Comments

  1. Terry Brauer on November 9, 2009 at 12:50 pm

    Dr. Angell has analyzed the House health reform bill accurately.

    However, even the expansion of Medicaid as provided is ludicrous: (1) The vast majority of physicians throughout the nation will not accept Medicaid patients … most, if not all hospitals, accept Medicaid patients, but often offer them less than ideal care; (2) States are in budgetary crunches and have no money to pay current Medicaid bills, let alone enroll more Medicaid beneficiaries; (3) the existing bottlenecks in access to care for Medicaid patients will be exponentially worsened.

    Proposed reform legislation is marginal at best and over-hyped as evidenced by the exaggerated declaration of its virtues by Democratic Members of Congress on Saturday. It is anticipated by some that ‘reform’ will evolve over time and that current legislation represents a start point.



  2. Kevin on November 9, 2009 at 2:35 pm

    I think Angell is absolutely right in her assessment. Even as someone living without health insurance, I would have rather no bill passed at all than this one. Above all I am absolutely against the idea of mandates. While I understand why they want to have them to reduce the cost of the system (to the government), it seems completely at odds with the proper limits of government authority in a free society to MANDATE that we all have health insurance.

    I find it frightening that anyone would think that it’s alright to do. And I hate to say it, but the idea of a mandate almost validates some of the worst things those Tea Party nutjobs say about our government. If this is passed, I may end up being fined for refusing to sign-up for insurance and then jailed for refusing to pay the fine.

    This situation is so frustrating – I feel terrified about what their proposing now and powerless to do anything to change it. And living in Texas, I feel like it’s a complete waste of time writing my congressmen who both have strongly indicated that they are against any sort of public option or a single-payer system.

    I do want health-care reform, but I want it done the right way, and this isn’t the right way.



  3. john on November 9, 2009 at 4:38 pm

    I like the analysis. It’s to bad we have to start over but who knows they might start sooner than later.



  4. Steve on November 10, 2009 at 5:08 pm

    My only question is this… why isn’t Congress signing up to be covered by the same legislation that they is so good for “the people”?



  5. Mike on November 11, 2009 at 5:38 am

    Legislators serve corporate interests who bribe them. They do not serve public interests which do not. The money used for the bribery is taken from consumers. Therefore, the only way to put the brakes on this fascist system is for consumers (in reasonably good health) to boycott the for-profit health insurance industry. This can be done by dropping any coverage that you already have and refusing to sign up for any coverage offered with new employment. Admittedly, this will take great courage. But under the current political structure, this is the only way that single-payer health care will ever become something other than a pipe dream.



  6. Chris on November 12, 2009 at 1:48 pm

    Does anybody think there are unscrupulous Democrats who wish for failure so they can use Universal Healthcare as their “Baby in a Bottle”?



  7. Vashti Winterburg on November 17, 2009 at 12:37 am

    Excellent article, as usual. I especially liked the drop to 55 and negotiated drug prices for Medicare.
    I would also love to know how much it would cost to drop Medicare to 55.
    A personal story. When my dad died my sister signed our mom up with the VA since she was a WWII vet. Her monthly drug bill dropped from over $450 a month to about $60. It’s pretty outrageous that the U.S. is the only western country that doesn’t negotiate for drug prices.
    Vashti Winterburg
    Kansas Health Care for All

    “We’re paying for a Cadillac! Why are we driving a Yugo?”



  8. Richard Heckler on November 19, 2009 at 5:48 pm

    This matter may as well be a major issue for the 2010 elections. This sort of sums up precisely why we must continue:

    10 Reasons to Support U.S. National Health Insurance Act

    Written by Andrea Miller

    Tuesday, 03 March 2009

    Here are 10 great reasons to support HR 676, the U.S. National Health Insurance Act:
    http://guaranteedhealthcare4all.org/sites/default/files/10-Reasons.pdf

    1. Everybody In, Nobody Out. Universal means access to health care for everyone, period.

    2. Portability. If you are unemployed, or lose or change jobs, your health coverage stays with you.

    3. Uniform Benefits. No Cadillac plans for the wealthy and Pinto plans for everyone else, with high deductibles, limited services, caps on payments for care, and no protection in the event of a catastrophe. One level of comprehensive care for everyone, regardless of the size of your wallet.

    4. Prevention. By removing financial roadblocks, a universal health system encourages preventive care that lowers an individual’s ultimate cost and pain and suffering when problems are neglected and societal cost in the over-utilization of emergency rooms or the spread of communicable diseases.

    5. Choice. Most private insurance restricts your choice of providers and hospitals. Under the U.S. National Health Insurance Act, patients have a choice, and the provider is assured a fair payment.

    6. No Interference with Care. Caregivers and patients regain their autonomy to decide what’s best for a patient’s health, not what’s dictated by the billing department. No denial of coverage for pre-existing conditions or cancellation of policies for “unreported” minor health problems.

    7. Reducing Waste. One third of every private health insurance dollar goes for paperwork and profits, compared to about 3% under Medicare, the federal government’s universal system for senior citizen healthcare.

    8. Cost Savings. A guaranteed health care system can produce the cost savings needed to cover everyone, largely by using existing resources without the waste. Taiwan, shifting from a U.S. private health care model, adopted a similar system in 1995, boosting health coverage from 57% to 97% with little increase in overall health care spending.

    9. Common Sense Budgeting. The public system sets fair reimbursements applied equally to all providers, private and public, while assuring that appropriate health care is delivered, and uses its clout to negotiate volume discounts for prescription drugs and medical equipment.

    10. Public Oversight. The public sets the policies and administers the system, not high priced CEOs meeting in private and making decisions based on their company’s stock performance needs.



  9. Richard Heckler on November 20, 2009 at 11:31 am

    Update: Senate Joins House in Attacking Women’s Access to Abortion Care

    About the disastrous anti-abortion provision in the House health care reform bill, and give you an update.

    The Senate version of the health care bill purports to be less harsh, but make no mistake: the anti-abortion provisions of this bill are harmful to women.

    What’s worse, we know there will be an attempt to amend the Senate bill to go all the way with a provision mirroring the House’s Stupak-Pitts Amendment.

    We are pulling out all the stops to prevent Stupak-like language from being added to the Senate bill.

    NOW chapters around the country are rallying and demonstrating, phoning, writing and emailing their Senators. Our message is simple: keep abortion safe, legal, and accessible to every woman. Anti-abortion measures have no place in health care reform!

    We need your support now before these harmful anti-abortion provisions are allowed to be passed in the name of health care reform.

    For justice and equality,
    Terry O’Neill
    NOW President

    ==========================================

    PFAW staff join NARAL President Nancy Keenan and staff outside of the U.S. Capitol before delivering more than 97,000 petition signatures to Senate Majority Leader Harry Reid.

    How is it possible that just one year after America made huge progressive strides — electing our first African American president and achieving sizable Democratic majorities in Congress — a woman’s fundamental right to choose is negotiable?

    I am as angry as anyone about this latest attack on Choice. The Stupak-Pitts amendment in the health care bill passed by the House of Representatives virtually bans all coverage for abortion services in the new health care system.

    Millions of women, even women who pay for private insurance plans with their own money, would lose their reproductive health coverage. It’s the most aggressive attack on Choice we’ve seen in a generation — and it’s imperative that we stop it.

    That’s why I want to thank all of you who signed PFAW’s petition to Senate Majority Leader Reid urging him to stop the Stupak-Pitts House amendment from being part of the Senate health care bill.

    Yesterday, PFAW joined NARAL Pro-Choice America and other allies to deliver more than 97,000 petition signatures to Sen. Reid’s staff.

    I plan on doing my part to help People For the American Way fight this right-wing attack on women’s rights.

    It’s unconscionable that of the House members who voted to take away reproductive health care coverage for women in the new system, 25 of them were considered firmly “pro-choice.”

    Now it’s our job to call those people out and stop any similar defections in the Senate. With your help, we’ll send the message to Senators loud and clear — that the right to choose is a fundamental human right and must not be up for compromise.

    We have the power to preserve Choice.

    Kathleen Turner,
    PFAW Supporter and PFAW Foundation Board Member



  10. D.Summer on January 29, 2012 at 8:05 pm

    Why dosent someone expose the Political Party and individuals as the republicans That if they they want to privatize Medicare Social Security . to do the same Make it a requirement for Congress or those nasayers Republicans to be reomoved from Gov Medical coverage we pay for them and make them pay the high Private premiums also from the private sector crooks . I hear some of our elected officials Like Rick Perry at age 60 collect retirement benefits from State & Federal Programs we others have to wait till age 65. but they can collect at 40. While being employed on State and gov pay .Agian If we loose our Medicare & gov assistance then make Congress and State officials loose thiers that we pay for .