UBERLUMEN

Posted by NEJM • November 18th, 2009 • Printer-friendly

Senator Chuck Grassley

The health care system has serious problems. Costs are rising at three times the inflation rate. Many Americans are uninsured. Millions more fear losing their insurance in a weak economy or because of preexisting conditions. Doctors are ready to close their doors because of high malpractice insurance costs and low government reimbursement rates.

Everyone agrees that something has to be done. But the reform proposals pending in Congress would make a bad situation worse. These bills would cause us to slide rapidly down the slippery slope toward increasing government control of health care. They contain the biggest expansion of Medicaid since the program’s creation. They impose an unprecedented federal mandate for coverage backed by the enforcement authority of the Internal Revenue Service. They will increase government spending by nearly $2 trillion when fully implemented. They give the secretary of health and human services the power to define benefits for all private plans and to redefine those benefits annually. From a new health-choices commissioner to a center for comparative-effectiveness research, these bills create dozens of new bureaucracies, increasing the federal role in health care. All of this amounts to a lot of power over people’s lives.

The House bill includes a government-run plan; the Senate’s bill may yet. A government-run plan would eventually drive private insurers out of business and lead to a government takeover of the health care system. A government-run plan is not necessary for health care reform unless your goal is to use the government’s power to drive down costs by rationing care and slashing payments to providers. In addition to limiting health plan choices and infringing on the doctor–patient relationship, a government-run system would guarantee U.S. taxpayers a staggering tax burden for generations to come.

Even worse, the bills fail to solve the fundamental problems in health care. They take no serious steps to reduce costs, either for the health care system or for individuals. The bills will cause insurance premiums for scores of people, especially those who are relatively young and healthy, to go up, not down. They tighten the allowable price variation for insurance rates, so that millions of people who are expecting lower costs as a result of reform will end up paying higher premiums.

The bills also impose new fees and taxes that will be pushed directly onto the consumer. Totaling about a half-trillion dollars over the next few years, these fees and taxes will cause premium increases as early as 2010, even before most reforms take effect. Then, after forcing premiums to go up, the legislation makes it mandatory to buy health insurance.

The bills also make problematic changes in Medicare. According to the Congressional Budget Office (CBO), the legislation imposes higher premiums for prescription-drug coverage on seniors and the disabled. The Senate Finance Committee bill creates a new, permanent Medicare commission with broad authority to make further cuts in Medicare. The damage that this group of unelected people could do to Medicare is unknown, although the top actuary at the Department of Health and Human Services recently concluded that cuts of this magnitude will limit benefits and decrease access to care for Medicare beneficiaries.

These points are good examples of the philosophical difference between the two sides. Some of us want to reduce the overall cost of the legislation, try to reduce the government’s role, make it harder for illegal immigrants to get benefits, allow alternatives to the individual mandate and harsh penalties, and reward states with extra Medicaid dollars if they pass medical malpractice reform. Instead, the prevailing plan is to move millions of people from private coverage into public coverage and create new taxpayer-funded subsidies for families making close to $100,000 a year. Yet even with all the changes, after raising billions of dollars in new taxes, cutting a half-trillion dollars from Medicare, imposing stiff new penalties on people who don’t buy insurance, and increasing costs for those who do, 25 million people will still not have health insurance under the Senate Finance Committee bill, and 18 million people will not have it under the House bill, according to the CBO. I don’t think this is what the American people had in mind when the President and Congress promised to fix health care.

It’s not too late for bipartisan legislation that builds on common ground to improve coverage and affordability, increase quality, and decrease costs. I’ve worked for years on bipartisan legislation that would change Medicare so that it paid not for the volume of services provided but for the quality of the care delivered. There’s also widespread support for health insurance exchanges and for ending discrimination based on preexisting conditions to make coverage more affordable and accessible. Allowing individuals to purchase insurance across state lines and enabling small businesses to band together when shopping for insurance are also proven methods for reducing costs and should be included as part of comprehensive reform.

Tort reform is another necessary component, since it would reduce abusive lawsuits that drive up costs and limit access to doctors. The CBO estimates that comprehensive medical liability reform would reduce federal budget deficits by roughly $54 billion over the next 10 years. The Democratic Congressional leaders have shown little interest in creating an environment in which doctors don’t have to engage in defensive medicine just to keep their practices open. The medical community should continue to argue for reasonable reforms that would cut down on unnecessary medical tests that serve no purpose other than to reduce malpractice premiums.

On several occasions, Republicans tried to take the legislative substance in a different direction. We tried to ensure that the President’s pledge not to tax middle-income families, seniors, or veterans would be carried out. We were rebuffed every step of the way.

And amendments offered by Republicans on the Senate Health, Education, Labor, and Pensions (HELP) panel and the Finance Committee to provide consumers with a lower-cost coverage alternative, similar to the high-deductible health plans and health savings accounts sold today, were consistently defeated. Those alternatives would have allowed more people to keep their existing coverage. The defeat of these amendments and the forthcoming pressures on employers and individuals mean that despite the President’s promises, a lot of people aren’t actually going to be able to “keep what they have.” In fact, given the long list of new benefit mandates and strict new actuarial-value requirements, a lot of people are going to end up paying more to meet the government’s new definition of health insurance.

Congressional Democratic leaders are advancing their extremist health care reforms with the bare minimum of votes. I disagree with that approach. Health care is one sixth of our economy — as large as the entire British economy. The legislation Congress is considering will affect every American, at every level of health and at every stage of employment. When the debate began, interested legislators of both parties set forth benchmarks that were no-brainers: Health care reform should lower premium costs, reduce the deficit, and bend the cost curve the right way. The bills before Congress don’t do any of these things.

It’s not too late to step back and start again. If both sides can set aside some philosophical differences and refocus on the principles that brought us to the table months ago, we can implement health care reform that improves the quality of life for those Americans who are suffering under the current system and that doesn’t degrade the quality of life for everyone else.

Financial and other disclosures provided by the author are available with the full text of this article at NEJM.org.