Politics & Economics --- CAPITAL: How the Thinking About Health Care Has Evolved
Source: The Wall Street Journal 04/12/2007
"Debating the ailments of the American health-care system is a chronic disease. It sometimes seems the same experts have been making the same points for decades: The U.S. spends more on health care than other countries, but doesn't have healthier people.
Americans with generous insurance use health care readily, and doctors provide it on demand because third parties pay the bill. And so on.
"I remember this from 1993," former Treasury Secretary Robert Rubin said this week at a Washington forum, recalling his years in the Clinton administration. "Every time I think about health care, I get a headache."
It would be easy to fill a column with the ways in which the health-care debate never changes. But, without offering optimism that a grand solution is imminent, three things are now apparent that -- if not new -- at least weren't widely appreciated 15 or 20 years ago.
Employer-based health insurance is slowly dying.
The notion that requiring employers to provide health insurance is the best route to universal coverage is fading. Sure, nearly 60% of Americans still get health insurance on the job. But even in a growing economy with a tight labor market, employer coverage is eroding. Fifteen years ago, says Joseph Antos of the conservative American Enterprise Institute, "large employers were concerned about rising health spending, but they were not leading the march to a big solution." Now they want out.
Employers -- either through premiums or through taxes -- will be paying part of the health-care tab for a long time, but there is surprising interest in requiring that every individual get health insurance, and then subsidizing those who can't afford it.
We don't know as much about medical science as we need to know.
It always has been true that there is a lot about disease doctors didn't know, and it is true doctors can cure diseases that were killers just a decade ago. But it is also increasingly clear that ignorance about what treatments work well and for whom is very costly, especially as new treatments are discovered and new technologies deployed. The flap over stents versus drugs for heart disease is only the latest example.
"I don't think there was very much recognition [15 years ago] about how little we know in areas that we spend large amounts of money on . . . ," says economist Gail Wilensky, a former Medicare administrator now at Project Hope, a global public-health charity. Dartmouth Medical School researchers have been showing for decades how differently medicine is practiced from one town to the next. There is surprisingly little agreement on what works and what doesn't. There is, however, a consensus that figuring that out is important and getting the health-care system to make better use of information technology is crucial to that end.
Americans want a lot of health care, are willing to pay for a lot of it and don't like their choices limited.
Maybe this isn't exactly new, but it is more certain. Americans rebelled against managed care, and particularly didn't like employers forcing them to enroll. "One of the lessons of the '90s is that every consumer insists on the right to choose a poor-quality physician," Ronald Williams, chief executive of Aetna Inc., said at that Washington forum, which was sponsored by the Hamilton Project, the outfit Mr. Rubin and others founded to devise ideas for centrist Democrats.
So no matter how many experts prescribe big integrated health-care plans as the best way to get medical care, Americans won't be forced into them. Some may choose such plans, but they want choice -- and politicians won't enact legislation that denies them choice.
Politicians and employers may, however, be willing to make Americans pay to satisfy their unlimited hunger for health care. President Bush, no fan of tax increases, has proposed raising taxes on those with the most generous health plans. Jason Furman, a former Clinton and Kerry campaign aide, floated a proposal this week that says Americans ought to pay more for the health care they buy (with the best-off paying more out of pocket than the poor.)
Some say the biggest change is that the anxiety of American workers and businesses about the costs and shortcomings of the U.S. health-care system have reached a crescendo and something big will happen soon. Could be. But we've heard that before.
One veteran of the health-care wars, Robert Reischauer, the former Congressional Budget Office director who now heads the Urban Institute think tank, observes a repeating 15-year cycle in which "building optimism and enthusiasm" about big-time health reform is "dashed by realities and politics."
Complaints about the American health-care system haven't -- yet -- produced the political will to do something, particularly since that something will pinch some big interests and generate fierce opposition no matter what form it takes. Some things don't change. "