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Various industry insiders were interviewed for this report. They examine the current healthcare debate taking place. You can read the raw interviews by visiting the Healthcare Reform section. Check out the online healthcare reform debate book as well.
 The last time we had a dustoff like this in Congress was in 1993, when First Lady Hillary Clinton pushed hard ... and failed spectacularly ... with a massive universal health care plan for the U.S.
All citizens would have been required to have health insurance, all companies would have been required to offer it, and a vast array of regulatory agencies, fee requirements, permissible coverages and controls on doctors, hospitals and drug companies would have been imposed.
Republicans quickly ridiculed it with "Harry and Louise" ads featuring a bewildered couple trying to understand the 1,000-page plan, and a "HillaryCare" organization chart that presented an impenetrable maze. The measure got nowhere, and a compromise plan fell apart the next year. The GOP captured control of Congress, and any thoughts of health care reform languished.
"In my opinion, Hillary failed because she presented an 'in-your-face' / 'all-or-nothing' solution," says Scott Golden, chief financial officer of Golden & Cohen, a health benefits consulting company in the Washington, D.C. area. "Given that strategy, people went cold on reform. I honestly believe that health reform could have happened years ago if she had initially taken a more moderate approach."
Now here we are 16 years later with another contentious liberal vs. conservative health care reform debate. Here are seven key questions that have emerged ... we asked a number of health experts for their comments.
Will America Accept a Public Option?
The so-called "public option" has become the most prominent feature of reform plans ... and the most partisan. The public option would be a new health insurance company run by the federal government to compete with private insurance companies. This is the key difference from Mrs. Clinton's plan ... the public option wouldn't be the only option.
"The public plan is not only necessary ... it is good for the country," says Dr. Maya Rockeymoore, who is president of Global Policy Solutions in Washington, D.C., and holds a Ph.D. in political science and public policy from Purdue. "It will help provide people with options in areas of the country, rural areas for example, where there are few private options for care. It may also provide a constant source of coverage for those who do not want to join a new plan every time they change jobs."
She says our current system "pays doctors and insurers more for treatment of disease and illness than for prevention and wellness services. A public option that embraces prevention and wellness and focuses on quality, affordable, efficient care would force private insurers to reform their systems accordingly. The establishment of a public option is the best way to rein in costs as well because it allows private insurers to adjust their models of care based on market forces as opposed to massive regulation."
For those who think a public plan would give too much control to government, "they need only to look to Medicare (which was enacted in 1965) to understand that a government-sponsored plan does not translate into government domination. Private insurers, hospitals and doctors remain influential in the face of Medicare’s existence and they even benefit from Medicare through its various components which include hospital coverage, outpatient care, Medicare Advantage/HMOs, and a prescription drug benefit."
For an opposite view, we have Dr. Stephen Kardos, who is board certified in pediatrics from the American Board of Pediatrics and a senior fellow of the American College of Osteopathic Pediatricians.
"A public plan is a dreadful mistake," he says. "There is enough power in existing regulatory authorities in each state and the federal government to take a rational risk-reducing approach to health care. Our government leaders must stop populist pandering and the extension of our federal government further into private business."
Scott Golden calls the public option "a speculative venture with no track record except for Medicare, which is scheduled to be insolvent in 2017." But it would be too much government control "only if it is the only plan offered, or the intent is to make it the only plan at some point. If the plan truly competes with carriers, then the government option will be like any other carrier."
Matt Modleski, vice president of Stovall Grainger Modleski, Inc., a health care consultant, notes that "when Medicare was established, there were all sorts of promises made and then summarily broken over time. Right now, if the one government program we have is unsustainable, common sense would say without a complete overhaul of both the delivery and reimbursement systems that a second government program that pays for additional access to the system will also be unsustainable."
Anything in between? Maybe from Dr. Alford N. Vassall, who has practiced medicine in New Mexico for many years and is a contributing author to a recent book, "Audacious Aging."
He believes that a public plan "that is based on a fixed percentage of the GDP and assigns funds to different portions of the system would be the most efficient model. A system which controls the cost by directly funding hospitals, physicians and such is the most efficient. Incentives have to be geared at changing behavior by encouraging patient responsibility. This system would need to abolish the tort system for medical injuries. If it paid for the education of all health care professionals and then compensated them at an appropriate living expense, this would maintain the system."
Will There Be Greater Emphasis on Wellness and Prevention?
Probably.
Dr. Kardos believes prevention should be the priority in any final health care bill if costs are to be controlled. He noted that in one labor union's generous health plan, only 26.9 percent of eligible women obtained a mammogram. Treatment of breast cancer in its early stages, if detected by this test, costs only $1,327 per month. In its late stages, that rockets up to $9,352 a month.
"The focus for the past 50 years in America has been to zero in on the 20 percent of people who account for 80 percent of health expenses," he says. "This has been a very costly strategic failure because the best you can do by 'managing' sick people is to squeeze out some nominal payment for procedures or avoid the procedures completely."
Dr. Eva Mor is author of the new book “Making the Golden Years Golden.” She has a Ph.D. in epidemiology from the School of Public Health at Columbia University and at Hebrew University.
She calls preventive care "a must. It will make our population healthier and with little or no need of expensive chronic illness care. It will be a great investment for the young generations, saving billions of dollars over the years."
Golden agrees with that: "Most claims are driven by certain behaviors such as overeating, excessive drinking, smoking, etc. If these non-healthy behaviors are controlled more effectively, people will be healthier and not tax the medical system as much, which will obviously reduce overall costs. I believe that for those who do not have these unhealthy behaviors, incentives should be used to encourage the same, good healthy lifestyles."
So does Dr. Rockeymoore: "Obesity is a major contributor to many preventable chronic diseases that are driving health care costs. Wellness insurance would provide critical support to Americans trying to maintain their health through gym memberships, nutrition education courses, weight loss programs, and tobacco cessation programs ... to name just a few. Wellness insurance could prove to be the catalyst to expedite cost reductions by creating healthier people and communities."
Is U.S. health care really that bad?
The World Health Organization ranks the United States as having the 37th best health care system in the world, behind Dominica (35) and Costa Rica (36) but ahead of Slovenia (38).
To Jim Lacy, CFO and counsel of ZirMed Inc., Louisville, Ky., that's bogus.
"With subjective reports from the WHO that call into question the U.S.’ leadership position in health care delivery and actually place it far from the top, there appears to be an acceptance that the U.S. system is somehow broken," he says. "Rarely are the WHO’s measurement factors scrutinized and reviewed. I approach this element simplistically: If I found that I had a serious, life-threatening illness and could travel anywhere in the world to have treatment, where would I go? Over 99 percent of the time, I would stay in the U.S. And, there are not areas in the U.S. that I would not travel for fear of a health related risk."
Lee Rabbitt, benefits manager for the Austin, Texas, branch of Watkins Insurance Group, has found that the problems with the current system aren't the "availability of health care ... we have plenty of doctors and hospitals ... it is the cost of the health care and thus the cost of the health insurance coverage. It’s a voluntary system, where many people are allowed to opt out and not pay for their health care or health insurance coverage, but get treated anyway.
"Health insurance is somewhere between $900 and $1,200 per month for a family in our area; not many families can afford to pay that, nor can they afford a catastrophic health event.
"Some of the things that add to the cost of health care are defensive medicine practices to avoid lawsuits, rampant use of expensive prescription drugs, employers who cannot afford to provide coverage and unhealthy lifestyles which lead to massive spending on diseases like heart disease, lung cancer and diabetes."
Dr. Vassall says health care demand is higher here than in other countries, and that's because "the U.S. has a population that makes unhealthy choices. This is done far more frequently here than anywhere else. I had the opportunity to hear a returning Iraq vet comment on how healthy the Iraqi children were and the state of their dentition far exceeded the average American child in spite of the fact the Iraqi had few health care resources. This points to the heart of the issue, that American citizens make poor health choices. As a result, they use the system far more frequently than other citizens of other countries."
Matt Modleski thinks this: "I do believe a complete overhaul of the health care system is required based on two facts alone. First, if we don’t do anything, by 2075 our current government-run health care business (Medicare) will consume 90 percent of all federal revenue. Second, today, in our current system, we kill between 4,000 and 8,000 people per month due to mistakes and errors. Those facts alone mean what we’re currently doing isn’t working."
Eva Mor contrasts the American system with Israel's: "Every Israeli is provided with health insurance coverage from the day they are born until the day they die.
"The health services are provided through four large HMOs, each an entity of its own. Each HMO has clinics throughout the country, and each person can choose an HMO and switch to another if desired. Each HMO has specialists and provides the full range of medical services and is interconnected with local hospitals.
"Payment for insurance is in the form of deductions from your earned gross income to the tune of 4 percent. For the elderly and unemployed, the government pays from this budget. There are direct payments to insurance companies from individuals who are self-employed. And one can buy additional coverage above the universal one.
"If we had in this country from five to 10 large health insurance companies that would absorb the smaller insurance companies, unify services, as well as charge rates for said services that are uniform, it would make it easier to provide health coverage for most of the population, including the uninsured with the addition of a public plan."
Will Care Be Rationed?
Golden: "The cost will be too high not to ration in some form. The reality is that you cannot have everything."
Dr. Rockeymoore: "Our current system rations in ways seen and unseen. And because scarce resources dictate that we have to make choices as a society, tradeoffs will continue to be a part of the health care system."
Dr. Vassall: "People believe they have not only a right to health care but the right to consume as much as they determine that they need. In a real, finite world, this is not possible as resources are not unlimited. Therefore, consumption has to be rationed.
"It is impossible to have high cost treatments for common problems. It is not even possible to have high cost treatment for uncommon maladies. This is the kind of thing that will exhaust the system quickly. High cost treatment can actually only be given to those who have the resources to pay for them. This may seem grossly unfair but actually is the only system that can be perpetuated. Otherwise we would need a lottery to decide who would benefit from a high cost procedure."
Modleski: "We need to be careful with the word rationing because one person’s 'rationing' is another’s prudent choice of therapeutic options. For example, if I have a sore shoulder and want an MRI, should I be able to get that MRI on demand? Or, should my primary care doctor prescribe two weeks of physical therapy, shoulder exercises and four days of Advil before ordering the MRI? If he does the latter first because 75 percent of the time it solves the problem without the cost of an MRI, have I been rationed? Without sweeping reform of the reimbursement system as well as the care delivery system, I see no way to add more access to the current system without some form of what people would see as rationing."
What's Right and Wrong with Medicare/Medicaid?
Golden: "By all accounts, Medicare is scheduled to be bankrupt in 2017. The only way for this program to be viable is to cut costs and/or services."
Lacy: "There are certain elements that are quite successful and others that are clearly not adequate. But, this is a complex demographic in the U.S. and one that has paid in for Medicare coverage for nearly 30 years. If the financial viability of the Medicare trust fund is the gauge, is the failure one of medical or fiscal proportions?"
Dr. Kardos: "Medicare’s popularity has diminished greatly in recent years as the government has been forced to shift uncontrolled medical claims expenses to plan members, hospitals, pharmaceutical companies and physicians. Multiple Medicare Gap programs are sold to supplement Medicare, and the 'doughnut' contained in the prescription drug plan has created unacceptable hardship to Medicare enrollees. Decreased payments to physicians have made them less accessible and increasing drug costs cause some patients to stop taking their required prescriptions."
Dr. Vassall: "The fees that Medicare perpetuates are below the cost of seeing the patient. This will be worse if the physicians have to obtain electronic medical records. The idea that using EMRs will substantially decrease the cost of care is a pipedream. Hospitals are unable to take care of patients at a break-even rate right now and most are operating in the red, particularly county institutions. The insurance companies are doing the things they do with regard to withholding coverage, because they would be bankrupt if they took care of all the conditions even at the prevailing rates of premiums."
Modleski: "Medicare is wonderful as long as we don’t have to pay for it, but we do."
Dr. Kardos: " Medicaid must reduce the disproportionate amount of money spent for transportation expense. We must make medical care accessible to patients close to where they live; in schools, churches and neighborhood physician offices. We also must pay physicians for time spent in nursing homes taking care of Medicaid patients and be sure any home taking care of Medicaid patients is equipped with appropriate medical equipment and nursing staff. Medicaid must hold providers and plan members accountable for performance measured by health status of members. We must publish physician performance data by community."
Vassall: "Medicare is not substantially different from Medicaid except the latter is run by the state. Once more this is a government program and spends more than it has in funds. This is the norm in any form of insurance that is run by the government. There is need for substantial change. It has to be run from the perspective of spending what is available and not spending what is not. It is also a program that does not compensate the actual costs of providing services."
Dr. Mor: "Medicaid is a complex program and if any of the programs needs to be revamped, Medicaid figures high on the list. We may need to revisit the guidelines for qualifying for entitlement and establish better controls to reduce fraud and abuse. Medicaid may be better controlled if it is broken up into two or three agencies, each providing different services. One agency may deal with the older population, focused on their specific needs. The other may deal with the poor and the needy, etc."
Has Small Business Been Shortchanged?
Ron Wince, president and CEO of Guidon Performance Solutions: At the current time, I believe that employers in general have been left out of the debate with the exception of when it serves the purpose of powerful interests. The current debate is like watching a pinball game without any regard to what the system will look like in actual execution. The major interests throw about assumptions about taxes and their impact on small businesses based on research and conjecture. In truth, any additional burden on small businesses will only further impact their ability to play a key role (which has historically been the engine of recovery) in what is becoming an extended and gradual recovery. Except for the large billion-dollar companies, no one is asking the opinion of business. I find this disappointing and risky."
Modleski: "As a small business owner myself, I think we need two things. First, we need to be better educated on how broken the system is and begin to demand information that permits us to make better choices. The second thing we need is access to larger risk pools whether regional or national. The argument for regional risk pooling makes sense based on regional demographics but the bottom line is this .. there is no reason that a company of 15 people located next door to a company of 3,000 people using the same insurer should pay double or triple the cost for the same coverage as the 3,000 person company. Making that adjustment alone would take a huge burden off of small employers ... temporarily. Small businesses create most of the jobs in America. If ever there was a time when our bargaining power was on the rise, this should be it … one would think."
Dr. Kardos: "Small business and individuals sign on and off health plans at a dizzying pace. Major health plans have to sell through a turnover of their entire enrollment in just 2 1/2 years. This occurs because small group and individual health care is purchased when use of the benefits is anticipated. When feeling well, members drop out, only to re-enroll when high expenses are anticipated. The administrative costs of such a business dramatically increase premium rates. Medicaid especially suffers from such high turnover. The solution: Longer term insurance contracts with a penalty for dropping out, no different from a cell phone contract. Higher benefits and guaranteed rates for longer term membership will go a long way toward improving quality and lowering medical costs."
How Will the Debate Play Out in Congress?
Golden: "There will be a stalemate that will be caused by expense analysis; it will be painful to listen to."
Lacy: "I am no oracle and my ability to forecast political action is worse than that of a weather person. However ... no politician will be against health care reform, but being 'for' anything is dangerous ... unlikely to happen."
Dr. Kardos: "Once the logic of this ill-defined effort for health reform is critically reviewed, I am confident the wisdom of our collective legislative bodies will discover that without truly new strategies for private and public health coverage, they will not pass any legislation. No currently discussed plans will change the country’s escalating costs for health care. So far there has been no reform proposed in the discussion about reform of the very nature of the system itself. What I see on the part of Democrats and Republicans is an attempt to drive health care reform through political posturing and sound bites."
Dr. Rockeymoore: "I expect the Republican caucus to place a considerable amount of pressure on their members to remain in complete opposition to the Democratic/Obama Administration agenda. As a result, I do not foresee any Republicans supporting a public plan. There may be some slippage within the Democratic Party. Blue Dog Democrats on the House side and some centrist Democrats on the Senate side have indicated their discomfort with the notion of a public plan (as it’s been conceptualized by the Obama Administration and more progressive Democrats)."
Dr. Vassall: "I do not see us making the sweeping reforms that are needed as the public is not convinced. The Republicans and the Democrats are in the same place believing the same illusion that somehow market forces or government forces can solve the problem. The problem can only be solved when persons are responsible for their outcomes."
Dr. Mor: "There is no question that we will see an overhaul of the health system. The question to ask is: to what extent, and will it be enough?"
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