President Barack Obama’s healthcare reform effort is, at least so far, characterized by a focus on an inclusionary process aimed at consensus building. The private sector organizations that have the knowledge and experience to understand healthcare system problems and inefficiencies, and that will need to be involved in implementing solutions, are being engaged and heard (PDF) by those who are crafting the detailed legislative proposals we’ll be talking about and debating later this year. It is — at least so far — all very civilized and high-minded, and hard to criticize.
What remains to be seen, however, is how the various participants will respond when the need to make decisions about specific concrete policy proposals comes face-to-face with the complex web of interests at the center of the U.S. health care enterprise. At the end of the day, health reform will create winners and losers. If it is done well, care will become more affordable, providers will be more cost-effective, and quality will be improved — there’s no reason to presume that these three goals are in any way incompatible. But as health spending is constrained and quality measures are implemented, some sectors will be disadvantaged, others may see significant growth, and there will be revenue and income redistribution. I doubt that the debate will remain so civilized and high-minded when the identities of the likely winners and losers become more clearly defined.
The seeds of contention are already apparent, as reported April 22 by Modern Healthcare. Blue Cross Blue Shield leaders held a press conference at which they characterized proposals for a government-run health insurance option as variously:
— A Trojan horse for a single-payer health care system (Tom Bowser, president and CEO of Blue Cross/Blue Shield of Kansas City);
— A destroyer through cost-shifting of the private health insurance marketplace because it would likely pay at Medicare levels (Bill Marino, president and CEO of Horizon Blue Cross/Blue Shield of New Jersey);
— And a thwarter of innovation (Scott Serota, president and CEO of the Blue Cross/Blue Shield Assn.).
Competition from a government-run plan would be bad, the Blue Cross leaders said, because private sector plans are more innovative than Medicare, and millions of Americans are happy with their employer-based health insurance today.
And here I thought the goal of a government-run health plan was to create an affordable option for people who can’t get employer-based health insurance, and that the likely model for such a plan was neither Medicare nor Medicaid, but rather the Federal Employees Health Benefits plan. Besides, if private insurers are in fact more innovative, and the insured like what they get now, won’t they be able to stand up to competition from an unimaginative, bureaucratically hamstrung government program? Could the Blues be engaging in some political posturing to defend their turf?
I’m not suggesting that the fears voiced by the Blue Cross leaders are totally groundless. A government-run insurance plan could, if the legislation were poorly written, upset the insurance marketplace, keep innovations away from enrollees, and fail to provide the quality enhancements that are integral to the health reform effort. A close look at the history of Medicare’s efforts to design “competitive bid” demonstrations for various services might lead one to believe that the government’s idea of “competition” is sometimes indistinguishable from a rigged game.
But I’m struck by the decision to go on the offensive so early, and to push a hot button like “single-payer” that is not now and not likely to become a part of the mainstream policy discussion.
Wouldn’t it be more constructive to engage in a process to educate legislators about the destabilizing potential of a government-run plan, and work with them to see if there is a plan design that would avoid that potential and still help get some much-needed insurance to the unemployed and the uninsured employed, before they pulled out the heavy ideological artillery? Well-designed eligibility criteria, market-based payment rates to providers, and flexibility in the design of benefits packages — including a high-copayment catastrophic option (as advocated by Clay Christensen in The Innovator’s Prescription) would all effectively address a good portion of Blue Cross’ fears. And it’s not as if the private health insurance industry, innovative as it may be in some ways, has proposed an effective solution to the problem of the uninsured.
A recent Boston Globe op-ed piece by Wendy Everett, president of the New England Healthcare Institute, reveals the more thoughtful, kinder and gentler face of industry’s incipient quarrel with the Obama program. Everett’s piece, “Innovation’s vital role in healthcare,” begins by outlining the essential role of innovation in improving healthcare (“Continued innovation is literally a life-and-death issue for patients”) and fueling the economy (“sustaining American leadership in medical innovation is more vital than ever in the current global economic downturn”), and then turns to the real subject at hand — comparative effectiveness research:
“It is critical that new comparative studies avoid having a chilling effect on innovation. The comparative effectiveness research program must be designed in a way that identifies interventions that best meet patient needs. And yet, in winnowing out some interventions even as it promotes others, comparative research will inevitably have an impact on innovation — and therein lies the rub.”
Whoops! Is CER going to kill patients and deepen the recession? Of course not. But it could slow down the pace of medical innovation, keep some valuable technologies out of the reach of patients, and (this next isn’t actually stated in the op-ed) have an adverse effect on the bottom line of some device and pharmaceutical companies.
I want to be fair. Everett is not simply pursuing a pro-industry agenda. She goes on to enumerate some critical policy choices — all perfectly sensible and reasonable — that would allow CER to sustain and promote innovation, and ends with a strong endorsement of the CER enterprise:
“In the long run, everyone should benefit from more and better information on what works and what doesn’t work in healthcare. For now, as policymakers work to structure the new program, they need to find practical ways to make comparative studies a useful tool for patients, physicians, and innovators alike. Designed wisely, comparative effectiveness research can achieve the best of both worlds: vast improvements in the healthcare evidence base along with sustained development and adoption of valuable innovation throughout the healthcare system.”
No quarrel there. And the op-ed turns out to be derived from a detailed NEHI white paper (“Balancing Act: Comparative Effectiveness Research and Innovation in U.S. Health Care”) that should be required reading for any policy-makers involved in developing CER efforts.
NEHI’s work on this subject, like much of its other work on topics ranging from waste and inefficiencies in healthcare, to health information technology to the role of life sciences in the New England economy, is a model of careful and thoughtful analysis leading to sensible and forward-looking conclusions.
So, just as the Blues’ response to the idea of a government-run insurance program seemed more aggressive than it might have been, Everett’s op-ed focus on the risks inherent in CER strikes me as aberrant — not standard operating procedure for NEHI. The cause, I think, is rooted in NEHI’s greatest strength: the extraordinary breadth and diversity of its membership, which encompasses the device, pharmaceutical and biotechnology sectors, payers, academic research centers and healthcare providers, trade associations, providers of services to industry, and patient groups, among others.
NEHI is an advocacy (but not a lobbying) organization deeply and honestly committed to improving the healthcare system and the quality of care available to patients. But the diverse members approach that common set of goals from different perspectives. Imagine the balancing act when the leaders of that membership sit down to set the agenda and choose among options on the fundamental issues that will have direct impacts on the distribution of resources among the various sectors of the health care universe. Imagine the tension underneath the unified surface. Imagine it leaking out, just a little, when a complex and subtle discussion needs to be summarized for the general public in an op-ed.