Against Backdrop of Intense National Health Care Reform Debate, Experts Gathered at HSPH

A distinguished panel of economists and political scientists hashed out the various health care reform proposals currently before Congress at a symposium Sept. 25 at HSPH, but there was little consensus among them on the myriad ideas currently in play.

They all agreed, however, that something must be done to change the status quo.

"I understand there to be four goals of health reform as currently being discussed: it is to cover the uninsured, lower cost growth, improve quality, and only tax rich people. My judgment on that is, that's impossible; that you cannot do all those four things," said Mark V. Pauly, Professor of Health Care Management at the Wharton School at the University of Pennsylvania.

Said Henry J. Aaron, Senior Fellow in Economics Studies at the Brookings Institution in Washington, D.C: "We will make mistakes whatever we do. And I think by far and away the most important issue is not so much what we do, but that we do something -- that we move off dead center on the issue of health reform."

He said that no matter what ends up passing this year, the discussion about health care will continue. According to Aaron, President Obama has said that, "if we succeeded with health care reform legislation, he would be the last President for whom this would be a major issue. I think the more correct observation would be that, if he succeeds, he will be the first in a long line of Presidents who will be introducing legislation on health reform, probably for as long as anybody in this room is alive."

The health care reform symposium, co-sponsored by HSPH and the New England Journal of Medicine, was held before a large audience in the Kresge cafeteria. It was moderated by Arnold Epstein, chair of the HSPH Department of Health Policy and Management and also an editor at NEJM. A webcast of the event will be available soon on the NEJM site.

"It seems impossible to overstate the importance of what this dialogue is all about and what we're contemplating doing," Epstein said in his opening remarks.

HSPH Dean Julio Frenk agreed: "This is really a pivotal moment in U.S. health care. It's an opportunity to reform health care after truly decades of discussion and to open the door to a health care system that greatly expands the proportion of the population that's actually exercising their fundamental right to health care."

He added that, "the U.S. health reform may look like the epitome of a domestic health issue, but it has huge global implications. And believe me, if nothing else, the rest of the world is watching with great interest the outcome of this reform. It will have lasting consequences both here and in the rest of the world."

Epstein noted that there are three bills currently before Congress. He said they all agree on certain key points: changes in regulations governing the insurance industry, such as ending the exclusion of those with pre-existing conditions; setting up exchanges to help individuals and small groups buy insurance more efficiently; expanding Medicaid; including mandates for individuals to buy insurance and for employers to provide insurance or pay in another way; and offering subsidies for the poor to buy insurance.

Differences remain on some key issues, including whether there will be a "public option" -- a government insurance plan similar to Medicare to compete with private plans; how large the subsidies will be to help people buy insurance; and where the money will come from to fund these subsidies.

The public option is probably the most controversial aspect of any of the proposals, and Aaron asserted that the option was garnering too much attention. "This has been a monumentally overhyped issue both by advocates and opponents," he said.

"The reason I say it is not because a public option doesn't have within it the potential to be a game changer, but because, given Congress' fundamentally ‘small-c' conservative attitude toward preserving the interests of major constituencies, the chance that a public option would be allowed in a major way to erode the position of private insurance companies and the health insurance business is close to zero," he said.

But Jacob S. Hacker, Professor of Political Science at Yale, said he believes the public option is "vital" to real reform and said he is not so sure the idea is dead.

"The one thing that gives me heart is that at every stage, when it looks like the public plan has been on the rocks, it's been rescued," he said. "It's come back because, as I said, it is essential for two simple reasons. One, it's an essential guarantee for Americans that they will, in a reformed insurance environment, have a real choice to the kinds of private insurance plans that have helped get us into our present mess. And second, it actually delivers substantial savings."
(On September 29, the Senate Finance Committee voted to reject the public health insurance option in one of the health care bills under consideration.)

Katherine Baicker, Professor of Health Economics in the HSPH Department of Health Policy and Management, commented that, "We haven't grappled with one of the deep questions there, which is, how much health care do we want everyone to have access to? We talk about whether or not health care is a right, as if it's a monolithic thing -- you either have health care or you have health insurance or you don't. But of course there's a continuum of things available through medical technology."

She also discussed concerns about mandating that employers contribute towards the cost of insurance. "There is an idea that if you make employers kick in some money to health insurance, that then gets additional resources to people who can't afford insurance coverage, and therefore will make insurance more affordable," said Baicker. "The illusion there is that there is somehow some extra employer dollars to kick into the system, and that if you just got stingy employers who don't provide insurance to pay for a little bit of the insurance that their workers would then be able to get, everybody would be able to afford more care than they can right now.

"The reason I think that that's an illusion is that really, whatever employers kick in to any insurance policy comes out of workers' wages."   

More information about health care reform is available on a site managed by the U.S. Department of Health and Human Services.

-- Michael Lasalandra. Photo by Suzanne Camarata.