Why IS health care reform so elusive?

[ Fall 2011 ]

Interview with John McDonough

John McDonough, HSPH professor of the practice of public health, was a senior adviser on the U.S. Senate committee responsible for developing the Patient Protection and Affordable Care Act, the landmark health care reform plan that President Barack Obama signed into law in March 2010. A former Massachusetts state legislator and executive director of the advocacy group Health Care for All, McDonough recently spoke with the Review about the revolutionary law, which he compares to the Social Security Act of 1935 and the Medicare and Medicaid Act of 1965. His new book is Inside National Health Reform.

Q:  What are the biggest myths and misconceptions about the Patient Protection and Affordable Care Act?

A:  A significant number of people believe that there are death panels in the law. And many believe that when the big expansions and the individual mandate take effect in 2014, they are going to have to give up their employer-sponsored insurance and buy individual coverage on their own. Both assumptions are absolutely untrue.

Q:  How does American public opinion break down on health care reform?

A:  About half of the public—mainly Republicans—says that the law should either be completely repealed or substantially repealed. About half—mainly Democrats—says the law should be kept as is or strengthened.

Q:  Does that suggest Americans have different core beliefs about the issue?

A:  There is a broad shared sense—actually, bipartisan—that we spend much more on health care services than we would need to if we had an efficient, effective health care system. The difference is how to do that. For example, Democrats wanted to reduce Medicare spending by $450 billion over ten years and use those proceeds to pay for expanding coverage to the uninsured. Republicans don’t mind cutting Medicare by $450 billion—but they wanted to use the money for tax cuts. It’s not an argument over facts or data. It’s an argument, fundamentally, over values.

Q: How did health care spending spin out of control?

A: If you go back to before the 1980s and look internationally at health spending as a percentage of gross national product, you find that the United States is expensive—but bunched among the leading nations. Not until the early 1980s did we become an outlier. We took off and grew at a much faster clip than all of the other industrialized countries.

That may be because, in the 1980s, the U.S. embraced with gusto this ethos that market competition would fix our health care system. At the state and federal levels, we abandoned different kinds of regulation and instead embraced “competition.” The idea was that it would drive down costs and create better value. But it didn’t.

Q:  In your mind, what’s the best health care system in the world?

A:  My best of all possible worlds is something like the French system. In terms of public satisfaction, the French are near the top. They spend only about 10 percent of their national income on health care services—very reasonable, by international standards. It’s one of the most effective and efficient and high-quality systems in the world. Everybody is covered. There is complete choice of providers. And even though France spends a lot less money per person than we do, they have more physicians, more hospitals, and more hospital beds per capita. Like many other national health care systems that work, the French system is coherent and cohesive in terms of its financing, workforce planning, access to care, and accountability. All those parts work together toward the common goal of delivering quality health care.

Q:  How will we pay for the new national law?

A:  The law gets paid mostly through two buckets. One bucket is ten years of changes in the Medicare program, which is going to generate about $450 billion in savings to the Federal Treasury. For example, the hospital industry agreed to give up $155 billion in revenue that they would otherwise obtain from the Medicare program—they figured that if insurance coverage went up in the U.S., they would eventually recoup the loss. Same deal with the home health industry and others. The other bucket is new taxes and assessments on higher-income individuals, new fees on pharmaceutical companies and medical device makers, and a fee on insurance companies.

Q:  What’s an especially effective provision in the new law?

A:  One of my favorite provisions in the law is a 10 percent tax on the use of indoor tanning services. When Senate Majority Leader Harry Reid brought out his version of the bill, initially there was no indoor tanning tax. Instead, there was a tax on elective cosmetic surgery that became known as the “Bo-Tax.” It was met with shrieks of anger from many consumers—particularly women—who felt that it was discriminatory, as well as strong opposition from the American Society of Dermatologists.

In the final version, the “Bo-Tax” was removed. At the last minute, the Senate substituted a tax on indoor tanning services. In recent years, we’ve seen an explosion in skin cancer diagnoses such as melanoma, especially among women between the ages of 15 and 35. From a public health standpoint, that’s one of the most defensible measures in the law.

Thea Singer is a Boston-based science journalist and author.