"Lesson: Know Your History and Learn From It" by Rashi Fein

Barack Obama is more than interested in helping right the wrongs in America’s health care system in an effective and efficient manner. To me that means some variation on an “Improved Medicare for All” (note: “Medicare for All” is not quite good enough) or what some call “single-payer.” Nevertheless, I do not believe that kind of a program is in the cards at this time. I believe we will have to settle for “improving America’s health care system in a more or less efficient and effective manner.” If so, we should make certain that that occurs in a manner that can be improved and built upon over time. Though a compromise, that’s a great advance even a somewhat effective and efficient health care system would be over where we stand today.

What are the things the president should know if he is to achieve his goal? Much can be subsumed under the heading: “Know Your History and Learn From It.” Under that heading I would include:

1. The problems with our existing system are real. And the trends are deeply troubling. Even so, there will be tremendous pressure not to address universal health insurance till we have “solved” the problem of the high and rapidly rising expenditures for health care.

Regrettably, most of the cost-cutting agendas that have been discussed thus far will turn out to be ineffective. That is so because most of them don’t want to hurt anyone and have no teeth. If we spend less, someone will receive less. That is unacceptable to those “someones.” It is hard to imagine getting from here to there without the adoption of a health care budget. At present we do not have the delivery structure to make a health budget effective. More importantly, we lack the political will. If we are not prepared to make the hard decisions that would contribute to real cost control, it may well be that we will remain unprepared till we enact universal insurance and have to deal with the resultant cost crisis. So be it.

2. Health care reform is not just about paying for care or removing some of the economic barriers to care. The president must understand that universal health insurance is very important, but it is not sufficient. Indeed, the president will be frightfully embarrassed if insurance reform is enacted without considering delivery system reform because the public will surely be disappointed with its lack of access. An insurance card is not a synonym for access. We must deal with the shortage or primary care physicians if we want to increase access.

3. The president should remember that change is not just a campaign slogan. Change really can happen: Medicare was enacted. But there is a lesson: Medicare did not appear upon the scene in 1965, the year it was enacted. It had been debated for years. Over those years more and more Americans came to understand it, more and more senior citizen groups were formed, more and more political action took place. Its proponents did not walk away from the battle when their first attempt failed to be enacted. President Obama can count on the people but only if he educates them. That will take time, but that’s the way it is.

4. Everything is connected. But you can’t cure every problem in one piece of legislation because to do so would make any proposal so complex that the public wouldn’t understand it and lack of understanding leads to lack of mobilization and lack of mobilization leads to failure. Furthermore, if the system that is designed is overly complex, the error rate will be very high (even if each step is carried forward efficiently). There is virtue in simplicity. Consider Medicare which except for the disabled is based on age in contrast with Medicaid which is based on income. Age needs to be checked once; income must be checked virtually continuously.

5. While half a loaf is better than none, that doesn’t tell the president whether to settle for half a loaf. The art of compromise is an art. There is no formula that provides an answer. Yet, I would posit an important consideration: any compromise should represent an advance toward a recognized goal and has to be the kind of action that can be built upon and does not have to be dismantled when we are ready for the next step.

The president will have many options. I would hope the president would not view the problem as one that is technical and requires some technical solution because it is bereft of values. The choices are replete with values. If the president believes he must retain the existing employer system either because of public support and understanding or because the idea of changing the flow of all dollars in one fell swoop seems too daring and daunting, he should recognize that that system is not appropriate in the long run and, therefore, that any plan should look toward phasing it out and should begin to do so by providing an alternative for some part of the population. One could begin a federal program for children, say up to age 12 or 15 or 18 and essentially take them out of the existing system of coverage as dependents under employer provided insurance with the view toward raising the age at periodic intervals. One could offer a separate federal program (of the quality that Congress now has) and make that available to employers and to individuals and have private sector insurance compete with the federal program (which over time could come to replace private insurance and making it easier to shift to a tax based system). There are numerous options, but the real requirement is that the president know what goal he has in mind. That’s the value part, the rest is technical. We are not yet ready for the technical. First we must know the President’s values and he must know ours.

Rashi Fein
Professor of the Economics of Medicine, Emeritus
Harvard Medical School
Rashi Fein helped draft several bills that would have created a national health coverage program while working with the Committee for National Health Insurance in the 1970s and 80s.