There seems to be a subtle shift in the momentum of health reform in the last few days. The turning point appears to be the Congressional Budget Office’s analysis of the cost of expanding coverage and the very limited impact, particularly in the next few years, of the proposed health spending control provisions. Faced with a string of monumental deficits, the American people, and even Congress, are extremely wary of programs that may add hundreds of billions of dollars a year to those deficits. As the CBO pointed out, people who previously did not have health insurance spend more on health care when they get coverage, adding to overall health expenditures. And government coverage extensions have a habit of costing far more than they were originally projected to cost. This reality is close to derailing reform efforts. But maybe that is okay, because the reform focus on really primarily been on expanding coverage to the uninsured. Maybe it should always have been on controlling costs and maybe that is what we should refocus on now.
If we can agree on some workable spending reforms and controls, lets put those in place. It will take several years for them to reach full fruition, but once we have enough evidence that they have bent the spending curve downward, we can implement the coverage expansion, hopefully universal coverage, because it is important for people to not perceive significant financial barriers to the receipt of care or to be anxious about how they would pay for a truly substantial course of treatment for a major disease. If we can’t figure out how to control spending, we shouldn’t be expanding coverage. There are some ideas that appear to have good potential–giving patients some financial incentives to pay attention to what care they are receiving; requiring doctors to share decision-making with patients on preference-sensitive care; forbidding providers from owning services and facilities to which they refer patients; limiting malpractice actions and awards, mostly so that doctors don’t have cover for excessive service delivery; defining clear end-of-life protocols that eliminate futile treatment and precluding suits when physicians follow those protocols; using more episode and value based payment mechanisms–and all should be tried and evaluated. If we can find a combination of methods to limit spending, we won’t have any problem agreeing on how to extend coverage.