Fighting for Our Health
Strictly speaking, the question is not whether we can afford to cover all Americans, even with a darkening economic forecast. We already spend far more per person on healthcare than comparable countries, which cover more people and get better results than we do. But one payer's savings are another provider's profits, and one patient's subsidies are another person's taxes. So Representative Pete Stark of California, the Democrat who chairs the House Ways and Means subcommittee on health, says, "how we structure [financing] is mostly a political question--not an economic one."
Health industry interests, employers and taxpayers are all going to have to make painful concessions to raise the needed $1 trillion. When holding hearings on healthcare reform, Stark says, "If anybody in the room is smiling, you keep going. And when everybody's frowning, that's when you drop the gavel because you know you have the right mix" of concessions.
Insurers have AHIP to represent their interests; drug companies have the Pharmaceutical Research and Manufacturers of America (PhRMA). Doctors have the American Medical Association; hospitals have the American Hospital Association. Big businesses have the Chamber of Commerce; small businesses have the National Federation of Independent Businesses (NFIB). Unions speak for the workers most likely to have insurance. Blue Dog Democrats will yap for those who dislike federal spending, and the Republican Caucus will growl at tax increases. But there has been no organized, well-financed lobbying apparatus for the almost 50 million uninsured and the millions more who may unexpectedly discover they have no coverage when they need it.
That, says Gerald Shea of the AFL-CIO, is why HCAN is so important. Most of the organized interests are professing a desire for reform. Shea takes them at their word, because even the healthcare industry is feeling the strain of a collapsing system. (Ironically, Shea took a job at the AFL-CIO held by Karen Ignagni before she joined the insurers in 1993, and he says, "I think Karen genuinely supports reform out of personal conviction and out of institutional reasons.") But the cost of change is so big that he doubts these groups can stomach what's required.
"My biggest fear is that people won't be able to make the amount of change we need to really make a difference," says Shea. "The question is not whether they want change, because I think they genuinely do. The question is whether they've got the spine to provide leadership for big change. Because unless we have big change, we'll wind up with something, but we'll continue to be eaten alive by the costs and we'll continue to see coverage just go down the chute."
How big is the change Shea's talking about? So big that it is impossible to describe with a word of only three letters. That's a shame, because the numbers involved here have so many zeros that they're next to impossible for regular people to understand. But the only way to understand the politics of healthcare is to follow the money, so bear with me.
The scale of the healthcare industry is so vast that it makes the $1 trillion or more in additional spending likely required by the president's proposal over the next ten years seem small. If trends continue, total healthcare spending in that window could equal thirty-seven times that amount. Healthcare spending already accounts for more than 15 percent of GDP, and cost growth has priced almost 50 million Americans out of insurance and is forcing businesses to drop coverage at alarming rates. If nothing is done, economists predict, our healthcare bills will double again by 2020 and we'll have more than 60 million uninsured.
Because we only think about insurers when they're raising our premiums or denying benefits, it's tempting to believe we could fix this problem simply by seizing unnecessary profits from greedy companies. Insurance companies may be greedy, and the tenfold rise in their profits over the past five years may be obscene when millions of Americans have lost their insurance. But the profits of the top seven for-profit insurance companies are equal to less than 1 percent of annual healthcare spending. Even if we eliminated insurance companies altogether and recouped some of the administrative costs, which can consume as much as 30 percent of some policies, we still would need additional money to fix our problems.
The biggest savings--an estimated $700 billion a year, or one in every three healthcare dollars--can be captured only by revolutionizing the way medicine is practiced. This money is going to treatments that have not been shown to make patients better and in some cases make them worse. One study of seniors in the Medicare program suggests that patients receive appropriate care only about half the time. A study by the RAND Corporation found that doctors perform surgeries in which the risks outweigh the benefits to their patients, as often as one-third of the time in the case of a particular heart procedure.