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Health-Care Reform Doesn't End in 2009. It Begins.


Jon Cohn delivers a thorough rebuttal to this morning's missive from Robert Samuelson, thus freeing up the chunk of my morning that would've otherwise been devoted to that task.

I did want to add one point, though: We have an unfortunate tendency to think of policy reform as episodic rather than continual. The process of reform is sold as a legislative Big Bang rather than an ongoing effort with lots of different policies all building on one another. This is as much the fault of reformers, who need to increase public support for their policies, as it is of reform's opponents.

But it doesn't make much sense. There's a lot of commentary about whether the health-care reform bills under consideration will do everything that's required to repair our health-care system. There's not a lot of commentary about whether the the bills under consideration will be a step forward in reforming our health-care system and thus make positive changes easier in 2013, and 2019, and 2022. But that's probably the more important question.

Samuelson's argument is that "fee-for-service medicine -- Medicare's dominant form of payment -- is outmoded." He wants us to move toward "coordinated care networks that take responsibility for their members' medical needs in return for fixed annual payments." That's the dominant payment system in countries like Britain. It is very rare in America. But there's one bright spot. Massachusetts. After its earlier raft of reforms expanded coverage and raised short-term spending, the state got serious about cost control. It formed the Special Commission on the Health Care Payment System, which just released a unanimous ruling urging that Massachusetts to abandon fee-for-service payment and adopt a coordinated care strategy based around fixed annual payments.

In other words, the only example of a unit of American government following Samuelson's prescription came in the aftermath of a reform package much like the one being considered in the Congress. This was not an accident. Reformers in Massachusetts would have told you then, and will tell you now, that creating a near-universal right to coverage was a necessary first step in building the political will for true cost controls. For Samuelson to argue against a Massachusetts-style reform plan on the grounds that he would like us to move away from fee-for-service is to be truly hostile to the evidence. Of the 49 states that have not implemented a Mass-style reform plan, none of them are moving away from fee-for-service. Conversely, the one state that has passed a Mass-style plan is moving quickly to attack fee-for-service.

The larger point is that given that there is precisely zero chance that the bills moving through the Congress will solve all the problems of the health-care system, the relevant question is not just whether they are an improvement on the status quo -- they unquestionably are -- but how they contribute to the next set of reforms. Health-care reform doesn't end if we pass a bill in 2009. It begins.

Photo credit: AP Photo/Hans Pennink.

By Ezra Klein  |  August 10, 2009; 11:58 AM ET
Categories:  Health Reform  
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James Fallows provides some historical context for all the politickin'

(via TPM)

Posted by: bdballard | August 10, 2009 12:01 PM | Report abuse

I get the wisdom of incremental reforms, but a single quite liberal state like MA isn't the posterperson for incrementalism that the US Congress is likely to follow.

In Congress, tsunami-like reform seems to be the approach, except the waves comes in 20 to 40 year increments. What essentially has changed in Medicare since 1965? Part D (Drug Care); and Private Sector alternatives to Part B/Part A (the so-called Medicare Advantage - that is subsidized by the government to give the private insurers a benefit for their bottom line profit.)

Congress hates reforms because they rock the electoral boat, so they do as little as possible of them. It takes a 100 foot high wave of impending disaster to get them to act. That isn't incrementalism.

Where, for instance, is the Medicare coverage for vision, hearing, and dental 45 years after the first Medicare law?

Posted by: JimPortlandOR | August 10, 2009 12:13 PM | Report abuse

Ezra I asked about this in a previous thread, but now it's actually on topic. ;)

Have you looked at PYLL/YPLL (Years of potential life lost) lately? A lot of the discussion of health care comparing countries center on the relatively crude measure of life expectancy, but as I understand it YPLL is more accurate even though we seldom hear about it.

I first learned about the metric from your Health of Nations series. From the latest OECD data, the US ranks third last for female YPLL among OECD countries with data (Mexico and Hungary are worse) and fifth last for male YPLL (Poland and Slovakia are also worse).

So YPLL makes it abundantly clear that the US isn't getting much in the way of results despite spending more per capita (and as a percentage of GDP) than any other major nation.

For details see:

Posted by: crust1 | August 10, 2009 12:21 PM | Report abuse

So here is another question - instead of one single monolithic 1000 page bill, would it have been better if it was collection of bills? One for iMAC, one for exchange and one for coverage expansion on continual basis as money is available / freed up. We could have seen interesting voting pattern. May be each committee in each Chamber could have taken a bill instead of all this overlapping.

Just thinking aloud.

I am not sure how much water it holds when President claims that he wanted both 'spinach and dessert'. The reason is so far he all seems to bother only more about costly dessert without much regard to fiscal balance and seems like just paying 'lip service' for spinach. (In other words, so far it seems the First Movie of 2 versions Fred Hiatt talked on this paper. Fred is indeed getting into groves with his recent commentary...)

Posted by: umesh409 | August 10, 2009 12:33 PM | Report abuse

Where, for instance, is the Medicare coverage for vision, hearing, and dental 45 years after the first Medicare law?

JimPortlandOR is right (as usual) but I think that proves Ezra's point, which, as I understand it, is that we will have to keep pushing hard to get where we want to be. What saddens me is the knowledge that pushing hard requires serious money behind it. I don't think that that money will be there after this round, if any degree of reform is passed at all.

Posted by: eRobin1 | August 10, 2009 1:00 PM | Report abuse

About 23% of all Medicare beneficiaries are in a Medicare Advantage plan w/capitation (Medpac 6/09 report). It's not particularly rare at all.

re: the intersection of public health payers and capitation, note that it's an open secret that Americhoice, United's Medicaid product, is their most profitable line of business and fully capitated.

the medicaid managed care model and medicare advantage model are probably what these plans will end up looking like (highly regulated yet ultimately profitable, decent customer satisfaction scores and quality scores); and, speaking to erobin's question, they use their economies of scale (and admittedly higher per patient costs in MA) to include things like dental, vision, etc. (though on a certainly inconsistent basis).

Posted by: ThomasEN | August 10, 2009 1:11 PM | Report abuse

As I've said before, it doesn't seem as if this bill cares much about HEALTH CARE.
They care about insurance, about grouping people together, about all sorts of things. But not the health CARE people get.
The number we keep hearing is that 45 or so million people have no health insurance.
Of those, may are here illegally.
Many have access to various plans, and choose not to take advantage of joining them (employer, affinity group, etc).
And many of them have access to a public plan (medicare/medicaid) and don't care, don't want to sign up or don't know about it.
So for a small number who aren't in the above - we have to change EVERYTHING about our health care plan (or, only change the good, leave in the bad?)? This doesn't make any sense.

The idea of tying your insurance to employment is incredibly outdated - but this bill only reinforces getting insurance thru your employer. Make it easier for people to get insurance (or better yet, HEALTH CARE) not thru their employer, and well, things will be better.

Check out some things the free market's doing - like Allow more of that.
Innovation isn't taking place in other countries, it takes place here (oh, one reason that other countries' health care is less expensive). Why get innovation out of the equation...because it seems as if we're going towards a govt run health care system with this bill...

Posted by: atlmom1234 | August 10, 2009 1:31 PM | Report abuse

*Innovation isn't taking place in other countries, it takes place here*

Anyone who works in pharmaceutical research knows this isn't true. In fact, biochemical and pharmaceutical research might be the *most* international of the major research and development fields.

Where do people get this idea from? do you actually know any biochemists?

Posted by: constans | August 10, 2009 2:38 PM | Report abuse

So, Samualson is a fool because he didn't learn the lesson of Mass. that if you pass reforms that expand coverage and spend more money first... you can eventually get a commission to issue a recommendation that you change the fee structure.

Wow. Solid argument.

Posted by: 98thStory | August 10, 2009 4:17 PM | Report abuse

Thank goodness for Jon Cohn......Samuelson does what I have seen so many other intellectual conservatives do---if you do not reform the system into the perfect system--right now--then you are wasting your time and you should do nothing until you can pass the perfect solution. This is impractical for something as complex as healthcare, impractical for something as large as healthcare, and impractical in that we simply do not legislate that way. We need to take an initial big step (and I believe the HELP bill is such a step) then continue to work on the other parts of the system that need support....primary care, more RNs/PAs, less fee for service, etc.

Posted by: scott1959 | August 10, 2009 6:31 PM | Report abuse

Jon Cohn delivers a thorough rebuttal to this morning's missive from Robert Samuelson, thus freeing up the chunk of my morning that would've otherwise been devoted to that task.

That's nice. It leaves the rest of us wondering why lying, untalented @ssholes like Samuelson, Hiatt, and Amity Shlaes still receive paychecks from this dinosaur.

Posted by: ifthethunderdontgetya | August 10, 2009 11:41 PM | Report abuse

Ezra - two points. First the Chairman of the MA Senate's Committee on Health Care was on C-Span. He said that the most important factor in the success of their plan was that all the (major) health insurance companies in the state were non-profit. Makes you think, eh?

Second, I have been saying all along that if we had an universal government run plan like HR676, we would be in a much better position to make needed changes in medical delivery and practice. Do you agree?

Posted by: lensch | August 11, 2009 1:12 PM | Report abuse

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