What is about to happen-or not happen-to health care in America,at least for the next few years?
We're not going to see any quick, large-scale expansion offederal health benefits to replace private health insurance.
We're not going to see any broad replacement for the catastrophicMedicare benefits passed by Congress, then dropped like a hot potatowhen too many seniors objected to paying for them.
When we do see new federal benefits-when and if in the shortterm-there will have to be new taxes or premiums or payments in oneform or another.
In an attempt to control costs, more of us are going to begetting care quarterbacked by someone-or someones-who decide whatkind of care we may have, what kind of care is appropriate for us andwhat is not. This is called 'managed care.'
Doctors, hospitals and patients-us-will all be subject toincreasing 'incentives' to give or get care 'efficiently.' Translatethat into: Don't spend too much, or it'll come out of your pocket.
And those who argue for some broad new 'national health plan' tosolve health problems-including the problem of all the 30-somemillion Americans with no health insurance and millions more with badhealth insurance-had better not hold their breath. Any near-termprogress will be incremental, not sweeping.
These are my predictions after a meeting last week with thegovernment's chief payer for health care, Gail Wilensky, the newadministrator of the Health Care Financing Administration.
This Medicare-Medicaid agency currently spends $165 billion ayear paying for care for 55 million old or poor Americans. The waysit spends it and the rules it adopts tend to set the pattern for thenation's entire spending on health, now in the $650 billion ball parkand growing.
Wilensky is a health economist with wide experience in and out ofgovernment. Those who know her find her both realistic and humane, acombination she might find agonizing when trying to provide humanecare without new dollars. There are no perfect prophets, but she isin as good a position as any American to tell us what the Bushadministration and Congress may be able to agree upon in theforeseeable future, which-in today's climate-I'd define as maybe ayear.
Her statements in an hour-long session with a health reporters'group:
On medicare benefits: If they are increased, 'we should do it ona more thorough basis, not by a piecemeal addition of three or fourbenefits,' for example, the mammography benefit for older women lostwhen the catastrophic legislation was canceled. But 'until we solveother problems'-most outstandingly the problem of financing-newbenefits of any kind may have to be postponed.
On financing: As for the March 2 report of Congress's BipartisanCommission on Comprehensive Health Care, 'the Pepper Commission,'recommending an $86 billion program of health insurance for theuninsured and for long-term care, 'I'm troubled by the lack of afinancing scheme . . . While it's okay to say that is a problem oftax-writing committees to some extent,' they might have suggested afew ways.
On long-term care for the aged and disabled, a crying need in themind of many seniors: 'An issue we've got to deal with is to whatextent do we use private insurance, and what is the government'srole?' Whatever the role of government, 'I don't think it needs to bebudget-neutral'-translation, not exceeding the current budget-'at alltimes . . . I do assume that any kind of program to come out of thisadministration would have its own financing attached.'
But whether we think about long-term care or other new benefits,we have to realize we're dealing with an aging population, 'we'llhave to be cautious in bringing in new entitlement programs.'
And given the rapidly aging population-a population that iscertain to cost more to care for in sheer numbers-'it is a questionwhether we will be able to broaden benefits regardless of income.'
On the uninsured or underinsured employed: 'I have great concernabout mandating employers to provide benefits,' for fear of thwartingnew small-business activity and putting minimum-wage workers out of ajob. 'We're struggling now {in this administration} with finding away to encourage employers or to give them a push, without raisingsome of the problems of mandated insurance.'
On value for money: 'There are a lot of concerns that we are notgetting value for our money, that some health care may not benecessary or appropriate. I think if we could make people believethey are getting good value, they'd be substantially less concernedabout the money they're spending.' On oversight of the quality ofcare, on research to determine the best ways of care-much of itresearch just starting-'not enough people have been minding thestore.'
On managed care: 'I'm a strong advocate of managed care' in manyforms-various forms of HMOs and other prepaid health plans, and planswith 'incentives' for a more conservative, more cost-conscious use ofone's health plan.
'I'm not for coercing people into managed care. I think theyshould have options, and should be able to opt out of a plan.' But'I'm for such incentives as paying a higher deductible if you choosea more expensive plan, or paying a higher co-pay if you go out ofyour plan' for care.
'Managed care plans have particularly great potential for theelderly, who have so much chronic disease and often take severalmedications, some with adverse potential. This is far easier tocontrol in a managed system.'
On doctors' medical liability insurance and its high cost becauseof so many malpractice suits: 'This is one problem that has to besolved, particularly if there is to be sufficient participation ofobstetricians in Medicaid and other programs' to give prenatal careto needy and high-risk women.
On hospitals: 'When we look at nationwide hospital bed occupancyrunning about 60 percent-and when most people think an efficientoccupancy rate ought to be about 85 percent-it's a pretty good cluethat there may be a problem' of too many hospitals. 'I'm not forfederal regulation of occupancy rates. I am for financial pressuresand financial incentives to encourage efficiency.' And we may needto make exceptions to make sure some needed hospitals stay open.
On hospital mortality rates, published annually by HCFA in thepast few years but much criticized by hospitals for lack of validity:'We'll keep publishing them. I hope we can improve them.'
Wilensky is obviously a believer, as she has often said, in'incremental,' step-at-a-time improvements in the health system,rather than some sweeping change to a nationwide, government-paidsystem a` la Canada or Britain. This may be realistic in a time whena President pledges 'no new taxes,' when any new payment methods forhealth care, whether called 'taxes' or something else, will bedifficult to enact, and when the nation has many other needs besideshealth care.
She is also is a believer in controlling today's rapidlyescalating health costs by (1) managed care, which ideally restrictsthe care we get to that which is needed and of proved effectiveness;(2) financial incentives-or penalties-to encourage doctors, hospitalsand patients tobe cost-conscious about care; and (3) accelerated research to learnwhat kinds of care are really effective and should be provided.
Is it realistic to think these steps alone can control healthcosts? I fear not. I fear that, as time goes by, some of us mayhave to sometimes accept less care-effective but expensive care-thanwe'd like, a process that is already happening in underfundedinner-city hospitals like D.C. General Hospital.
But this is called 'rationing,' so I hope Wilensky is right.
Next Week: The definitive report on chicken soup.
