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Olimpia Zagnoli

Letters

Seeking Choice in Health Reform

August 30, 2009
The New York Times

To the Editor:

Re “Real Choice? It’s Off Limits in Health Bills” (Economic Scene, front page, Aug. 26):

As a physician, I was encouraged by David Leonhardt’s article. He hits the nail on the head. Real consumer choice is not addressed in the bills currently being considered in Congress and by the White House.

In contrast, the Wyden-Bennett bill speaks directly to the issue of choice by phasing out employer-based health insurance and allowing individuals and families to choose the health plan that’s best for them. Moreover, the universal coverage this bill proposes is comprehensive, portable, affordable and financially sustainable.

Unfortunately, President Obama seems to feel that universal coverage can be accomplished without changing the status quo. It is time to rethink this position, educate the American public on the real costs of employer-based health care and move in the direction of true health care reform.

Those who stand to benefit most are the American people themselves.

Daniel N. Ovadia
Santa Barbara, Calif., Aug. 26, 2009

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To the Editor:

David Leonhardt correctly argues that private insurance plans and employers exercise too many of the choices in today’s health care system, and that a better system would give people more control of their own care. But the other essential half of the dyad that should control the use of medical resources is physicians.

Doctors in consultation with their patients — not insurance plans, not employers and not government officials — now make most of the decisions that determine how health dollars are spent. Fee-for-service payment and an entrepreneurial, fragmented system heavily weighted in favor of specialists cause unsustainable cost inflation.

A reform that does not address these problems, as well as eliminate or reduce the role of private insurers and employers, cannot succeed. Regrettably, none of the proposals now before Congress meet this requirement.

Arnold S. Relman
Marcia Angell
Cambridge, Mass., Aug. 26, 2009

The writers are physicians and former editors in chief of The New England Journal of Medicine. Dr. Relman is professor emeritus of medicine and social medicine at Harvard Medical School, and Dr. Angell is a senior lecturer in social medicine there.

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To the Editor:

David Leonhardt’s article promoting “real choice” in health insurance alludes to a fundamental difficulty with this approach. Without some system for helping the consumer know what he is choosing, the whole premise of the free market breaks down.

As Mr. Leonhardt observes, today’s employee depends on his company to provide a menu of sensible choices. As the well-known problems with Medicare Part D insurance demonstrate, having the consumer deal directly with insurance companies is a risky undertaking.

The two major issues, which apply to the broader case as well, are understanding what is covered and being able to change providers if the coverage is modified.

This is not to say that the current system should continue. Mr. Leonhardt’s description of its fatal flaws is spot on. But any proposal for “competition” and “free market” mechanisms must include some way to make the consumer an educated consumer.

I expect that one part of this must be government regulation of the details of the insurance that can be offered. Until such mechanisms are added to any free-market scheme, the sensible fears of the currently insured will prevent its adoption.

Marc Auslander
Millwood, N.Y., Aug. 26, 2009

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To the Editor:

For most people, “real choice” in health care is not the choice of an insurance plan; it’s the choice of a primary care physician.

Employer options come and go, and one private plan is usually as good as another, as long as an involuntary switch doesn’t come between a family and a trusted, longtime caregiver. Fragmented physician panels that capriciously interrupt continuity of care are resented by patients and physicians alike.

As in so many other ways, single-payer health care provides the answer: one big panel of doctors, with complete freedom of choice for patients. Of course, that’s not politically viable.

It might protect hard-won, deeply valued doctor-patient relationships, and it might save money and produce better health outcomes. But we wouldn’t want to harm the insurance industry!

Bruce Soloway
Bronx, Aug. 26, 2009

The writer, a physician, is vice chairman of the department of family and social medicine at Montefiore Medical Center.

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To the Editor:

Historically, Americans have believed in economic competition, freedom of choice and fairness in seeking economic opportunity.

During the rampant industrialization of the nation near the end of the 19th century, competition fell victim to monopolies. The passage of the Sherman Antitrust Act in 1890 was watershed legislation by the federal government to maintain competition.

During the Progressive Era leaders like Woodrow Wilson and Theodore Roosevelt were obliged to call for regulation in business and finance. Franklin D. Roosevelt ushered in even greater federal regulation during the Great Depression.

The current recession has compelled the federal government to become a more gigantic player in the marketplace. President Obama should stick with his call for a public option to bring about choice and competition within the health insurance industry.

Don Blankenbush
Pennington, N.J., Aug. 26, 2009

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To the Editor:

Regardless of their respective strengths and weaknesses, all of the bills for health care reform are too complex to explain, grasp and support. And Republicans have made it abundantly clear that they will oppose any truly meaningful change.

Yet these very obstacles present the president with the opportunity to do what is sensible and right: to put his conviction, passion and clout behind a single-payer system.

Will people be afraid of so radical a change? The majority probably will; people tend to fear the unknown.

But “the shock of the new” is as old as innovation itself. Eventually, people adapt to change and ultimately embrace it.

Byron Alpers
Shorewood, Wis., Aug. 26, 2009

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To the Editor:

Re “World’s Best Health Care” (editorial, Aug. 26):

The United States health care system is not the world’s best by almost any measure. But one must understand that health care is typically measured by its outcomes. These outcomes, like longevity and infant mortality, are more than just a consequence of availability of health insurance and access to doctors and hospitals.

Health care outcomes are influenced by many complex and poorly understood factors that relate to society’s structure, including socioeconomic forces and race. This is true in the United States and globally.

The American health care system is in bad need of reforms that will eliminate the tragedy of 46 million uninsured people.

But our government and its citizens also need to study and address the broader issues, like economic inequity and racial segregation, that underlie our inability to achieve the health care outcomes that other societies have achieved. Otherwise, we will be very disappointed with the results of the current legislative efforts.

Garrett M. Nash
New York, Aug. 26, 2009

The writer, a physician, is an assistant professor of surgery at Weill-Cornell Medical College.

    Seeking Choice in Health Reform, NYT, 30.8.2009, http://www.nytimes.com/2009/08/30/opinion/l30health.html

Economic Scene

Real Choice? It’s Off Limits in Health Bills

August 26, 2009
The New York Times
By DAVID LEONHARDT

Consider the following health insurance plan.

It refuses to pay for certain medical care and then doesn’t offer a clear explanation. It does pay for unhelpful care that ends up raising premiums. Its customer service can be hard to reach or unhelpful. And the people who are covered by this insurer have no choice but to remain with it — or, at best, to choose from one or two other insurers that are about as bad.

In all likelihood, I have just described your insurance plan.

Health insurers often act like monopolies — like a cable company or the Department of Motor Vehicles — because they resemble monopolies. Consumers, instead of being able to choose freely among insurers, are restricted to the plans their employer offers. So insurers are spared the rigors of true competition, and they end up with high costs and spotty service.

Americans give lower marks to their health insurer than they do to their life insurer, their auto insurer or their bank, according to the American Customer Satisfaction Index. Even the Postal Service gets better marks. (Cable companies, however, get worse ones.) No wonder President Obama’s favorite villain is health insurers.

You might think, then, that a central goal of health reform would be to offer people more choice. But it isn’t.

Real choice is not part of the bills moving through the Democratic-led Congress; even if the much-debated government-run insurance plan was created, it would not be available to most people who already have coverage. Republicans, meanwhile, have shown no interest in making insurance choice part of a compromise they could accept. Both parties are protecting the insurers.

That’s a reflection of the thorny politics of health care. On one hand, big interest groups are lobbying hard to keep some form of the status quo. Insurers don’t want people to have more choice. Neither do employers and labor unions, which now control huge piles of money spent on health care. Nor do hospitals and drug makers, which benefit from all the waste now in the system.

On the other hand, the people who stand to benefit most from having more choice — all of us — are not agitating for change, because the costs of the system are hidden from us. A typical household spends $15,000 each year on health care. But most of it comes in the form of taxes or employer deductions from paychecks, which means insurance can seem practically free.

As a result, people may not like their insurer, but they don’t hate it, either. If anything, they are more anxious about losing their insurance than they are eager to be given more choice. And that anxiety has driven the White House’s decision to pursue a fairly conservative form of health reform.

To be clear, the versions of reform now floating around Congress would do a lot of good. They would make it far easier for people without an employer plan to get health insurance and would make some modest attempts to nudge the health system away from its perverse fee-for-service model.

Yet they would not improve most people’s health care anytime soon. Giving people more control over their own care would. White House advisers, however, decided against that option long ago. They worried that opening up the insurance market would destabilize employer-provided insurance and make Mr. Obama’s plan vulnerable to the same criticism that undid Bill Clinton’s: that it was too radical.

They may well have been right. Then again, given all the flak they have been taking anyway, they may have been wrong.

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The best-known proposal for giving people more choice is the Wyden-Bennett bill, named for Ron Wyden, an Oregon Democrat, and Robert Bennett, a Utah Republican, who introduced it in the Senate in 2007. There are other broadly similar versions of the idea, too. One comes from Victor Fuchs, a Stanford professor sometimes called the dean of health economists, and Ezekiel Emanuel, an oncologist and an Obama health-policy adviser.

In the simplest version, families would receive a voucher worth as much as their employer spends on their health insurance. They would then buy an insurance plan on an “exchange” where insurers would compete for their business. The government would regulate this exchange. Insurers would be required to offer basic benefits, and insurers that attracted a sicker group of patients would be subsidized by those that attracted a healthier group.

The immediate advantage would be that people could choose a plan that fit their own preferences, rather than having to accept a plan chosen by human resources. You would be able to carry your plan from one job to the next — or hold onto it if you found yourself unemployed. You would never have to switch doctors because your employer switched insurance plans.

The longer-term advantage would be that health insurance would become fully subject to the brutal and wonderful forces of the market. Insurers that offered better plans — plans that drew on places like the Mayo Clinic to offer good, lower-cost care — would win more customers.

“That’s the way the rest of the economy works,” says William Lewis, former director of the McKinsey Global Institute.

Politically, though, the full voucher plan is still too radical, which is why the Wyden-Bennett bill has attracted support from only 13 other senators — four Republicans, eight Democrats and Joe Lieberman. So Mr. Wyden has come up with a narrower version.

It expands the exchange that Democratic leaders are already planning to create for the uninsured so that many more people would be allowed to use it. (If the exchange were limited to the uninsured, any government-run insurance plan, a crucial part of reform for many liberals, would not be available to most people.) But Mr. Wyden isn’t having much luck with this idea, either. The support for the employer-based system is simply too strong.

And the defenders of the employer system have some legitimate arguments. An insurance exchange may end up having some of the same pitfalls as 401(k) plans, in which some workers make poor choices. Having employers navigate the complex landscape of insurance, the defenders say, may be better for employees.

Here’s what I would ask those defenders, however: Given all the problems with health care — the high costs and decidedly mixed results — how comfortable are you defending the status quo? Why force people into a system you think is better for them?

If people were instead allowed to choose, all but a small percentage might indeed stick with their employer plan. In that case, a Wyden-like proposal wouldn’t amount to much. It certainly would not destabilize the employer-provided insurance system.

Then again, if lots of families did switch to a plan on the exchange, the impact would be quite different. With fewer employees signing up for on-the-job insurance, companies might shrink their benefits departments. The number of companies offering insurance would keep dropping. The employer insurance system could begin to crumble.

But wouldn’t that be precisely the fate that the system deserved?

    Real Choice? It’s Off Limits in Health Bills, NYT, 26.8.2009,
    http://www.nytimes.com/2009/08/26/business/economy/26leonhardt.html