| Today's Managing Health Care Costs Number is 3 |
A large number of Republican Senators expressed doubt and concern about all three of the Republican repeal plans that failed to pass the Senate over the past few days. Lindsay Graham pointed out that "skinny repeal"" would have disrupted the individual markets in many states. Rob Portman and Shelly Moore Capito and Dean Heller worried that Medicaid cuts would have devastated their states. Yet all of these Senators voted for various versions of the bills they had decried. They voted for them with mere hours (or less) to review the bills, which the Congressional Budget Office estimated would lead to 33 million more uninsured (full repeal with no replacement), 22 million more uninsured (repeal and replace), and 16 million more uninsured (skinny repeal).
John McCain stepped up and joined Lisa Murkowski and Susan Collins to stop the "skinny repeal" in the wee hours this morning - although all three have faced pressure from Mitch McConnell and taunts and threats from Donald Trump. Paul Ryan even offered promises of a Conference Committee - trying to reassure Senators that the House would not simply pass the Senate bill as is.
I expect Zombie Obamacare Repeal will be back, and there's no guarantee that the Republicans won't get the votes in the future. But for now, we've dodged another bullet - and efforts to throw 1/6 of the US economy into turmoil have at least been put off.
We can't fool ourselves into thinking that we have preserved a wonderful system, though. The Commonwealth Fund continues to remind us that our system is the most expensive in the world, and we have the worst outcomes of all developed countries.
Eric Schneider and colleagues of the Commonwealth Fund had a perspective piece published on nejm.org two weeks ago that pointed to four ways the US health care could transition to being the "number one" health care system in the world. It's good to read commentaries from forward looking optimists at a time when public policy seems so grim. Their suggestions didn't involve more money, but would require fundamental rethinking of how we finance, organize, and deliver health care. Repeal of Obamacare would make it virtually impossible to achieve these goals.
- Lack of access: This is driven largely by cost barriers - and has to be solved by a combination of providing more generous insurance to lower out of pocket payments - but we also will need to genuinely lower the cost of health care. Higher deductibles and more cost sharing will just make this worse.
- Underinvestment in primary care: I would have instead characterized the problem as overinvestment in expensive specialty care. The authors would have us increase primary care capacity - although I doubt costs would come down without decreasing specialty capacity.
- Administrative inefficiency: The authors note that our finance system leads to multiple layers of value-destroying costs. These are pretty entrenched, but simplifying systems and getting rid of administrative costs would help.
- Disparities: As long as disparities continue to be so striking, we will continue to have terrible outcomes for those with less access (to health care and perhaps more importantly to environments that promote healthier behavior).
It's hard to see us making progress on these four fronts when we have a Congress and Administration focused on lowering taxes on the super-rich, willing to toss tens of millions off insurance, ignoring climate change and dismantling the bipartisan legacy of environmental protection. Red states like Texas in the vanguard of the Trumpist approach to health care and to government now see shocking increases in rates of maternal mortality, and decreases in life expectancy.
But staving off repeal (for now) at least means we'll not be even further behind when we have the next opportunity to improve health after the departure of the current administration. We owe a debt of gratitude to McCain (and Murkowski and Collins) for keeping us from further backsliding early this morning.
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