On health care, sides agree on where to go, not how to get there

MERIDEN – To preface his remarks on health reform, Stuart Butler noted that he wore his “kumbaya tie” for the occasion.

“If you were thinking this was going to be the health care equivalent of mortal combat, you probably should leave now,” Butler, vice president of domestic and economic studies at The Heritage Foundation, said Thursday at what was billed as a “hype-free” health reform debate.

Indeed, on many points, Butler and his counterpart, Len Nichols, director of the Center for Health Policy Research and Ethics at George Mason University, agreed. And in many ways, that was the point of the conversation, which returned frequently to the importance of bipartisanship and transparency in achieving significant changes in national policy.

Both men predicted the demise of the employer-based health care system and said the nation must still find a way to control health care spending. They agreed on the need to give everyone access to health care at a cost individuals and society can afford.

What they disagree on, they said, is how to engineer it.

The debate, sponsored by Connecticut Health Advancement and Research Trust, the parent organization of the Universal Health Care Foundation of Connecticut, occurred as Americans remain deeply divide on the health reform law.

In a September poll conducted for the Kaiser Family Foundation, 49 percent of voters said they had favorable views of the Patient Protection and Affordable Care Act, while 40 percent said they viewed it unfavorably.

Most people surveyed saw some benefits to the law. Sixty percent believed low-income Americans would be better off, and 57 percent said the uninsured would be. But only 42 percent believed the country as a whole would be better off. And asked whether “you and your family” would be better off, only 32 percent said yes; among people 65 and older, only 21 percent did.

Butler and Nichols spoke of the enormity of changing the health care system. Butler noted that if it were its own nation, the U.S. health care economy would be larger than Britain’s.

“You cannot have a conversation about serious, comprehensive, transformational health reform in this country without making half the population angry and the other half scared,” said Nichols, who served as a senior advisor for health policy at the Office of Management and Budget during the Clinton administration’s health reform efforts.

“This is normal democracy when you talk about something as big as the economy of England,” he added. “It touches every single one of us in profoundly personal and special ways.”

Butler said health reform will bring a struggle over how much control should be held by the states and how much should be centralized with the federal government. He warned that the law will do little to rein in costs, saying the cost-saving provisions range from “the misplaced to the delusional,” and questioning whether people would ultimately embrace cost-saving changes.

Expanding health care coverage first, without first controlling spending, he said, reflected a political strategy. Starting with spending cuts would sap public enthusiasm for changes.

Nichols offered a different view: Health care changes are not popular for incumbents, but the country can’t afford not to make them.

“The status quo is driving jobs out of the United States, whether you like it or not,” he said.

Nichols said the law changes two obsolete business models. It stops insurers from covering only the healthy. And it alters incentives away from a fee-for-service system, which encourages people to receive more medical services, to one that rewards value.

Both said they expect to see the demise of the employer-based health care system.

The reform law includes tax subsidies for some people to purchase health insurance through marketplaces called the exchanges, which Butler predicted will overtake tax subsidies for employer-based coverage. He said he expects more employers to discontinue health coverage, possibly in a shift similar to the shift from pensions to 401(k) plans, with employers giving workers a vehicle for coverage but no longer being fully responsible for it.

“That era was going to end anyway,” Nichols said.

Health reform, he said, would create a marketplace to catch people who do not have employer-sponsored coverage and give them access to economies of scale in purchasing insurance. The demise of employer-based coverage, he said, would be a good thing, allowing companies to focus on being competitive, not whether they have good risk pools for insurance.

Both men lamented the lack of cooperation and bipartisanship in Washington.

Bipartisanship, Butler said, requires openness and taking matters one step at a time. It would be better to tackle health reform piece by piece, he said. When you try to do everything at once, he said, people on each side imagine what it will produce.

“This is why a lot of people in America think that the health care legislation is a plot to socialize America,” he said.

When the reform bill was being debated in Congress, Nichols said he was told by a health care executive, a lifelong Republican, “I know Republicans in Congress are lying about this bill. But I don’t trust Democrats to tell me the truth.”

“We have lost the trust it takes to run a republic,” Nichols said.

Some of the questions posed to the panelists related to Connecticut’s SustiNet Health Partnership. SustiNet – created by the Univeral Health Care Foundation – grew out of an effort to achieve universal health care with a public option before federal health reform passed. A board is working to develop a SustiNet health plan, which is intended to be offered to public employees, Medicaid recipients and the public.

“You’re basically doing what PPACA is on a small scale at about a 6-month-ahead-of-us pace, so we thank you for being an experiment for the nation,” Nichols said.

Nichols urged policymakers to establish a bipartisan, balanced group of people who can deal with both cost and coverage and address the issues in a civil way that is clear to the public.

Butler warned that it is difficult to create a level playing field for insurers in a system with a public option, and suggested making sure that the people who set the rules for competition remain separate from the public insurance plan.

Big changes rarely work precisely as planned, making it important to make adjustments as the plans progress, he said.

And, he said, there is a necessary condition for the plan working: A shared vision.