Health Affairs, 26, no. 6 (2007): 1551-1552 doi: 10.1377/hlthaff.26.6.1551 © 2007 by Project HOPE	New Online   Pay Cuts For Medicare Docs   Access To Care Woes   Public Coverage More Efficient   Empowering Consumers

This Article Abstract Reprint (PDF) Submit a response to this article Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services E-mail this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to My Personal Archive Download to Citation Manager Reprints & Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Roper, W. L. Search for Related Content PubMed PubMed Citation Articles by Roper, W. L. Related Collections Health Reform Politics

Perspectives

PERSPECTIVE

Here We Go Again—Lessons On Health Reform

Abstract

 
The 2008 election will focus renewed attention on fundamental health care reform. Lessons from past politically driven reform efforts show that although fundamental reforms may make for good politics, a systemic shift in how health care is financed and delivered is unlikely to occur. Calls for fundamental reform over the past twenty-five years have prompted incremental changes that have had a major impact on the U.S. health care system. Many of these changes were driven from outside the political system. The forecast based on past experience is not radical change; it is more of the same.

The themes I wrote about then still hold. The cost of health care has "dominated U.S. policy discussions. ...We continue to have tens of millions of Americans without health insurance coverage. ...There are also major questions about health care quality." Health care reform has proved to be like the weather: Every one talks about it, but no one really changes it. The outlook, then, is like that often given for the weather: "more of the same."

Key reasons for "the same."

1. We have a closely balanced political system at the national level. In the twenty-five years of Health Affairs, we have had divided partisan control for all but six and a half of those years. Without having Congress and the executive branch firmly in the hands of a single party, as it was in the 89th Congress, when Medicare and Medicaid became law, legislative initiatives will be modest and incremental.
   
2. There is a limited range of policy options for fundamental reform. The range of proposals given serious consideration—by Democrats and Republicans—has been remarkably stable over the past years. It is not quite true that there is nothing new under the sun, but we do suffer from too few new ideas. Whether in expanding access, improving quality, or constraining costs, we are now debating what was suggested twenty years ago.
   
3. Despite the growing rhetoric, Americans remain generally disengaged from the difficult choices posed by fundamental reform. When Health Affairs was launched, the health care sector had just reached 9 percent of the economy. Most recently, it has surpassed 16 percent of the economy. Rising health care costs are like cooking a frog. As long as the temperature rises slowly, the frog won’t jump out of the pot. It’s hard to get the American people, and thus the political system, to tackle the tough choices involving the cost of health care. As we have seen, controlling costs usually results in controlling care. The cost burden has not reached a level where the trade-off between cost and care is palatable. And access and quality tend to be talked about in arcane terms that most Americans cannot understand.
   

Political climate for reform. So what is the outlook for health care reform now? It appears that health care issues will feature prominently in the 2008 national election. If one of the political parties succeeds in carrying both houses of Congress and the presidency, that party will likely be entitled to claim an electoral mandate for health care reform. But a mandate, as we learned from the Clinton presidency, means that there is a window of opportunity, not the certainty of action.

The next months will be filled with efforts to formulate innovations in health care—to be able to claim that some candidate’s proposal is really new—and there are some interesting proposals on the horizon. For example, should there be consequences for Americans who do not obtain health insurance? Personal responsibility has resonance with the American people, and wellness is a growing trend among employers interested in reducing their health care costs. How far does personal responsibility extend to health insurance and health care?

Changes in the past quarter-century. None of this is meant to say that there will be no change. Substantial change has happened over the past quarter-century. Public health insurance for children has moved from being a welfare benefit to something available to all poor and a substantial share of lower-income children. Private health plans are available as an alternative to fee-for-service in Medicare. Medicare has a prescription drug benefit. Quality is part of the agenda. Minor ailments can be treated at drugstore clinics and Wal-Mart superstores. And the application of technology is rapidly moving past its benefits in care delivery into areas of care management that will have a direct impact on patients and providers.

Science and clinical practice—not politics. The internal dynamism of the U.S. health care system will continue to drive change. The pace of change will continue to be set by advances in science and clinical practice. The lead article in the New England Journal of Medicine will continue to have more impact on health care than the Congressional Record.

In contrast to the hurdles to innovation in the political system, the hurdles in the health care system are comparatively few. While the political system has debated fundamental reform, the past quarter-century has seen the arrival and transformation of managed care, multiple initiatives to improve quality, and the arrival of consumer-driven health plans. All of these forces of change have arrived from outside the political process. They suggest that the great force for change in the U.S. health care system will be the accretion of small changes rather than fundamental reform imposed by the political system.

IF THE FUTURE HOLDS "more of the same," we may again be energized by visions of broad reform that ultimately plays out in a succession of smaller changes. And while incremental reforms might not be politically exciting, I believe that the collective impact of changes begun over the past twenty-five years will take us a long way in refashioning how health care is financed and delivered. It is now time to push ahead aggressively—for here we go again with health care reform.

Editor's Notes

 
Bill Roper (roper{at}med.unc.edu) is dean of the University of North Carolina at Chapel Hill (UNC) School of Medicine and chief executive officer of the UNC Health Care System.

The author gratefully acknowledges the help of Hanns Kuttner and Doug Miskew.

NOTES

Top NOTES

 

1. W.L. Roper, "Financing Health Care: A View from the White House," Health Affairs 8, no. 4 (1989): 97–102.[CrossRef][Medline]

                      What's this?