DorlandHealth

Richard Scott

In the early morning on Christmas Eve, the U.S. Senate convened to hold a vote on a landmark measure of health reform—H.R. 3590, or The Patient Protection and Affordable Care Act. Following a strict party-line vote of 60-39 the bill passed as the most comprehensive public health reform effort since the creation of Medicare in 1965.

Now slated for debate following the new year, the bill, or some form of it, will likely pass in January. This week, Case In Point Weekly sat down with Dr. Georges C. Benjamin, executive director of the American Public Health Association, to explore the potential ramifications of the bill, what it means for public health, and where the APHA stands on some of its key measures.

Richard Scott: Recently the APHA urged Congress to move forward with health reform. Why the urgent call now? 

Georges Benjamin: Each over year 44,0000 people die prematurely because they do not have health insurance, over one half of all individual bankruptcies are due to  health care costs, and about 100,000 people die unnecessarily because of medical errors. We pay twice as much as other industrialized nations and get poorer results for our population as a whole. The irony is, for many in the system we give the best care in the world but for others it is fractured and most inefficient.  We also have a system that is unevenly balanced toward sick care and not prevention. Congress must act now to stop this national tragedy.

RS: Is the Senate bill fit for passage? If so, why [was] it being held up?

GB: The Senate Bill is overall a good bill. However there are some provisions we do not like at all, like the increased restrictions on women’s rights to choose and others that can be strengthened like the affordability provisions and the absence of a real mechanism to force competition with the insurance industry (a public plan). It was being held up because of profound ideological differences between and within the parties, the opportunity for political deal making by some, and the complexity of the legislative process in the Senate (requirement to get a super majority, i.e. 60 votes).

RS: Does passing a grand-scale bill outweigh the quibbling of minor clauses/provisions?

GB: This legislation is important. Because health care is so complex, even minor clauses/provisions can have profound effects. While it is best to get it as right in the first place as possible, the old adage of “not having the perfect be the enemy of the good” is an excellent guide. People are dying while we are quibbling and we should remember that as well. The “sausage making” is a normal but often painful part of our democratic process. In the end we will get something that is enduring, imperfect but a platform we can build upon to perfect.

RS: What are the strongest portions of the bill for controlling costs? For providing public health resources and services?

GB: There are several important provisions that control costs. First getting 30 million people in the system of coverage will reduce costs by getting people care earlier, cheaper and reduce the cost shift to others. It has been estimated that $1,000 is added to everyone’s insurance premium because of the cost shift from the uninsured. A similar type of cost shift occurs to businesses that cover their workers from businesses that do not. The effort to pay for quality and not volume, the research that will occur to identify things that do not work will incentivize providers to do more of what works and less of what does not (will improve quality and safety); payment bundling, move to accountable care organizations, and efforts to move to electronic medical records will save billions and is understated in the savings estimates.

We believe that the public health and prevention components of the bill will enhance value and in some cases save money. Recent studies in Massachusetts concerning the public health tobacco provisions of their universal health care legislation has shown significant savings because they invested in public health and medical efforts to address tobacco, the nation’s leading preventable cause of death. A recent study by the nonpartisan Trust for America’s Health showed that an investment in targeted community-based interventions would save billions in federal health insurance programs.

There are several important provisions that support the population health system. They include:

• Workforce provisions to enhance the primary care and public health workers through loan repayments and scholarships. [Ed note: Read about the importance of workforce policy here.]
• Increasing support for community health centers.
• Requiring better data collection to allow the improvement in efforts to eliminate health disparities.
• Enhancing school based health care services.
• Supporting research for public health and prevention programs.
• The inclusion of a public health investment fund for community grants and public health infrastructure.
• The strong support for workplace wellness programs.

RS: What issues, if any, would the APHA like to address with the bill?

GB: The legislation leaves out components we think will further reduce costs like the public option or the Medicare buy in and allowing the safe importation of prescription drugs. It should not reduce women’s reproductive rights, nor put in place additional burdens to the process. There are areas where affordability can be strengthened as well.

RS: Where does the bill stand now?

GB: The Senate bill will go to conference in early January.

RS: How much of the passed bill will be open for alterations?

GB: The final legislation will get made in conference. We hope it will include the best ideas from both houses; note that a lot of the concepts are the same in both the House and Senate bills. The overall structure will remain the same. That being:

• For people under age 65 it will:
  • Use Medicaid to cover the lowest income Americans (Somewhere between 133% - 150% FPL)
  • Give federal support to subsidize workers up to around 400% FPL ($88,000 for a family of four)
• For everyone it will:
  • Make major insurance reforms for all of us to prevent common insurances practices that undermine access to care and coverage. Numerous insurance reforms such as: Prohibiting retroactive rescissions; extending COBRA; prohibiting denials based on preexisting conditions; eliminating annual or lifetime limits.
  • Make insurance more affordable
• For Medicare eligible & those over age 65) It will:
  • Strengthen Medicare by improving efficiency and quality.
  • Make prescription drugs more affordable.

The final debate will focus in five main areas: abortion language, the public plan, immigrant coverage, ensuring affordability, and balancing the identified revenue streams to pay for it.  

RS: In the APHA’s view, what most directly targets and creates affordable care within the bill?

GB: Bringing down the costs for everyone is an important goal. The bill accomplishes this by covering 30 million more people and reducing the cost shift to everyone. This will reduce the growth in premium costs for all. Insurance subsidies for individuals/families and small businesses that will reduce individual costs is a major affordability provision; the individual mandate will stop the cost shift from those that should be covered to those that are as well.  First dollar coverage of prevention services is an important tool to shift the system toward prevention.