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VOICES OF REFORM: KFF's Drew Altman on Keeping the Coalitions Together

December 8, 2008 - 9:29am

A few weeks ago, Kaiser Family Foundation president and CEO Drew Altman wrote an essay about the two camps in health reform, on one hand the coverage expansion group and the other, the delivery system reformers. “The health reform field is like a Venn diagram with circles that intersect (though not by a lot),” he wrote. “They think about different problems and often attend different conferences.”

If we have broad, comprehensive reform, no problem. Both agendas advance, in ways that reinforce and complement one another. But if politics, economics, ideology or interest groups break down that big effort, meaning that our remaining option is a scaled back more incremental approach, a rift between the two groups, he wrote, “could stand in the way of progress on health reform if care is not taken to avoid it.”

A few days after he wrote that, while researching another article I was working on, Drew and I had a chance to talk about where we are in health care and what may lie ahead. In the two or three weeks since we chatted, we’ve gotten even stronger signals from both the incoming Obama administration and top senators that they want a comprehensive approach—cover everyone in a retooled cost-effective system. In other words, we get the coverage chicken and the delivery egg (or maybe it’s vice versa) And even in the stimulus package being planned for next month, we’re seeing signs that both coverage (Medicaid funding) and delivery system (Health IT in particular) are likely to be included.

But Altman (whose most recent email exchange with me on the topic was reasonably optimistic about where we are right now) knows that the stars have aligned for health care before, only to (apologies for the mixed astronomical metaphor) see them eclipsed. That worries him, particularly because everyone is so intent on making the big reform happen this time that they don’t want to dwell on a fallback option. Which needs to be more than just SCHIP expansion or a bit of Health IT if it’s to be a meaningful step ahead that we can build on. He wrote in that essay:

The health community needs to be on guard for this new rift which could undermine the chances for action. If it does come to an incremental effort it will be important to preserve elements of both health reform agendas to keep the health reform coalition together and to advance the twin causes of short term consumer relief and longer term delivery reform in tandem. And if it comes to it, it will also be important to plan an incremental effort carefully and not stitch it together as a last minute fallback if more comprehensive legislation collapses. Little attention seems to be directed to that challenge today for fear of undermining a broader effort, but that's a subject for another column.

In our conversation, I told him that from my perspective here in DC (and maybe I just don’t get out to enough meetings) that “overlap” in his Venn diagram is expanding. The coverage people, it seems to me, have become more sensitized to how the cost and delivery system problems, properly addressed, can make covering all Americans with high quality care a more sustainable proposition. And I can’t remember the last time I had a conversation with a “delivery system” person who wasn’t also making the moral and economic case for expanding coverage. (I have just arrived in Nashville for a conference full of delivery system people so I’ll let you know later whether I’ve changed my mind.)

Cost, Drew reminded me, means different things to different people. To the policy experts, it’s about those huge curves and numbers, the $2.2 trillion we spend, the 16 percent of GDP and so forth. To ordinary Americans, cost isn't some macroeconomic trend on a PowerPoint. Cost means how to pay the rent, put food on the table, and have enough money left over to keep everyone healthy.

“I want to be very clear,” he told me. “There’s a critical agenda about quality and efficiency. It’s critically important. But that’s not what’s motivating the public…What’s moved this issue back to the forefront (for the public) is cost.”

“It’s not about access and bad outcomes. It’s an economic issue," Altman said. "We in the health care community failed to grasp how it’s being perceived and experienced by regular people.”

One more warning, for anyone naïve enough to believe that health care can be “fixed” once and for all. He told me:

It’s not like we see a bridge and repair it. Health care is not an engineering problem, something we can just fix and move on. Health care has been in crisis for as long as I’ve been in health care, which is a long time. Other nations struggle too, with new technology and costs. It’s an ongoing process. It’s an everlasting struggle.

  It just doesn’t need any new rifts to make it harder.

There MUST be a solution!

We are well beyond the point of "diminishing returns" from the third party dominated, employer sponsored health insurance system. Due in part to the over engineering of health benefit design by generously compensated health benefit consultants, there is precious little value left in the exchange relationship.

Dress it up as you may, but this paradigm aka "managed care" in all its permutations, is nothing more than a cost shifting charade that punishes the weakest among us.

Who gets stuck with the retail burden of health care? Not the health plans or members they represent. It's generally the uncovered or uninsured who bear this burden unassisted by an advocate or informed navigator of prudent purchasing from providers or their intermediaties.

A weakened economy notwithstanding, health reform - both from an access and system reform POV, must proceed. There are solutions! Lets get creative.

Cost and Coverage

Reducing the cost of individual healthcare services could provide enough money to provide access for everyone. We could accomplish this by introducing price competition at the service level.