The Stairway To Health Care Heaven

I have little doubt that sometime this month, or early in 2010, that the U.S. Congress will pass, and that the President will sign, a major reform of the U.S. health care system. The final act will be along the lines of the bill being considered now in the U.S. Senate, with a few variations from floor amendments, and perhaps with some conference committee adjustments in the direction of the U.S. House bill on collateral issues.

In the several years that follow its adoption, we will see a major reduction in the number of people who have no health care coverage and the uninsured population will be drawn much more heavily from the ranks of undocumented immigrants. The nation's undocumented immigrant population appears to have fallen in 2008 and 2009 and is likely to continue to fall in 2010. Immigration reform along the lines proposed by President Obama on the campaign trail, even if watered down, will probably further reduce the nation's undocumented immigrant population. We won't have universal health care, but we will have something close to it, which will make the gap filling systems we have, like free samples from drug companies and charity care, more effective at filling the gaps that remain.

Providers will see their bad debt and charity cases fall dramatically, and see the amount of work to be done rise. We can also expect to see reduced use of emergency rooms in major urban poverty centers, as a health care provider of last resort. Specialized health care systems, like worker's compensation and no fault automobile insurance will also likely see a major upheaval as their niches move to an environment where health insurance coverage is more common.

The new system will have flaws. Some of those are visible on day one. The new system will continue to be a bureaucratic nightmare and will continue to have insufficient means of controlling provider level costs.

But, increasingly, health care reform will not be a moral argument about whether people should have access to health care, or an argument about how large an appropriation of public funds is appropriate to spend on health care. Hot button issues like abortion will also be resolved indefinitely.

In four years or so, the health care debate will be about bureaucratic tangles, cost control, quality control and efficiency. At this point in the debate, everyone but health care providers and health insurance companies will be far more unified in purpose. It will be a wonkish debate about money and claim processing systems. Also, at this point in the debate, bills that solve the remaining problems piecemeal can work from a more functional foundation, allowing Congress to return to its normal pattern of incrementalism.

Parts of the system that no longer make sense in the wake of reform, that survived because there was not enough political muscle to change them in the current round of legislation, will lose political support as it becomes clear that they are anachronisms or irrelevancies.

Instead of arguing over whether every women should have health care coverage for maternity care, for example, the debate may turn to whether this narrow market segment might make more sense to provide through national single payer system, rather than the general system used for other health care, since maternity care is a particularly poor fit for the traditional insurance model of health care. Or, perhaps, the nation will be sick of processing mountains of paperwork and develop a system where people with health insurance pay their share of the bills only to their insurance company after the bills have been fully vetted and adjusted, and end direct provider billing of people with health insurance. Or, perhaps, the health insurance industry will agree on a standardized billing protocol, that makes it easier for everyone to deal with billing isues. Or, perhaps, providers will be required to have a single uniform charge for every service that they provide that is publicly available.

I've long argued, for example, that creating an unsubsidized public option, either at a state or federal level, once universal or near universal access to health care is in place, is politically much easier than creating one as part of a larger package of reforms. The lack of government subsidy is much more obvious in a narrow bill that deals only with a public option, a bill with no meaningful appropriation is easier to get thought the legislative process, and it is hard to lobby for not having competition, when that is the only issue left in the debate.

It may take many steps to get our nation's health care system to a point where it is something that we can be proud of as a nation. But, I am quite optimistic that the bill that will soon be passed will start our climb in the right direction. By the time my elementary school aged children are out on their own, and I am approaching my golden years, we may be close to having met this goal.