Why Health Care Reform Is So Difficult in the United States

Why is it so hard to change the American health care system? And so much easier to change other countries’ systems?

I pondered this question recently while attending the Commonwealth Fund’s International Symposium on Health in Washington where our latest survey comparing primary care in eleven countries was discussed. I heard presentations describing changes that have been, or are being, implemented in England, France, Germany, Norway, Sweden, Switzerland, the Netherlands, Canada, Australia and New Zealand. In some cases, these are fundamental reforms in how medical care is delivered and how providers are reimbursed. Many of these countries can demonstrate real improvements in the quality of care and efficiency in their systems.

Evidence of how much more difficult it to improve this country’s system is provided by the OECD data from nineteen countries on the number of “deaths amenable to medical care,” that is deaths that could have been prevented by appropriate medical care. It is bad enough that the United States has dropped to last place – with the highest proportion of preventable deaths – of all nineteen countries measured. The data also show that all the other eighteen countries had lowered the number of preventable deaths over five years by much more than this country’s modest 4% improvement.

I would suggest that all of the following are reasons why it is easier, in some countries much easier, to reform their systems than it is to change ours:

1. Their systems are so much simpler. Ours is much more complicated with our “thousand points of payment,” Medicare, Medicaid, Kaiser, the VA, the Mayo Clinic, HMOs, PPOs, and millions of employers and their different health plans.
2. They already have universal coverage, so they can focus on improving quality, efficiency and cost containment without a huge ideological debate about the roles of government and the private sector.
3. They have parliamentary systems, where their governments can usually win the votes of a majority of legislators and only a simple majority is needed. It is much, much harder for an American president to win enough votes in both houses of Congress, including a filibuster-proof sixty votes in the Senate, for controversial new legislation.
4. Lobbies, representing special interests, are much more influential in this county.
5. The power of money; elected officials in most other countries do not have to raise larger sums of money for their campaigns, and are therefore much less beholden to industries or professional groups.
6. They only need a bare majority of votes in their legislatures. None of them have anything like the US Senate’s ability to filibuster.

Another factor that may also make a different is the influence of partisan news networks, especially Fox News, and of talk radio, that spread emotional and often misleading arguments, fuel populist feelings and dumb down the debate.

I should note here that the ease with which parliamentary systems can enact major reforms is not always a good thing. After World War II, Britain’s Labour government nationalized its substantial steel industry. It was then privatized (i.e. denationalized) by the next Conservative government, nationalized again in the 1960s and then denationalized in the 1970s – by which time it had been almost wiped out.

However, when we look at the difficulties our presidents since Theodore Roosevelt have had when trying to pass major health care reforms, one wonders if the uniquely American barriers to change and reform are really desirable.

Voters Want Abortion-Neutral Health Care Reform

A few months ago, I warned that some folks were attempting to misuse healthcare reform to restrict access to abortion. They have come a long way since then, endangering the vital struggle for healthcare — indeed, torpedoing reform is a key goal for many involved in this effort.

Americans oppose using abortion as a means of derailing health care reform and oppose using health care reform as a means of restricting abortion. The more voters find out about what is happening on Capitol Hill with respect to this issue, the angrier they are getting, because language inserted in the House bill will take away coverage for abortion that tens of millions of women already have.

Taking away existing coverage not only violates the public will, but also does fundamental violence to Democrats’ explicit promise that if you like what you have, you will be able to keep it.

In a national survey we conducted for the Women Donors Network, nearly half (47 percent) of the electorate said, “Political differences should not prevent us from moving forward on an otherwise good health care reform plan.” Another 22 percent believe that health care reform should not move forward unless “a woman’s right to choose an abortion is protected.” Only a 26 percent minority believe that health care reform should not move forward unless “we are certain that government money will not be used for abortion.”

Voters clearly oppose the restrictions embodied in the House bill, rejecting even their underlying premise. By over a 20-point margin, voters believe that those who receive partial subsidies should be able to buy plans that cover abortion. By two-to-one, voters would feel less favorably toward a member of Congress who voted to prohibit subsidy recipients from purchasing an insurance policy with abortion coverage.

Indeed, voters’ antipathy to placing abortion restrictions in health care reform is so strong that their inclusion leads voters to oppose reform itself. By a 16-point margin, voters would oppose a health reform plan that prevented private insurance plans from covering abortion.

Debate on the issue strongly favors opponents of abortion restrictions. We presented voters with an argument against allowing coverage of abortion focused around the view that “taxpayer money should not fund abortion.” Matched against an argument in support of covering abortion that suggested, “health care — not politics — should drive” these decisions, 59 percent subscribed to the pro-choice viewpoint and just 36 percent took the anti-choice position.

At a more fundamental level, voters simply do not want Congress making these decisions. Just 14 percent favor Congress and the president making coverage decisions with respect to abortion. Indeed, despite popular disdain for insurance companies, twice as many would prefer they decide whether to cover abortion instead of having politicians make that determination. A significant plurality (43 percent) support empowering an independent commission to make coverage decisions on abortion.

Americans do not want reform to be an excuse for tightening restrictions on abortion or for taking away health coverage millions already have. Nor do they want an abortion debate to stop reform. Voters want an abortion-neutral health care reform.

The way out of this conundrum is clear to voters, if not to legislators. A compromise offered by Rep. Lois Capps (D-CA) enjoyed majority support and was fully acceptable to the small minority that favors further restrictions on abortion. What opposition there was to the Capps compromise came primarily from pro-, not anti-choice voters. Nonetheless, the House swept it away in favor of language much more drastic and deeply unpopular.

The Capps language affords an opportunity to untie the Gordian knot in favor of the anti-choice forces, but does so in a way that is at least minimally acceptable to the pro-choice majority.

Coal in Your Christmas Stocking?

Is there anyone left, on either side of the political spectrum, who wants the Senate health care bill to pass?

Republican Mississippi Governor Haley Barbour had this to say about the Senate bill last week, “This health care plan is like mackerel in the moonlight. Longer that it's out there, the more that it stinks.”

And yesterday, MoveOn said this about the Senate Democratic health care bill in an email to its members, "America needs real health care reform—not a massive giveaway to the insurance companies. Senator Bernie Sanders and other progressives should block this bill until it's fixed."

When Haley Barbour and MoveOn are saying about the same things—this bill should be stopped in its current form albeit for very different reasons—that says a lot.