by Bernadine Healy M.D.
(c) David Horsey
Change is in store for healthcare in America, and it could be a done deal by year's end.
The House and the Senate have been paring down the unexpectedly high cost of their proposed health reform legislation, and President Obama is confident that a bill will pass that transforms the current patchwork, private-public blend of healthcare into a more streamlined, standardized, and government-directed system.
Promising quality, affordable care to everyone, the President assures people that they will be able to keep their own doctors and insurance if they wish to, see a return of $2,500 to their pocketbooks, and become decidedly healthier. But restructuring will inevitably call for sacrifice on the part of most individuals.
Some elements might change before a final bill is in hand, but enough common threads have emerged for people to look beyond the headlines for an idea of how the new system will affect them personally.
For starters, consider these seven ways in which your healthcare experience is apt to change:
1. You've had a heart attack or lost your job? No matter what, you'll always have access to affordable health insurance
This equates to peace of mind not just for the estimated 46 million Americans now lacking coverage but also for those who have insurance. The economic downturn is a chilling reminder that under the current system, virtually anyone facing a run of bad luck could be quickly wiped out by medical bills.
The new plan would, for the first time, impose some sort of penalty on employers of any decent size that do not offer health insurance. If you don't like your employer's choices, you will be able to get coverage on your own through a new health insurance exchange, accessible online, where companies that sell health insurance will be obliged to offer standard policies to all comers regardless of age, work status, or health.
Competition for customers in this government-sponsored bazaar should create a buyer's market -- a big improvement over today, when people hunting for insurance on their own lack any coverage guarantees and any bargaining power whatsoever.
The exchange would become especially competitive if it were to feature a public or nonprofit cooperative type of plan. Obama's vision of public insurance has been hugely controversial, since it could be a "Trojan horse," a way to sneak in a single-payer system. Federal powers to undercut prices and regulate the industry could, in a heartbeat, knock out private insurance choices.
Regardless of its fate this go-round, a public plan will stay on the drawing boards.
2. Despite the promise of savings, your wallet will take a hit
Chances are, you and your family will be required to have health insurance -- a mandate Obama has rejected in the past. On your annual IRS filing, you could be asked to swear that you are covered, with deadbeats fined. Taxpayers also will shell out whatever it takes to help those who can't afford coverage buy in.
Costs have been estimated at $1 trillion to $2 trillion over the next 10 years. And this could spiral upward, depending on the richness of the minimum health package that every citizen must have.
Where does this money come from? Cuts in Medicare and Medicaid payments, and taxation.
You'll owe more income, Social Security, and Medicare taxes as tax breaks geared to help people manage health expenses are reduced or eliminated. One big target: the tax-free status of premiums paid by your employer, the backbone of most private health coverage now. That benefit can amount to anywhere from $5,000 to $20,000 in premiums for a family, entirely tax free.
Also on the chopping block are deductions for sizable medical expenses that come out of your pocket and the tax-free flexible spending accounts that you might have with your employer. If you are one of the several million people who have catastrophic-care policies coupled with tax-free health savings accounts to cover lesser medical items, expect those plans, too, to be curbed.
Uncle Sam has also been taking aim at your sinful pleasures.
Keep an eye out for new excise taxes on sugar-sweetened drinks (even if you are skinny) and on beer and wine (even if you take but a heart-healthy glass a day).
Federal tobacco taxes were already raised in April by 62 cents per pack to cover the recent expansion of children's public health insurance. As the feds look for new sins to tax, who knows? They might be persuaded to legalize marijuana.
3. If you live in Albuquerque and get desperately sick in Philadelphia, your entire medical history will be accessible in a few clicks on the Philly ER computer screen
Health reform takes visions of electronic medical records on smart cards tucked into your wallet or on microchips under your skin to a new level: a national record system available online.
Your record will never be lost and will be available wherever you go, reducing delays, errors, and unnecessary repeat tests. In return, your most intimate history will be available for medical research and analysis, including comparative-effectiveness research, which is central to health reform because it analyzes which treatments work best at what cost.
The national medical record system will make you a part of the biggest and most detailed database ever assembled on Americans, stretching from cradle to grave. Although the government will do its best to ensure your privacy, the records will exist out there, accessible to a vast number of users who have nothing to do with your care.
It's not evident yet if you'll be able to withhold information that you might deem sensitive -- a past abortion, a sexually transmitted disease, a family history of mental illness, or a positive genetic test for Alzheimer's disease, say.
Nor is your recourse clear should a mishap or a misappropriation of your health files occur. Lower-tech instances of that have certainly happened.
4. Even though your loved one's cancer very likely would be helped by a $50,000 drug treatment, his doctor might well say no
That would happen if comparative-effectiveness research has deemed that the benefit of the drug to the average patient doesn't justify its price when compared with other treatments or no therapy. In a major break with tradition, such cost considerations based on averages will be factored into medical practice guidelines, which currently weigh only the latest evidence about whether a treatment works and how it stacks up with the usual or a new competing approach.
The point of comparative-effectiveness analysis is to put a brake on health expenditures that, while they may benefit certain people, are determined by some sort of government-recognized body to be too great a financial burden on society.
Comparative studies will look hard at the big-ticket new drugs and technologies that the Congressional Budget Office estimates drive more than half of the increases in healthcare costs. Established practices, like using the annual PSA test to routinely screen men over 50 for prostate cancer, will also be scrutinized and perhaps modified or even ended for some; this blood test, proponents point out, sometimes triggers expensive and unneeded treatments. Hurdles to establishing "standard practice" based on comparative effectiveness are the conflicting or inconclusive science for many complex conditions and the differing medical and social judgments -- should a healthy 90-year-old get a pacemaker? -- that lead to varying guidelines from highly respected groups.
It's intended, however, that standardized practice guidelines will be available, disseminated, and even embedded into your doctor's government-certified computer: As described in the Obama budget, computer pop-ups will appear to help your doctor make decisions. And through the same network, his or her choices can be monitored for consistency with the guidelines.
More uniform care is bound to improve the performance of weak doctors, but many experts worry about intruding on the seasoned judgment of the good physician.
They also warn that government micromanaging --if not rationing -- of care, driven by reasons other than patient well-being, is not apt to go down well, particularly when that patient has a face.
5. When grandma, who is declining from chronic heart failure, suddenly awakens struggling for air or with crushing chest pain, she may have trouble getting into the hospital
Hospital readmission of elderly patients within a month of a prior hospital stay is a big expense in the Medicare budget and has drawn heavy fire from the administration. The assumption, as stated by the director of the Office of Management and Budget, Peter Orszag, and others, is that doctors and hospitals didn't get it right the first time and so should be penalized with lower reimbursement, which will put a damper on readmissions.
Several studies, however, reveal a more complex picture of elders plagued by serious underlying chronic conditions like heart or lung disease that are aggravated by their bodies' gradual wearing out. Indeed, both here and in other developed countries, the extended life spans brought about by medical research and ever better treatment have sharply driven up hospitalization costs for elderly patients with chronic disease -- a formidable foe to any budgeteer.
Since more than 90 percent of such Medicare patients survive at least a year after their repeat hospital stay and so are not exactly hospice candidates, families may be shocked in the future when such readmissions are categorically discouraged. This effort to pull back on costly treatment is iconic of a broader theme in reform: a focus on wellness, not sickness.
6. An HMO and a primary-care doctor are apt to coordinate your wellness-oriented care
This change should especially please overworked and relatively underpaid primary-care physicians, now in short supply; the government may well be showering them with bonuses. Tilting the scale toward primary care over specialty care, with your primary-care doctor serving as overseer, if not gatekeeper, will shift the focus of doctors and dollars from treating to preventing disease.
If you need to see a nephrologist or an orthopedic surgeon, however, the privilege might be harder to come by. With fewer of them, waiting times for their services will be longer, and some will turn down government insurance because of continued cuts in reimbursement.
It's hoped, however, that the prevention emphasis will bring a drop in obesity and diabetes, smoking and teen pregnancy, heart disease and cancer, reducing the need for expensive disease-focused care.
7. You might find your doctor prescribing acupuncture for your back pain and a trip abroad for your surgery
Complementary and alternative practices, often dismissed by mainstream medicine, will be encouraged by your health plan as a low-cost substitute for standard care. As President Obama said recently when asked about acupuncture for chronic pain, if there's evidence it works, support it.
The British national health system has just approved acupuncture as part of standard care for aching backs. Other forms of alternative medicine are sure to follow.
So will alternative places. Indeed, you may soon be buying your prescription drugs in Toronto for half price with the government's blessing, a practice the Food and Drug Administration has in the past adamantly rejected as unsafe and illegal. And scheduling a coronary artery heart bypass or joint replacement in Singapore or Mumbai may become routine as a way to save insurance plans as much as 80 percent of the cost.
Tens of thousands of people without coverage have already pioneered the medical tourism route, paving the way.
It's a sure win in comparative-effectiveness studies -- and that's a clear signal that medicine as we know it is going to change.
Hard Choices on Healthcare Reform
by Mortimer B. Zuckerman
In the 1980s, if you had a heart attack and got to the hospital, you had about a 60 percent chance of living a year. Today, it is over 90 percent. We have been able to transform the health of the American public because of the rapid development of new medicines and technology. These innovations have come at a cost: They are responsible for as much as two thirds of the annual spending increases in healthcare. We'd like to get back to the costs of 1980, but nobody is willing to go back to 1980 medicine
Not Enough Healthcare to Go Around
by Michael D. Tanner
We tend to talk about healthcare in the philosophically abstract. "Is healthcare a right or a privilege?" goes the refrain. In reality, it is neither. Healthcare is a commodity -- and a finite one at that. There are only so many doctors, hospitals, and, most important, money to go around. ...
Lack of Competition in Healthcare Insurance Market
by Kent Garber
Should healthcare reform include an option for Americans to buy insurance from the government? President Obama has made it a priority, arguing that a government plan would make the insurance market more competitive and help lower costs. Republicans aggressively oppose this, asserting that a public plan would all but destroy the private market.
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(c) 2009 U.S. News & World Report