US health reform debate is reaching critical phase, says expert

BMJ 2009; 338 doi: (Published 16 June 2009) Cite this as: BMJ 2009;338:b2458
  1. Caroline White
  1. 1London

    The battle over healthcare reform in the United States has reached a critical phase, says Simon Stevens, previously health adviser to the former British prime minister Tony Blair and now president of global health at UnitedHealth Group.

    Mr Stevens, who also chairs the United Centre for Health Reform, was speaking in Liverpool last week at the annual conference of the NHS Confederation, ahead of a key meeting between the US president and the American Medical Association on 15 June.

    The complexities of the current systems in the US, together with the need to convince a wide array of congressional committees, meant that “widespread system change will take a lot more than a popular president,” he said.

    Barack Obama has set out eight key principles for reform, including cost containment; affordable healthcare coverage for all; guaranteed choice; and an end to barriers to insurance coverage for pre-existing medical conditions.

    Earlier this month the former majority leader in the Senate, Tom Daschle, put President Obama’s chances of success at no more than 50:50 when the decision on the plans is made in the autumn.

    “The problem has been defined as cost rather than coverage or quality,” said Mr Stevens, “but there is less alignment beyond that about what needs to change” and an “increasing mismatch” in public and expert opinion.

    In May an analysis by the well respected Dartmouth College concluded that 30% of US health care was inappropriate or unnecessary, he said, but public opinion put the figure closer to 16%.

    Similarly, there is little agreement on what is driving up increased costs. The public thinks that drug companies are to blame, while experts think it’s technology and public expectations.

    Negotiations in the Senate and the House of Representatives about the shape of required legislation are also taking place this week, and Mr Stevens said that the president had learnt from the Clinton administration in 1993, when the last major (but failed) attempt at healthcare reform was made.

    “You need to get momentum going while you still have a head of wind behind you, rather than letting it run into the sand,” he said.

    President Obama has also set out eight general reform principles, rather than “producing a phonebook of draft legislation,” as Hilary Clinton, who chaired the task force behind the earlier reform attempt, had done. And President Obama “has been careful to say that if you like your existing coverage you can keep it, rather than throwing the whole thing up in the air and starting again.”

    It increasingly looks as though there will be a legal requirement for every individual to take out health cover, with public subsidies for low income families, but Congress has called for $100bn (£60bn; €73bn) to $250bn of savings a year over the next decade to offset rising costs. These would come from tax breaks for employers who offer health coverage, “sin taxes,” and changes to the payment structure of the Medicaid and Medicare programmes, which are likely to mean “significant cuts in doctors’ pay,” said Mr Stevens.

    In Massachusetts, where every resident has had to take out healthcare insurance since 2006, 29% of people said it was still difficult to find a primary care doctor, he added. “So it’s not just a coverage issue, it’s a supplyside issue too.”


    Cite this as: BMJ 2009;338:b2458

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