With Democrats increasingly confident that they can pass major health care legislation this year, some of the nation’s foremost experts are warning that the emerging bills do not do enough quickly to tamp down soaring medical costs — the biggest problem facing the majority of Americans, who already have insurance.
As Congress prepares for heated floor debate (the Senate Finance Committee is expected to approve its bill on Tuesday), the experts, including policy analysts, hospital executives and current and former health officials, say lawmakers must make crucial changes.
They urge adjusting the legislation to reshape more aggressively the health system, from one that overly rewards quantity of care to one that promotes high-quality, cost-efficient treatment that will save lives and money.
While such a shift has been a talking point for President Obama and Congressional Democrats for months, the political debate in recent weeks has focused largely on the proposals to provide health benefits to the millions of people without coverage and to regulate the insurance industry more tightly.
Provisions to overhaul the health care “delivery system” have gotten less notice, and experts said the proposals are too timid.
“The discussion has gone from health care reform to insurance and payment reform,” said Toby Cosgrove, the president and chief executive of the Cleveland Clinic, which Mr. Obama visited in July and often holds up as a model of how hospitals would operate in a revamped system. “We’re not really reforming the system,” Mr. Cosgrove said. “We are reforming how we pay for it. It’s certainly all about politics right now.”
A statement on Saturday by four former surgeons general calling the health care system “unsustainable” and urging bipartisan cooperation was the latest example that health experts overwhelmingly support swift action and generally support the main proposals in Congress. But many, like the surgeons general, stress that lawmakers must do more to lower costs.
The health debate, in many ways, is premised on the idea that Americans and the government could save hundreds of billions of dollars by eliminating wasteful spending on things like duplicative scans or laboratory tests that might be avoided by electronic records, unnecessary hospital readmissions that could be averted by better follow-up care and patient infections that could be prevented by rigid safety protocols.
Better Care for Less?
Can all that money really be saved without rationing care or lowering the quality of treatment? “In three letters: yes,” said Elliot G. Fisher, director of the Center for Health Policy Research at Dartmouth College, which produces an atlas showing how Medicare spending varies widely across the country with no evidence that higher expenditures achieve better outcomes for patients. In fact, the opposite is often true.
But Dr. Fisher said the bills did not include a tool to promote cost-efficient care: reducing Medicare payment rates as a penalty if costs rise too fast. “Rather than across-the-board cuts,” he said, “let’s only do the cuts in regions that are growing too fast in per-capita spending. There’s a way to guarantee savings.”
The absence of such a provision is not a result of special-interest lobbying but rather lawmakers’ basic instincts to protect their home turf: high-cost regions fear being punished by steep cuts, and low-cost regions want flexibility to let their costs rise, if necessary, and not face restrictions tied to their historic efficiency.
Dr. Fisher praised many components of the legislation, but said that much of the proposed cost-savings, intended to pay for covering the uninsured, comes from across-the-board cuts without creating incentives for cost-efficient care. “We know what’s going to happen if you cut prices,” he said. “They will do something else to make the money. So we’re not thinking as clearly as we could.”
A number of strategies to transform the health care system, such as promoting research into the most effective treatments and encouraging doctors and hospitals to form “accountable care organizations,” are included in the legislation, but either in a limited way or as small demonstration projects.
Experts, including Dr. Cosgrove of the Cleveland Clinic and Denis A. Cortese, the chief executive of the Mayo Clinic, said lawmakers could be more aggressive on those fronts. They also said the bills could do far more to push Americans to take responsibility for their own health, especially by reducing obesity.
In other cases, steps to improve quality like a new Medicare payment model proposed by Senator Maria Cantwell, Democrat of Washington, that is included in the Senate Finance Committee’s bill, would not be fully in place until 2017.
Continuing to Rise
Lawmakers have said they do not want to force changes too quickly, but experts warned that in the meantime costs will continue to soar for the 250 million Americans who have insurance and who, faced with confusing and expensive legislation, are asking: “What’s in it for me?”
Along with reducing the ranks of uninsured, a top goal of the legislation is to slow the steep rise in medical costs. But budget experts said there is only one big initiative in the legislation aimed at that goal — a proposed tax on high-cost insurance plans. That proposal, in the Senate bill, is fiercely opposed by many Democrats in the House.
A group of experts pulled together by the Engelberg Center for Health Care Reform at the Brookings Institution, while praising the Senate Finance Committee bill, has issued a report urging that more steps be taken to reduce long-term spending. The Engelberg Center’s director is Mark McClellan, who led the Centers for Medicare and Medicaid Services under President George W. Bush.
A member of the group, Elizabeth A. McGlynn, associate director of RAND Health, said that her firm’s research showed that the legislation would do more to provide benefits for the uninsured than to change the overall upward trajectory in spending.
“We are not really seeing a lot of evidence that the trajectory would change very much,” Ms. McGlynn said.