The Nation's Uninsured: Part 2

Will the uninsured get health insurance, a panel discussion sponsored by US news and world report and the American Medical Association. What follows is the second installment of highlights from a recent discussion at the National Press Club. Panelists are US Senator, Max Puckett, Democrat of Montana and Chairman of the Committee on Finance; the President of the Healthcare Leadership Council, Mary Greeley and Paul Cucklee; Executive Director, Deloitte Center for Health Solutions. Here now is the discussion moderator and editor of US news and world report, Bryan Kelley.

BRIAN KELLEY:

You know, the elephant in the room here, _____, is the presidential and congressional elections. We have had a number of these sorts of discussions on health issues over the years, but it is not always that we have them, you know, 6 weeks before a very pivotal election, which obviously changes the circumstances in noble ways at the moment. So I want to talk about the politics of this a little bit and you know, starting with the senator, how much is the uninsured issue and more broad we have performed how much is it an essential issue on the campaign trial from what you are seeing, both presidential on the one hand and then clearly some of these senate races and house races, which may ultimately have more to say with the outcome here. What is your sense of outcome here?

MAX PUCKETT:

I think it is very important. A lot of Americans are wild about our healthcare service, but they understand it, and so I think all Americans just want improvement, but they are very concerned about changes that might disrupt what they currently have. Now cost is the issue right here more than anything else, so it is cost of premiums out of pocket, but it is also the cost not being insured, although people do know that they can perhaps go to emergency room, they get emergency care, it is a deep concern. We clearly are going to have to address healthcare front centered next year. Irrespective of some of the issues of the day, people want to do something about high costs of healthcare and also the disparity of care while people might throughout the country know that we pay few dollars to paper healthcare, say Medicare for example, not for the _____ compared to South say Miami and other states, so there is huge geographic disparity is about $700 billion total if you could buy in both the public and the private sectors and that bothers people a lot too.

BRIAN KELLY:

I will throw this out to Mary and Paul, either one of you; does the current political climate make it easier or harder to move forward on this issue?

MARY GREELEY:

I think healthcare always ranks in the top 3 issues and sometimes it arises to the very top.

BRIAN KELLY:

Right.

MARYANN PAUL:

And then another issue will come along like energy that is just more directly affecting people in the hearing now, which really makes me think that there is a lot that we can be doing in the private sector without waiting for congress or the government to step in and do it for us. That would be great if we could pass legislation that would provide health insurance coverage for all, but if the economy is in trouble, if it is going to be challenging for congress, then what can we be doing in the private sector again to try and lower those costs to do more outreach to those that might be eligible for these programs and that may be where we have to spend the bulk of our time. I think healthcare is always going to be again one of the top 3 issues, but we have to be very careful. It actually is working well for the vast majority of people and if you threaten the coverage that they have, they do not like that threat of dislocation, may not be totally happy with it, but I certainly do not want you to turn the system upside down, which probably argues for incremental steps that we might be taking depending on what does the budget deficit look like, how can we demonstrate that we are going to get better value before we really have what I call the big bang solution. I think that is unlikely. I think it is going to be smaller steps and it is not going to be steps only taken by the government or only steps that are done through legislation. There is a lot that we can be doing in things that are underway.

BRIAN KELLEY:

You raised the presidential campaign, which is my next question and I am going to put this out as a free flow of question, I am not going to put anybody on this spot. If you do not want to deal with it, you do not have to, but how had you assess McCain versus Obama plans on how they would move this issue.

MAX PUCKETT:

No hesitations right (Laughs). Girl or boy frankly, sometimes my colleagues they go too far overboard to try to be nonpartisan that the fact that the object of evidence is that probably McCain plan would not address the insurance problem as well as the Obama plan if the studies at Urban Institute just reach that conclusion I believe and one reason is because the McCain plan revised so much more in the individual markets compared with the Obama plan in the individual markets, it is my judgment it does not work very well. People pay too much, but they cannot get insurance and people often do not get insurance and also the O’Bama plan moves more people into public programs as does McCain program directly that will mean more coverage as people go in the public programs as well as Medicaid and children health insurance and what not and also the McCain plan is pretty disruptive and I think it looks to limit an employer exclusion and the Obama plan does not and anything if that is disruptive, it is going to cause some angst where at least among people, so I would think basically probably _____.

BRIAN KELLEY:

Mary, Paul, you want to talk about this?

MARYANN PAUL:

Well, Off The Devil's Advocate _____, just, you know, to sort of comment on some of the features because I think there are obviously very, very different approaches, so the question is, is there something of value in each of these approaches? My concern about broader expansion of public programs like Medicaid and the SCHIP program, but primarily Medicaid, we know right now that there is a cost shift from the Medicaid program over to those that are covered by private insurance because the Medicaid program tends to under-reimburse, underpay for the services that are provided and more importantly from a patient perspective, often times there is not the access to the network of specialists and physicians that you might have under private insurance coverage. So that is why we have always been a proponent of can we do a better job of expanding private coverage and getting patients better access to a wider variety of providers. I think senatorMcCain also is trying to see if there is some way as we are looking at how can we change the cost curve in healthcare, is there some way that we can get consumers and patients more involved in managing their healthcare both from a quality perspective as well as the cost perspective. We are all that have employer provided health insurance coverage, but fairly insulated. The employer pays it, I think, if you would want to ask your employees, do you know what your employer is contributing, most of them do not really know what the true cost of that health insurance premium is. So I think there is this idea for how to get the consumer a little more connected to that aspect of it, but I agree with the senator office, we really have to be careful. They were not dismantling of the employer-based health insurance systems that we have this working so well and if there is some way to connect some of the ideas and principles in Senator McCain's proposal that still would keep you attached to that employer-based insurance coverage. They have done a good job of sort of managing the cost trying to bring wellness and prevention programs into the benefit packages, I think there has been a lot of innovation in employer-based health insurance products, and we certainly would not want to lose that and if we were to think of going to an individual market, we certainly would have to have some of the reforms that I think the senator is concerned about.

BRIAN KELLEY:

I think this is an even more difficult and _____ and during this discussion, for example, there are a couple of hot buttons where public will say they just will not tolerate and what are they one is that individual mandate. Is there going to be an individual mandate in America? Hillary did hers per plan, Barack only partially, McCain, though, now there is a national pool, is an alternative national pool, that is a hot button for Republicans too, both of those who are single, Both of those are the step from the door to single payer r, which is its anathema that there are so many. It is going to be extremely hard and it does take insurance market reform and when it was complicated, things _____ possibly imagine with small group coverage, good difference states had the rating provisions and not the individual market as another, I mean, it is just really, really complex, so if we are going to have a system where the people are all working together, somewhere another, and everybody is insuring the benefit and insuring the pain and where we get a cost under control, this is going to be exceedingly, exceedingly difficult. Anybody can write a dream bill, the problem is getting legislation passed to book by the president and that's where the rubber is going to meet the road here, and I just urge everyone just to step back a second before reaching assumptions and the conclusions that an effort to try to find a solution this can be very, very difficult.

.MAX PUCKETT:

Brian, the big bets are two. If you are McCain with a family policy at $11,700, does a family deduction of $5000 make people responsible in their purchases of services and does consumer directed model of care for about half the population been the curve from an 8% per year cost spiral. That's a huge question and from an economic standpoint, just simply doesn't make sense. On the Obama side, the question is would the government’s role as the insurer, payer, and director of care for north of 140 million people that Medicaid, Medicare, SCHIP, Pleasant Hill, and now picking up 25 million of these 46 million, who are uninsured. So, is the government role now managing their purchasing for 140 million sit well with a population that has been conditioned to think big government means postal service, it means the education system, it means inefficiency and ineffectiveness. Those are the two big bets, and I think what will happen is rational heads will come together; remember that the President has to present a new budget in February right after election. So we have to start thinking 24 and 36 months out. I think there will be a blending of these. I think this is not Blue State, Red State. I think this is fiscal meltdown of the US system at a point where Senator Baucus says we also have these other problems with the credit markets, with our fuel, and with an ongoing war. So I think the economic reality will force us to address these in a centrist way and I think we will see a blending of both, but not a direction in either, but a blending of these two.

BRIAN KELLEY:

Let me add someone on top of that and make it really feel good this way and add climate change. We have got climate changes next congress that's going to add about 20% cost to energy. You know, the time when economy is not doing too well particularly with the financial services difficulties, healthcare cost squeeze, adding climate changes can make things a bit difficult, but as the deck of cards were dealt, <_____>going to play as best as we can.

You have been listening to Will the Uninsured Get Health Insurance, highlights of a panel discussion presented by US News and World Report and the American Medical Association at the National Press Club in Washington DC. Panelists were US senator, Max Baucus, president of the Healthcare Leadership Council Mary Greeley, and Paul Keckley, executive director, Deloitte Center for Health Solution. The discussion moderator was editor of US News and World Report, Brian Kelly. Thank you for listening.

You've been listening to Public Health Policy in America, a special ReachMD XM 157 interview series with our nation’s top thought leaders in public health. This month ReachMD XM 157 will be discussing the many issues challenging public health policy in America. For a complete schedule of guests and programming information, visit us at www.reachmd.com.