By Timothy D. McBride

Despite the importance of passing health care reform, it appears that the general public has very little understanding of the scope and importance of these reforms, or how the wide-ranging positive benefits will have on average Americans.

Much of this is due to overheated rhetoric, a misunderstanding of the proposals by the press, purposeful distortions by both sides of the debate, and the complexity of health reform. For example, much attention has been paid to the so-called “public option” which the right wing has described as a “government takeover of health care,” and the left wing has described as the only provision worth fighting for because it will keep the insurance plans “honest.” Both claims overstate the significance of the public option since by all estimates, even if it survives, not many will sign up for it, and the plan will resemble private plans, not a Medicare plan.

When the reforms are phased in, 96 percent of American citizens will be covered by health insurance -- up from an insurance rate of 83 percent today -- according to Congressional Budget Office estimates. Contrary to fears that the legislation will lead to a government-run health system, 58 percent of the persons obtaining coverage will obtain coverage from private insurers, in a new Health Insurance Exchange. This Exchange will be much like the array of private insurance plans offered to Congress and the President today. The remaining persons insured under the plan would be low-income children and adults insured through Medicaid and the children’s health insurance plan.

In Missouri, over 800,000 persons are estimated to be uninsured today. However, the Congressional reforms would reduce the number of uninsured by over 604,000 reducing the uninsured rate to less than 4 percent (from a current rate of 16 percent). Over 270,000 persons would obtain insurance through the Health Insurance Exchange, another 200,000 adults through Medicaid, and 130,000 children through Medicaid.

Although much of the focus has been on the provisions that would expand coverage for the uninsured, little attention has been paid to other provisions which could have wide-ranging impacts on the health sector. For years there has been little attention paid to public health issues. Most chronic diseases (such as obesity) can be prevented through lifestyle and environmental changes. So the proposal would implement policy changes to encourage preventive health and wellness, encourage physical activity and good nutrition, enhance the public health system, encourage health promotion activities, and enhance access to behavioral health services.

Also receiving very little attention are significant provisions to enhance the infrastructure of the health system. Since the health reforms are estimated to lead to 36 million more persons obtaining health insurance, this could significantly strain the medical care system. However, significant new funds to enhance the health workforce for primary care physicians, nurses, physician assistants, social workers, and public health workers are found in the proposal. Funds are also included to resolve payment problems afflicting physician payment, at least temporarily.

The recession led Congress to pass significant stimulus spending which has made the public concerned about the rising federal budget deficit. It should be comforting then that the President has promised he will not sign a bill unless it is deficit neutral.

While it is worth noting that much of the costs of increased coverage is paid for by the previously uninsured themselves (if they can afford it), the remaining costs are covered by taxpayers. About half of these costs will be covered by reductions in Medicare spending, and a significant share of these reductions will come from reductions in a program widely recognized to be in need of spending reductions, the Medicare Advantage program. The remaining costs will likely be covered by tax increases, most likely on a combination of high-income taxpayers (as President Obama promised in his campaign) or on high-priced health insurance plans.

As health care reform continues to move forward we can take significant steps towards removing the scar of the uninsured that has long stained our country. The proposals are not perfect, nor will they solve the problem overnight. But we cannot let the perfect be the enemy of the good. We just have to get started on solving this problem.
McBride is Associate Dean for Public Health in the Brown School at Washington University in St. Louis.
Copyright (C) 2009 by the Missouri Forum. 12/09