CHR - Press Relations
Blog topic: No longer only income redistribution
With many details still undetermined, proposals for national health care reform have now passed the House and are coming closer to passage in the Senate. Given the still unknown content of the over-2000-pages-long newly proposed legislation and its potential repercussions, some comments from the medical community appear appropriate.
The issue is not only, as much of the media want us to believe, that this legislation affects one sixth of the national economy. While this fact from an economist's view point, of course, is a central theme, for the average citizen the question always comes down to "how will this affect me?"
And here, we believe, our specialty of reproductive endocrinology and infertility has a few lessons to teach. This area of medicine, even under currently existing health care laws, has for decades been operating outside of routine spheres of medical care. In a majority of states and under federal guidelines, infertility is, paradoxically, not considered a "disease" and, therefore, does not fall under existing insurance laws. Consequently, in most states (with some exceptions) infertility does not represent an insurance-covered benefit.
The treatment of infertility, as a medical condition, may, therefore, represent a first example of selective censorship of medical care under federal legal guidelines but, as the new legislation strongly suggests, it may be far from being the last one to come.
Legislation reaching the President's desk will, likely, extend insurance coverage to a significant percentage of the currently uninsured. While President Obama promised that he would sign only budget-neutral legislation, profound evidence of budget manipulations unfortunately suggests otherwise. Budgetary realities will, therefore, at some point in the near future force the government's hands and, obviously, will mean further rationing of what will and will not be considered covered benefits.
For infertility services this offers a rather bleak future. Since Medicaid and Medicare never funded infertility care in the first place, it seems unlikely that such services will be added to federal coverage under the new law. Even more importantly, we would not be surprised if even private insurance companies, which either voluntarily or mandated by state laws, extended such services were to retreat, and seek to have existing mandatory state laws revised.
Current unilateral Democratic efforts to push through legislation, at practically almost any cost, follow Obama's election battle cry of "yes, we can." They, likely, reflect the recognition that significant election losses at mid-term elections in 2010 are unavoidable, and will be even bigger if the current legislative majority continues to show no legislative achievements whatsoever. Bad achievements, in other words, appear still better than none at all. In short, we are cruising towards reform at any price!
In Merriam-Webster and Wikipedia the word "reform" is defined as bringing from bad to good; changing from worse to better; or simply, to improve. It didactically, therefore, should suggest betterment of a situation. But when has anybody last heard a politician (Democrat or Republican), as part of the ongoing health care debate really address how health care could be improved? All we are hearing is how medical insurance can be expanded to the currently uninsured, and at lowest possible cost. Where is betterment of American medicine in all of this?
One, indeed, can argue that expanding insurance coverage to the currently uninsured, by itself, reflects better health care. This may be the case for beneficiaries of such expanded insurance coverage. There is, however, absolutely nothing in either current House or Senate proposals that would improve health care for the vast majority of U.S. citizens who already are insured. Indeed, to the contrary: their level of health care will be diluted by demands from the newly insured and, therefore, their quality of medical care will decline.
This dilution will take various forms: Medicare recipients will, likely, be most affected since it seems almost certain that half a trillion dollars (550 billion) will be cut from the current Medicare budget to finance the newly arrived insured. There is also talk about cutting Medicare physician reimbursements by another 250 billion dollars, though, as one amongst many budget gimmicks, this money may be reinstated outside of currently debated health care reform legislation (including these physician payments in the current proposals would preclude the budget "neutrality" promised by Obama).
Should Medicare reimbursements be further cut, even more physicians will give up on providing Medicare services. Those who stay will face increasing patient loads at poorer and poorer reimbursement rates, - clearly not a recipe for improved quality of care to the elderly. How will it help them to have insurance coverage if they will not be able to get access to physicians in timely fashion?
The country already grapples with a tremendous nursing shortage. Assuming all kinds of medical staffing will not be adjusted (and funded) to increasing numbers of insured, conditions will only get worse. The same applies for equipment. With millions of potential new users requiring additional CT-scans, MRIs and colonoscopies, either more equipment is purchased or waiting periods will expand, as our neighbor, Canada, so well demonstrates.
Listening to what is going on in the chambers of power, it appears that what counts is to pass legislation, - any legislation! Nobody really seems interested in addressing these real issues. Expectations, likely, are that current staffing and equipment capacities will simply adjust to an increased patient load, which would confirm the suspicion that the currently insured will be significantly diluted in their current levels of health care.
As health care they presently receive is redirected towards the newly insured, one is reminded that President Obama during his election campaign made no secret about his strong support for the concept of income redistribution (remember the encounter with Joe the plumber?). What he then, however, failed to tell the public is that he not only favors income - but also health care - redistribution. Health care - redistribution does not only affect the so-called rich (whatever the definition may be) but fall squarely on the middle class.
And then there is, of course, also the concept of taxing so-called luxury medical services, whether this includes more generous insurance coverage than the government feels is appropriate or a five percent luxury tax on elective cosmetic surgery and other procedures. Here, too, it is not only the rich who are affected. Unions for decades compromised on salary demands in compensation for better health insurance plans. And it is not only the rich who get Botox injections, have hair implants or undergo liposuction these days.
Since infertility is not considered a disease, how long can it be until the government considers infertility a target for similar luxury taxes? After all, if Medicaid and Medicare don't offer infertility coverage (and should there in the end be a public option insurance plan, it will neither!), wouldn't infertility coverage, offered by private insurances, be a taxable luxury item?
What is really never noted by the media in the current health care debate is the totally unprecedented nature of interference into personal medical responsibilities the current health care legislation represents. No longer is the government only responsible for the fairness of income distribution but, for the first time in the U.S. history, the government claims the right to determine what represents appropriate levels of health care insurance; and if you have too much, government takes the right to redistribute your coverage.
Is this really a power we want our government to have?
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