The campus health care debate: Professors on the House bill

They may not have floor votes, but they sure have opinions.

Columbia health experts are chiming in on health care reform, and their perspectives illuminate the complexity of a debate that reform supporters hope will culminate in an overhaul of the American health care system.

Last Saturday, after months of debate both on and off Capitol Hill, the House passed legislation promising sweeping health care reforms in an action President Barack Obama called “courageous” and Republicans derided a fiscally irresponsible “government takeover” of the private health insurance system.

Closer to home—among faculty at the Columbia University Medical Center and the Mailman School of Public Health—reaction toward the Affordable Health Care for America Act has been correspondingly mixed, and suggestions abound.

“On balance we are making progress nationally, and that is a good thing,” said Irwin Redlener, a clinical professor at the Mailman School. “On the other hand, we’re all caught in this reality, this realpolitik, of how much can actually be achieved.”

Redlener praised the provisions of the House bill that would prevent insurance companies from denying coverage to individuals with pre-existing conditions, as well as the provision of insurance security for people when changing jobs. He also lauded the requirement that everyone purchase insurance or face a financial penalty.

But Redlener noted that, for better or for worse, a lot of time and congressional conflict remain between the bill and Obama’s signature.

“There are a lot of things that have not happened and won’t happen under the current House bill,” he said. “But it’s certainly not going to be the final thing that arrives on the President’s desk.”
Other experts were hesitant to commend even parts of the bill.

Prantik Saha, an assistant clinical professor of pediatrics at Columbia Medical School, questioned the efficacy of the government-run “public option,” which has been one of the most contentious issues in the nearly year-long debate.

“The bill requires people to get insurance, and at the same time the government-sponsored plan in the exchange, I’ve heard, has premiums that are actually more expensive than private insurance premiums now,” Saha said.

A Congressional Budget Office report confirmed that public option premiums under the House plan would be higher than the average private insurance premium.

Saha added that he considers health insurance a right, not a privilege for those who can afford it, and he supports universal health care. Toward that end, he advocates a “single-payer” system, in which the government would be the sole provider of insurance and the private company system eliminated.

“In a single-payer system, everyone would be covered,” he said. “There would be no such thing as qualifying for coverage, and there would be no relentless drive for profit.”

But a single-payer plan would be extremely controversial—perhaps, when it came to a Congressional vote, prohibitively so. Opponents cite the core free-market principle of competition, and worry that a single-payer insurance system would force individuals satisfied with their private insurance plans to change to a plan they like less.

Michael Sparer, department chair of health policy and management at the Mailman School, outlined three approaches to covering the approximately 50 million people who are currently uninsured: The government can expand public health insurance offered by Medicaid, Medicare, or a “public option,” it can use regulatory authority to mandate that employers offer insurance or that individuals obtain a private plan, or it can work to make private insurance more affordable and accessible.

These options are not mutually exclusive, and, Sparer noted, “The House has a very expansive bill, designed to use all of those tools,” paid for “by raising taxes on the wealthy and by cutting reimbursement rates on Medicare.”

Sparer said he believes Medicaid is the most effective route to universal coverage.

“The best way to help low-wage, uninsured folks is through a Medicaid expansion, expanding the Medicaid program, and combining that with giving people the right to buy into the Medicaid program,” Sparer said.

Peter Muennig, also a professor at the Mailman School, agreed.

“My ideal would definitely be to simply offer Medicaid plans as a universal public option that anyone could buy into at the actual cost to the government,” Muennig said. “Those who could not afford to pay at the government cost would receive a subsidy. There would be one central billing source, and one central source of medical records.”

The House legislation meets Sparer’s and Muennig’s reasoning partway, as it would extend Medicaid eligibility to individuals with incomes below 150 percent of the federal poverty level.

While Redlener, Saha, Sparer, and Muennig all champion universal coverage, Columbia Business School professor Frank Lichtenberg is not convinced such a system is feasible.

“Many other advanced industrialized countries have universal coverage, and they manage to provide health care of reasonable quality at a lower cost than we do in the United States,” Lichtenberg acknowledged. “However, to some extent, I think that other countries are free-riding or obtaining the benefits of the U.S. health care system.”

Lichtenberg explained that, in his view, one of the reasons health care is so expensive in the United States is that Americans in many ways subsidize the rest of the world.

“We pay higher prices for drugs and other medical innovations,” Lichtenberg said. “That allows those innovations to be available to other nations at significantly lower prices.”
Asked his opinion on the public option, Lichtenberg called its prospects for Senate passage “quite low.”

But while Lichtenberg remains skeptical of the public option, Mailman School professor Wendy Chavkin said she wishes it were even stronger.

“What I would have liked to see—and I guess there’s some vague hope that in the reconciliation process [between the House and Senate] we’ll get a little closer to this—is a robust public option,” Chavkin said, calling the House plan “thin” and criticizing what she sees as its narrow focus with regard to women’s health, particularly abortion.

“They [legislators] have thus far accepted an amendment that would completely prohibit the use of any public funding for abortion,” Chavkin said. “And they’ve done it in a way that will actually make it very difficult for people to get any kind of insurance coverage for abortion.”