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Common Ground Emerging Amongst Health-Care Factions in Reform Plan

By Mark A. Goldberg
and Theodore R. Marmor

The Washington Post

Perhaps the first of many conflicts that the administration's high-powered health care task force will have to resolve is the war of words that dominates the debate over health care reform. For the past year, three phrases have defined (albeit imprecisely) the reform plans jostling for support.

These three labels -- single-payer, play-or-pay and managed competition -- have served as a handy shorthand for complex arguments and ideas, united groups of more or less like-minded reformers and made the debate easier for the press to cover and, at least in theory, for the public to follow. Now, however, they are blocking reform.

Obviously the chances of passing a reform package would be enhanced if those who favor change were not divided, by themselves and others, into three contending groups. But the labels are more than a tactical inconvenience: They mask differences within categories of reform (between, for example, alternative managed competition plans) and obscure similarities across them. Moreover, the most effective reform package would incorporate elements from all three types of plans. What's needed, as a matter of politics as well as substance, is a fusion plan -- one that would bring together reforms and reformers.

A fusion plan for health care reform ought to be built on three principles. First, we can't solve any one of the three aspects of the health care crisis -- cost, access, and quality -- without tending to the other two. If we put all our emphasis on controlling health care spending, quality and access will suffer. If we focus just on making sure everybody has coverage, costs will soar and quality will erode. And if we do nothing but improve the quality of care, fewer and fewer people will have access to more and more expensive services.

Second, we need a plan that would work quickly -- that would clamp down on cost increases, cover the uninsured and lay the groundwork for improvements in quality sooner rather than later. The longer we wait to fix the health care system, the harder the job will be.

Third, we need to be prudent. The stakes are too high -- in terms of health and money -- to put all our faith in one theory, model or mechanism. What's needed is a plan that maximizes the chances of success -- that is, to borrow a term from the computer industry, fault-tolerant.

The basic building blocks of a fusion plan -- one that could succeed substantively and politically -- are strewn about, awaiting assemblage. In fact, many admixtures have already been misclassified under one or another of the standard-issue labels. (A case in point: The plan that candidate Clinton spelled out last September -- and that he, and numerous commentators, described then as a managed competition strategy -- was in fact something of a hybrid.) The elements include:

-- A requirement that employers assure coverage for their employees and a commitment, with adequate public financing and a firm schedule, to the phase-in of insurance for those outside the workforce. Initiatives to increase the market power of health care consumers (the development of purchasing consortia and an infrastructure of information about quality and prices to support them).

-- Incentives to create more, and more efficient, provider groups.

-- Tough cost controls to keep spending in bounds.

-- Measures to simplify health insurance, including a standard benefits package, a single claims form (instead of the thousands of different forms now bedeviling providers, consumers and insurers) and electronic billing. (At least 20 percent of what Americans spend on health care, more than $180 billion a year, goes to pay for administration and paperwork.

-- Steps to improve the quality of care and reduce the amount of unnecessary or inappropriate treatment (including increased research on the effects of alternative procedures) and to help consumers judge the quality of care offered by competing provider groups.

-- None of this is to suggest that it will be easy to refine a fusion plan beyond these basics, to develop political support for the plan (and its financing) and to implement it. But the alternative, a protracted and counterproductive squabble among rival factions, is surely less appealing.