A Conversation with Oregon's John Kitzhaber, MD: The Politics of Health Care
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- Introduction
- The State of Things in Oregon
- Waivers, the Next Round
- Covering the Uninsured
- The Politics of Health Care
- A Community Approach
- How to Reward Brave Reformers
- Breaking Down the Bigger Picture
- A Hypothetical Political Scenario: Fixing a Broken System
- The Perils of Redistribution
- Paying for Services
- An Unhappy Time for Medicine as a Profession
- A Platform For Health Care Reform In 2004
The Politics of Health Care
Goldsmith: Some people believe that if the current economic slowdown continues, we could see another ten million people lose coverage and see the number of uninsured in the country poke above fifty million. Is employer-based health insurance doomed by its apparent inability to control costs?
Kitzhaber: There are a lot of people besides employers who are interested in maintaining employer-based coverage: labor unions, health plans, and a very large number of workers. But I believe that the employment-based system is a just another financing mechanism. There's a political charge around an employer-based system. There's a political charge around a single-payer system. And what we never really get down to in this country is a discussion of what we're paying for. Most of the debate is over how you pay for it. Even in Clinton's plan, the real difficult politics the ethical questions were about what we pay for. The politics of health care continue circling around health care as an economic commodity, not around the benefits that flow to us as individuals and as a society from health care.
Goldsmith: But look what's happened to the political debate in the last five or six years. It's all been about making sure that no one denies anybody benefits. We have mandated forty-eight-hour obstetrical lengths-of-stay. We have any-willing provider laws. We have laws entitling us to go to the emergency room if we think we're critically ill, and insurers have to pay. We legislatively trashed the health plans for trying to question the value of medical services. It seems like the entire political dynamic is to not encourage anyone to think about whether what they're getting from the health system has value.
Kitzhaber: I think that's an accurate description of the political establishment s attitude. It's also a failure of leadership, quite frankly. I think the people get this, but I'm not sure the lobbying groups get it. If you look at the reality of our health care system, we deny people things all the time; we're very inconsistent. I mean, there will be a particular issue like mandated forty-eight-hour stays or whatever. There's a political constituency around the issue, and some lobbyist comes down and beats on you to get what he wants. But the fact of the matter is that the cost of doing that squeezes somebody out somewhere else.
Goldsmith: Do you think people actually do understand that there's a consequence to them from the political open-endedness?
Kitzhaber: I think they're beginning to connect the dots. For example, labor unions are beginning to understand that a 20 percent increase in health care costs is going to mean a reduction in their workers total compensation package. I believe there's a magic moment coming here, where one finds a common set of interests among employers and employees on this issue. That's why I think that bad economic times create an excellent opportunity to move the debate forward. It's happening in Oregon right now.
Goldsmith: At the very time that people are motivated to address the issue of what they're buying, though, the fiscal capacity to expand coverage is stripped away. I think it's remarkable that you ve been able to sustain the political momentum behind a further increase in coverage in this fiscal climate. I have a feeling that's not going to be the case in a lot of other parts of the country; the temptation will be to give back some of the coverage gains that were made during the boom. Can you imagine what you're doing happening in New York or New Jersey or Massachusetts or just about anywhere else in the country except Oregon?
Kitzhaber: It may not ultimately survive in Oregon. But we are thinking outside the box. I gave a talk to the labor unions the other day about prescription drug costs, trying to bring home the point that the health care benefit ought to have some value related to health. If you can get to that point, it fundamentally changes the debate. I talked about a thirty-year-old man who works in my office, Caucasian, otherwise healthy, who went to his doctor with wrist pain and came back with a sample of Celebrex and a prescription. Now, there's no indication that ibuprofen, at $7 a month, is less effective then Celebrex at $75 a month. He didn't get the prescription filled.
Goldsmith: I can hear it now: My boss, the governor, said I had to talk to you about this.
Kitzhaber: He did go back to his doctor after he talked to me. But it was a good example of the problem. There was a $68 cost difference, which bought no health benefit. My point to the unions was that they shouldn't bargain their wage gains away for that $68. They shouldn t make an employer pay for that $68, because they'll just lose the $68 later somewhere else. We must get people to move beyond health care benefits as an undefined economic commodity and agree that we want to pay for health benefits that actually are beneficial in terms of health. It forces the debate to a different place.
Authors and Disclosures
John Kitzhaber, a physician, is at the end of his second term as governor of Oregon. Prior to that, he served in the Oregon State Senate; he is regarded as the architect of the Oregon Health Plan. Jeff Goldsmith, a health care analyst, lives and works in Charlottesville, Virginia. He is a native Oregonian.
Health Affairs. 2003;22(1) © 2003 Project HOPE
