Is There Any Prospect for Health Care Reforms During the Second Term of the George W. Bush Administration?

Kenneth Zuckerman, M.D.

Dr. Zuckerman is the Harold H. Davis Professor of Cancer Research and Professor of Oncology, Internal Medicine, and Biochemistry/Molecular Biology at the University of South Florida College of Medicine and H. Lee Moffitt Cancer Center and Research Institute. He also serves as director of the Division of Medical Oncology and Hematology and director of the Hematology/Oncology Fellowship Training Program.

It will come as no surprise to Plenary Policy Forum attendees at the 2003 and 2004 ASH annual meetings that I believe that the current U.S. health care system, in which rationing of the limited available funds for health care occurs almost solely on the basis of socioeconomic status, is inefficient, open to abuses by patients, providers, and especially payers, does not promote the highest quality of health care for all, and is immoral. I believe that a federal government-regulated single payer universal health care system is the most likely and perhaps the only way to guarantee healthcare to all and to allocate available resources in a way that is not only cost-effective, but also moral. Then reality hits. There is virtually no possibility that such reforms can be enacted in this decade, given the current political climate. Thus, the philosophical, social, and moral considerations that drive me and many others to seek a single payer universal health care system for the U.S. must take a back seat, temporarily, to practical considerations of achieving the best possible reforms that can help the most people in need of health care services over the next few years.

Is the public clamoring for reforms?
Overwhelming bureaucracy, insurance company employees overruling physician decisions, and the appearance of money trumping medical judgment and compassion have frustrated large segments of the population. Egregious examples of the rule of money and bureaucracy capture public attention briefly. However, there has been no organized, large, influential group that has conducted a sustained campaign against the current system or for any specific health care system reforms.

How far might Congress move toward health care reform?
Congress completed a very difficult process of reforming Medicare in 2003 and currently has almost no enthusiasm for any additional substantive changes in the Medicare system. Thus, there will be no further significant expansion of Medicare eligibility or benefits while prescription drug coverage that is set to begin in 2006 is being assessed. The current composition of Congress guarantees a conservative agenda. The most that should be expected regarding health care-related legislation is tinkering at the edges, promoting individual initiative and private sector approaches to health care delivery and compensation.

Does the Bush administration believe that there are serious problems with the current U.S. health care system?
There have been no outward signs that anyone in the upper echelons of the Bush administration believes that there are any serious systemic problems with the current health care system. During the recent presidential campaign, President Bush indicated that he thinks there are two main problems with the American health care system -- a need to reduce the number of Americans without health insurance and the added cost to the system of medical malpractice litigation.

Is the Bush administration committed to any specific health care reforms?
It is very clear that no significant changes in the structure and operation of the U.S. health care system are being contemplated. For people who are not on Medicare, the President has proposed that use of insurance-buying cooperatives, individual tax-free health savings accounts to purchase health insurance and pay for medical expenses, and small tax breaks for small businesses to provide health insurance for employees should be expanded. The allowances in these proposals ($500 to $3,000) are grossly inadequate to meet the costs of health insurance premiums and medical expenses or to be an inducement for those who do not have health care insurance to obtain it on their own. Thus, cash-strapped low- and middle-income Americans, who lack health insurance now, remain exceedingly unlikely to spend their limited disposable income on health insurance. Finally, President Bush has proposed opening or expanding 1200 community health centers for low-income Americans and increasing the eligibility of low-income children for state health care programs - a very worthy program, but one which would be dependent on the governors and legislatures of each state to make this a budgeting priority in the current tight budget climate.

What improvements in our health care system are feasible in the current climate?
Because health care programs for low-income Americans are state/federal partnerships, success of such programs is heavily dependent on the economy and status of state budgets. It is reasonably likely that there will be expanded eligibility for health savings accounts and modest tax breaks for small businesses that share health insurance costs with employees. However, their impact on the health care system will be minimal. It also is likely that non-economic damage awards in malpractice cases will be capped. However, malpractice suits, including indirect costs of "defensive medicine," contribute less than 1 percent to the total health care costs, and no studies have demonstrated a significant effect on health care costs in states that have instituted malpractice award caps. It is certain that there will be no significant expansion of federal government health care programs in the next four years. Thus, it is essential that we who are advocates for the best possible health care system greatly increase our efforts to work with other groups to sustain an active long-term public and government advocacy program and continue our efforts to work productively with the administration and Congress to bring substantial change in the American health care system to the top of the political agenda.

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