SAN FRANCISCO - As the clock ticks toward what could be final congressional approval of the most sweeping health-reform legislation in more than 40 years, a little perspective is in order.
The health-care system is complex, yet Americans' experiences with it are deeply personal, making it a prime candidate for distortions and emotional manipulation. While people hold different views about what the nation should do about its coverage, cost and quality problems, facts and nuance often get lost in the political rhetoric of the debate.
Here's how three experts who follow health-care policy weighed in on five of the biggest myths and half-truths about the proposed overhaul.
ASSERTION: IT WOULD LEAD TO A GOVERNMENT TAKEOVER OF HEALTH CARE
That's hardly what the reform effort is designed to do, said Henry Aaron, senior fellow at the Brookings Institution in Washington.
"Here's a plan, the primary purpose of which is to extend private health insurance, and it's called a government takeover. It's just bizarre. It's false," he said. "Even the tiny glimmer of possible validity in that argument, which a public option would provide, is not going to be part of any final bill."
The only place government-sponsored insurance would be extended is by increasing eligibility for Medicaid, and even that proposal has limited reach, he said.
"What they're talking about is health insurance for roughly 200 million people who either get it through work or buy it individually through private companies. Those numbers would increase, not decrease."
It's true that public programs have been keeping the ranks of the uninsured from growing even more during the recession than they would have without those safety nets. Medicaid and the state children's health insurance program have been picking up some of the people who lost private, employer-sponsored health insurance when they lost their jobs over the last few years.
But the gap is still wide: About 29 percent of people had some form of government health insurance in 2008 compared with 58.5 percent of Americans who had private, job-based coverage, according to the U.S. Census Bureau. About 15 percent, or 46 million Americans, had no coverage.
"The distinction between who's delivering health care and who's paying for health care is routinely confused and distorted," said Stephen Zuckerman, a health economist at the Urban Institute's Health Policy Center in Washington. Medicare, for example, is a government-financed program, but private doctors make the clinical decisions and deliver the care.
"Government-run health care is like the Veterans Administration, where the government owns the hospital, employs the physicians and finances the care," Zuckerman said.
Len Nichols, health economist and director of the health policy program at the New America Foundation, agreed. "Government-run health care would be if the government employed the providers and they were all paid a salary and you had no choice but to be treated by them."
The bottom line: "More care is going to be financed by government, but more care is not going to be provided by government," Zuckerman said.
ASSERTION: AN OVERHAUL WOULD LEAD TO RATIONING, WHERE MORE PEOPLE FACE DENIALS OR DELAYS IN HEALTH CARE
"This is the big red herring of the current debate," Aaron said. "The United States is so far from having an institutional framework from which rationing could occur that it's not a discussion that has much relevance to the reality of our current system or of the system that would emerge if the bill would pass."
Americans don't support what he called hard rationing, when a person has the money to be treated but is prevented from getting care.
"The American public is quite accepting of rationing in the softer sense, that if you can't afford it you can't have it," he said. "Pushing back that frontier is part of the objective of [the legislation.] The main thrust is to reduce rationing in terms of price rationing."
Employers and private insurance companies ration care all the time by deciding what's included in benefits packages and at what level of employee cost-sharing.
"While not everyone gets everything, there's a very high volume of care that's provided in the U.S., and there's very little in the bill that would likely change that," Zuckerman said. "Rationing is one of the more inflammatory words that gets used that has no basis beyond what currently happens."
Still, if the bill succeeds in providing millions more people access to health insurance, an increase in demand for medical services may affect some who already have coverage, depending on local market conditions, Aaron said.
"There is a possibility in some specialties and in some areas that the increase in demand could strain supply and therefore make it somewhat more difficult for those who have no problem getting a physician appointment or hospital bed to do so," he said.
Such a problem would be "relatively easy to solve," Aaron said. Opening new clinics and authorizing more health-care workers to carry out routine procedures could help ease the pinch. "It's the sort of thing we know how to do real quick and reliably."
ASSERTION: THE BILLS DO NOTHING TO ADDRESS OUT-OF-CONTROL COST GROWTH
"The single biggest myth is that no one is thinking about cost-growth containment," Nichols said. "In fact, most of us think about little else."
Lawmakers don't talk about it as much as they're working on it, he said, "because frankly the rationing rhetoric has been so effective. The people who on the one hand historically have been in favor of fiscal rectitude who are now screaming rationing are making it very difficult to have an adult conversation about cost-growth containment."
The political challenge is to address the estimated one-third of medical spending that's wasted every year on care that doesn't improve people's health.
The bills call for the federal government, through Medicare, to send a signal and change payment incentives so that patients receive high-value care the first time, Nichols said. It's not a one-size-fits-all approach and is designed to account for regional diversity, he said, noting the proposed pilot projects and payment reforms make a serious attempt to correct "mispriced procedures."
Zuckerman was more guarded about whether the bills have enough teeth to rein in costs.
"In the short run, cost-containment elements are not strong, but there are pieces in the legislation that could play out over time to contain costs," he said. "It doesn't look like the cost containment [elements] of the bill are as strong as they could be, but to say they're nonexistent is an overstatement."
ASSERTION: IF YOU LIKE YOUR HEALTH INSURANCE YOU CAN KEEP IT
President Obama touted this idea early and often as he campaigned to overhaul the system, but can he deliver on that promise?
Many experts speculate that it would work out that way but caution that it's not guaranteed, especially since the two bills assess the potential problem differently. While people wouldn't be forced to change what they have, employers may decide for them if they wager they'd be better served to drop coverage and let their workers shop for policies in the new insurance marketplaces the bills envision.
"There are penalties for employers that don't provide coverage so there is this pay-or-play notion, but depending on the penalties it still might be financially beneficial to employers not to play," Zuckerman said. "In the House bill the penalties are much more severe on employers than they are in the Senate bill."
"The idea of having penalties is to prevent employers from dropping coverage," he said, noting that the voluntary system is dynamic and not fully predictable. "You can imagine over time that the penalties could end up looking reasonable relative to the cost of coverage."
Still, employers may choose to change or drop coverage in the next few years with or without health reform, Zuckerman said.
Obama's pledge likely doesn't qualify as a myth, Aaron said. "In practice, the vast majority of people covered by private insurance will end up keeping their private insurance and won't notice any material change."
ASSERTION: THE BILLS ARE TOO BIG, AND CHANGES SHOULD BE TACKLED ONE BY ONE INSTEAD OF ALL AT THE SAME TIME
It's been 15 years since the U.S. came even remotely close to passing comprehensive health reform. While this year's attempt is ambitious, people who decry the scope of the bills underestimate how many moving parts need to work in unison to achieve the desired results, Nichols said.
"It's got to be done as a package," he said.
For example, health insurers would be newly required to accept all comers regardless of their preexisting conditions in exchange for a new requirement that individuals have coverage or face financial penalties.
Addressing cost control without extending health insurance at the same time wouldn't work either, Nichols said. "You cannot get to serious cost containment without the salve of coverage."
"The status quo is not sustainable," he added. "The people who argue that having somebody pay a dollar more or lose their extra glasses in their Medicare Advantage plan is somehow equivalent to leaving 50 million uninsured and doing nothing to contain the cost growth that's eating our economy alive, that's just folly. That's what opponents are trying to get Americans to accept yet one more time."
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