In honor of the Senate Finance Committee's passage of the Baucus health care overhaul, today we bring you the second in our series of interviews with health-care policy experts. The first interview was with Sally Pipes of the Pacific Research Institute. The second, presented here, is with Scott Gottlieb, who is a doctor, a fellow at the American Enterprise Institute, and the former deputy commissioner for medical and scientific affairs at the Food and Drug Administration.
I begin by mentioning that some descriptions of the American health care system are pretty grim, with stories about cancer patients being denied treatment by their insurance companies. Is American health care in good shape or bad shape? "We have outstanding health care, but we have problems with access," Dr. Gottlieb replies, characterizing the American systems as one with "very high quality health care, but some troubling gaps." These gaps, he said, aren't just for the uninsured – many of those waiting in hospital emergency rooms on nights and weekends have insurance, but their regular doctor's office just isn't open during those hours. He downplays the statistics ranking America's health care system as lagging those of some other nations, saying that many of those rankings are skewed with criteria that favor single-payer systems. Much of the excess morbidity and mortality that those rankings fault America for, he points out, takes place within the government-funded Medicaid system that serves the poor.
Next, I inquire about the political difficulty of the shift advocated by many free-market-oriented health-care experts, away from payments by third-parties such as employers and insurers and toward payment by the consumer. Isn't it a hard political proposition, I ask, to make people start paying themselves for something that they are used to thinking of as cost-free? "That's one of the fundamental problems," he said, noting that people have gotten used to consuming "prepaid health care" rather than buying insurance. He says that political liberals think it's unethical or morally repugnant for people to have to take costs into account in decisions about their medical care, and that those liberals have as allies medical device manufacturers and drug makers who want to insulate consumers from the costs of their products. "Why does Pfizer want no co-pays for Medicare Part D? Because if people had to pay out of pocket for Lipitor, a lot of them would switch to Zocor," he says. A change to consumers paying for their own care, he says, would require "a cultural shift."
Can capitalism help improve American health care or solve some of the access problems? Dr. Gottlieb says markets and competition are starting to rise to meet market needs and opportunities. Some Medicare Advantage programs, for example, are staffing 24-hour clinics, but the Medicare Advantage program is targeted for elimination by the Obama administration's health insurance overhaul. Some insurers are offering catastrophic plans, but "a lot of states prevent companies from offering those plans. State legislatures have been lobbied by the dentists, by the chiropractors, by the IVF doctors." He said he met one woman who has put together a discount card that allows patients to visit a network of doctors who agree to treat them at the same rates they would be reimbursed by Medicare. The fundamental philosophical divide, though, Dr. Gottlieb said, is between the defined benefit approach favored by Democrats and the defined contribution approach favored by Republicans. Similar to the debate over pensions, a defined contribution would give individuals or families a tax credit or subsidy to spend or perhaps save as they choose on medical care. A defined benefit would guarantee access to certain services.
I ask why so many of the groups that vocally opposed Hillary Clinton's effort to change health insurance during the Clinton administration are either silent or in favor of the Obama administration's plan this time around. "A lot of these groups have been bought off by the government," he says. Doctors, for instance, are dependent on a legislative fix for Medicare reimbursement rates. Insurers hope for an expanded market. Drug companies want to avoid government price fixing on medicine. "The companies may well get want they want," he says. He notes that all these interest groups are "far more dependent on government than even 15 years ago." In fact, the private share of health expenditures has shrunk to 53.8% in 2007 from 56.1% in 1993, according to government data, and, Dr. Gottlieb observes wryly, it will be "even a smaller percentage two months from now."