REFORM, AGAIN

A report published by the National Academy of Sciences last week declared that the “American health care system is confronting a crisis.” Closer to home, a report published last week by Anthem Blue Cross and Blue Shield, Maine’s largest insurer, asserted that bold change in this state is necessary because “doing nothing is not an option.”

The shared tone of urgency is warranted. Even as the cost of private health insurance jumps by more than 12 percent a year, patients pay more out of pocket and benefits dwindle. Soaring malpractice premiums further drive up cost of care and lessen availability. Stressed-out health care, increasing medical errors, needless loss of life is a vicious cycle. More than 41 million Americans lack health insurance and either suffer needlessly or use needlessly expensive emergency-room services for routine problems.

In other words, it’s a lot like it was nearly a decade ago, when newly inaugurated President Clinton proposed sweeping reform and got his head handed to him. One difference: Back in ’93, only 35 million Americans lacked health insurance.

The two reports are alike, not just in sounding the alarm, but in what they recommend. The academy suggests that three to five states be designated to participate in a pilot program for sweeping reform. Health insurance should be extended to all residents, either through tax credits or by expanding Medicaid and the Children’s Health Insurance Program. A non-litigious alternative to malpractice that would provide fair and timely compensation should be created. State-of-the-art information technology should replace the clumsy, costly and error-prone paper-based records systems. Also: improved primary care at community health centers, better care for patients suffering from chronic illness, greater emphasis on prevention. The Anthem report, no doubt driven by the growing single-payer movement, suggests much the same, a pretty strong hint that Maine should be among those three to five pilot states.

It’s always disheartening to find oneself in the same jam one was in 10 years earlier, but there is some reason for encouragement here. The academy report, though resembling the Clinton blueprint, was commissioned by the Bush administration. Health and Human Services Secretary Tommy Thompson, who rose to fame (or, to some, infamy) as a welfare reformer in Wisconsin, knew what he was getting into when he asked for the academy’s help, he himself described the current system as “inefficient to the point of becoming archaic.”

When the Clinton reform got shredded, the conventional wisdom was that the only way this sprawling, slowly evolved system of health care would change would be through tiny increments, not through sweeping reforms. After a decade of worsening conditions, sweeping reform is back in fashion.

Although the National Academy of Sciences is exactly what its name says and is famously nonpartisan, it recognizes political reality. Unlike the “big government” ethic of the Clinton reform, the academy proposal is based upon a philosophy of relying upon states and the private sector. There may be reasons why a “top-down” federal program would be more efficient, more fair, more whatever; the records shows that it is unacceptable to a large portion of Congress and of the public.

This is incrementalism, but of a different sort. Rather than drip out tiny improvements in the health care system at a rate so slow they cannot keep up with the negative forces, the academy report proposes sweeping change as a demonstration project for a select group of states, with the number of states expanded incrementally. When the call goes out for volunteers for this demonstration project, Maine should raise its hand.