Former AAFP EVP Spells Out Complexities of Health Care Reform

Residents and medical students recently got a crash course on health care reform from former AAFP EVP Robert Graham, M.D., who now is board chair of the Alliance for Health Reform. "We spend 16 percent of our gross domestic product on health care," said Graham during the AAFP's National Conference of Family Medicine Residents and Medical Students here. "(The cost of health care) is going up at a rate of two to three percentage points above basic inflation."

He added that those costs are "One of the reasons people are so concerned about the implications of not having health reform." Health care costs could be the greatest threat to the financial stability of the United States in the next 10-20 years, said Graham.

Both the House and the Senate departed for the August recess before voting on health care legislation, leading Graham to ask, "Why is (health care reform) so difficult in the United States?"

"Every other industrialized nation that we compete with economically or think of as our peer socially has solved the basic fundamentals of financing and organizing a health care system, so people feel like they know how they’re going to get care," said Graham, professor and Robert and Myfanwy Smith Endowed Chair in the department of family medicine at the University of Cincinnati College of Medicine.

He noted that there are three basic objectives to any health care system:

It will be "almost impossible" to adequately address all three objectives in one bill, said Graham.

"That is a standard that is probably unfair to hold any individual or bill to because nobody else in the world has gotten there," he said. "We'd do well if we could make measurable progress toward all three of those objectives, even though we didn't nail even one of them."

Part of the problem, he said, is that supporters of health care reform don't agree on what issues are most important or how best to address the issues.

To prove his point, Graham treated his audience as a mock Congressional conference committee, laying out the issues and then taking several votes.

On the subject of universal coverage, Graham asked how large companies should be to be included in a mandate if employers are required to offer health care coverage. A large portion of the audience voted that companies with 50 or more employees should be mandated to offer coverage; a similar-sized portion, however, voted for companies with 250 or more employees.

The majority of the audience voted against taxes on health care benefits. Graham then asked how should the nation fund universal coverage?

If a tax were imposed on the wealthy, at what level of family income should the tax be imposed -- more than $250,000, more than $500,000 or more than $1 million, asked Graham. Half a million was the most popular answer.

Graham said that if reform efforts fail, politicians aren't likely to push the issue again in the near future.

"If we do not get health reform this time, you can anticipate several things to play out over the next five to 10 years," he said. "One is politicians will say, 'I'm never going to go there again.'"

Democrats previously failed to pass health care reform during the Clinton administration, and Graham said a second setback under a Democrat president -- especially at a time when Democrats have a majority in both houses -- could make the party hesitant to try again.

Graham said there likely would be changes in the health care system even if reform fails, including efforts by Congress to put restrictions on Medicare costs, payer constraints on providers with below-average outcomes and a shift in businesses from defined benefit plans to defined contribution plans. There also could be fewer businesses providing health benefits because of cost.