Hundreds of health plan representatives heard three former governors—two of them physicians—argue over what role federal money should play in health reform as the America's Health Insurance Plans convention began its annual convention in San Diego on Thursday.
Former governors Howard Dean, MD (Vermont), Jeb Bush (Florida), and John Kitzhaber, MD (Oregon), agreed that the current system is functionally flawed. And they agreed that health plans, employers, and consumers need to take more responsibility for their own healthcare.
But they disagreed on how much of a role the government should play, and whether any level of its regulatory presence would stifle innovation to improve the delivery of medicine.
For many in the room, listening to Dean might have resembled hearing the enemy speak. Health insurance companies are vehemently opposed to a public plan.
But Dean considers public health insurance a necessity. "I think it is absolutely essential. And I don't think health reform is worth doing without a public option."
"What the president is proposing to do is say, if you like what you have, you can keep it. If you're comfortable with the private insurance market, you can keep it. Not only that, but we'll help you buy it. There will be a government subsidy based on your income, particularly helpful to small businesses, that you will receive to buy healthcare in the private market," Dean said. "But you will also have a choice of buying into a public plans such as Medicare or some other public plan. And I'm one of the few defenders of that in this room."
"Now I know people in this room, in this industry, are very, very fearful," he said. "This is the center of opposition."
He looked at the rows of representatives of Aetna, Blue Cross, and dozens of other companies assembled and said, "Your living is at stake here. But I don't think it's going to be as tough as you think it is."
The reason, he said, is that most of the nation's CEOs, despite "incredible inflation," prefer to have employer based health insurance. He emphasized that there is still a role for private health insurance, but one that would be shared by public plans.
Bush, however, argued for government to step back. "Beware of too much intrusion by the federal government in all of this," he said. "I'd be very, very cautious of ever expanding federal government."
Bush said too much of the debate centers on access, and not responsibility, saying patients should be given more incentive to more take responsibility for lifestyle decisions that affect their healthcare.
"In almost every other aspect of our lives we ask people to be responsible for their own decisions. But in healthcare, by and large today, individuals are not responsible for their healthcare decisions," he says.
Bush urged for more emphasis on disease management, which he said "should be allowed to happen more often than it is."
"Gov Dean," Bush said turning to face his fellow speaker, "my concern about the federal government is based on my experience as governor. Every time we tried to do something innovative, there were always all sorts of burdens in place and rules imposed" that prohibited efforts to help those treating Medicaid beneficiaries "make sure they were given proper training, education and medication, and giving them the prescriptions so they could live a healthy lifestyle."
"Prevention really matters" he said. "Our whole system is geared toward sickness. We have to find a way, culturally, economically, and through government regulation, every means, to change this so there are rewards for prevention."
Bush also urged health plans and health policy officials to create a system that does a better job in rewarding, by paying providers more, for better healthcare outcomes.
Kitzhaber, now director of the Center for Evidence Based Policy at Oregon Health and Science University, tried to refocus the debate to one about quality.
"The purpose of the U.S. healthcare system is not to finance universal healthcare. The purpose is to produce health. Healthcare is a means to an end. It has no intrinsic value outside of the relationship to health outcomes," Kitzhaber said.
"The problem is not how we pay for healthcare. The problem is what we're buying," he said.
"Unfortunately," he said, "most of the debate today – including the debate on Capital Hill—is not about how to improve the system to improve the health of the American people, but how to finance the system we already have. And I think that's a fundamental misdiagnosis of the problem."
As an example, Kitzhaber said, the healthcare system won't always pay for prenatal care, "but it's happy to resuscitate a 400-gram infant in a neonatal unit."
And, he added, "the most common admitting diagnosis for people on Medicare is congestive heart failure, but there's no incentive to keep people out of the hospital by managing those conditions on a day-to-day basis once they get out of the hospital."
An estimated 1,200 officials from dozens of health insurance companies are attending the conference, which ends today.