Q&A With Health Policy Expert Thomas Oliver

Thomas Oliver, PhD, MHA, is an associate professor of population health sciences at the University of Wisconsin School of Medicine and Public Health (SMPH) and associate director for health policy at the UW Population Health Institute.

 

A political scientist by training, he looks at health care delivery, finance, systems and reform in the context of how state and federal governments function.

 

He previously was on the faculty at the University of Maryland and Johns Hopkins University. Since joining the School of Medicine and Public Health in 2007, he has worked with his colleagues and the Wisconsin Department of Health Services to evaluate a major expansion of Badger Care, which provides health insurance to low-income working parents and their children.

 

Oliver answered questions recently about the future of health care reform.

 

What do the results of the 2008 presidential election tell you about the possibilities for health care reform?

 

The results of the election suggest that we need to do something different in regard to health care reform, and that the government is going to have to play a pretty substantial role. This is something that people seem willing to accept, at least for a while. It was a pretty clear call for a change of course.

 

Thomas Oliver

Where will health care reform fit in Barack Obama's plans?

 

Obama made health care reform one of his major issues and a centerpiece of his campaign. But that was before the economy was in complete meltdown. Now, health care issues are really being subsumed under the state of the economy and people's ability to keep their homes and jobs and afford the basic necessities of life.

 

But it's easy to see how logically you could connect health care coverage to this much bigger set of economic problems because we're going to experience much larger increases in the unemployment rate. A lot of the people who have or will become unemployed actually have had decent health care coverage. They risk losing that coverage and not necessarily getting it back with a new job. The economy is both forcing the need for more coverage and possibly preventing the means of doing it.

 

How would we pay for broader coverage?

 

Obama will have to find ways to keep expanded coverage from completely blowing the federal budget or requiring a major tax increase. One possibility is that expanding coverage might allow you to build bigger and stronger purchasing power. Programs with many people in their coverage pools — like federal and state governments through Medicare and Medicaid programs and even large employers — would take a serious look at how they could achieve better cost efficiencies.

 

What kind of efficiencies?

We have to use resources in a much more targeted, careful way. Providers — who make most of the decisions as to what therapies are recommended, tests are ordered, drugs are prescribed and how long people stay in various settings in the system — will have to think about being more efficient and not ordering things that are unnecessary or potentially harmful. Stricter controls might be imposed on drug prices.

 

But you need enough information and good economic incentives to make that work, and we haven't really figured out how to "pay for performance" by linking clinical decision making with health outcomes, or to identify who absolutely should get a certain service or drug and who can do without it. The problem is that we have certain kinds of payment systems that encourage doing too much and other systems that encourage too little, so you have to blend information and accountability with payments to find an efficient and acceptable middle ground.

 

Is "change the system now, figure out the details later" the best way to go?

 

The history of almost all national health insurance systems says it is — Britain, Taiwan and Chile. The best and most comparable place to look is Canada. In the early '70s, Canada pointed to the provinces that had universal hospital and medical insurance and said that all provinces would establish their own systems, and that the federal government would help regulate it and provide resources for it.

 

Compared to the rest of the world, Canada has a very expensive health care system because it has a lot of the same kinds of payment systems that we have in this country. They have to negotiate very hard with doctors and hospitals, but compared to the U.S., they're much more efficient and everybody is covered and they do a very good job.

 

Can you summarize the main points in Obama's health care reform plan?

 

The Obama plan would not intentionally affect any of the people who already have satisfactory insurance. But it would "top off" each of those existing areas of coverage. So the State Children's Health Insurance Program will almost certainly be expanded, covering all children, up to middle class levels, who otherwise couldn't get health care. I think this will happen very soon after the new president and members of Congress are sworn in.

 

I think we'll also see some flexibility for raising income eligibility for Medicaid programs, for either working or non-working adults. Many states have almost no opportunity for Medicaid coverage if you don't have kids. I think that will begin to be loosened, in line with what the next phase of Wisconsin's Badger Care Plus is doing.

Also, I think Obama will keep advancing different ways to pool individuals and small businesses to allow at least an approximation of the health insurance premiums they could get as big companies, state governments or school systems.

 

Does the plan make sense to you?

 

Obama's plan uses the tools that logically make sense if you're not going to start a new system from scratch. The other obvious alternative is to open up Medicare to younger Americans and make it our national health care system, but that is unlikely to happen in one quick step.

 

More than 80 percent of all Americans do have some health insurance coverage, although this number is going down, and close to 50 million people aren't insured. Since we've already built these various health insurance programs, it will be hard to get many of those folks to want to switch.

 

What other considerations besides using resources more efficiently do you feel need to be emphasized in a reformed system?

 

We have to deal better with end-of-life care because a huge proportion of resources are used there. An estimated one-quarter of all Medicare spending goes to beneficiaries in their last year of life. We also have to deal with providing better front-end primary care for everybody, and we must improve prevention.

 

Health care reform plans that come forward should be addressing these big three challenges in the name of tomorrow's costs, if not today's. And we need to keep people healthier before they get to Medicare, so they don't break the bank there.

 

Are there other issues that come into play?

 

The health care system itself needs to be more accountable, but better health starts outside the health care system. More effort needs to be made to get patients to stop smoking, for example, or stay away from unsafe environmental hazards or wear helmets while bicycling. We need to focus more on building better environments for people to walk in and kids to play in.

 

How important a role will the U.S. Congress play in health care reform?

 

I think Obama would be wise to let Congress take the lead and throw his political capital behind something that's negotiated in the Congress, which means it's been worked out with the key interest groups. I think there's a lot of hope for working together.

 

Obama is the first person who has come into the White House directly from the Congress in almost 50 years. Most of the presidents in that period never served in Congress or were a legislator. Obama will be much more able, presumably, to understand where the legislative leadership is coming from, having been there himself.

 

Will the national focus on health care reform affect what's happening on the state level?

 

Yes, it may allow a few states like Wisconsin, Vermont, California or Maryland, which have been talking about reform and have had real plans on the table for some time, to anticipate more federal support and encouragement. But it's entirely possible that people will say this is just hard politics and we're in the midst of a budget crisis, so let's turn to Washington for leadership on this.

 

What needs to happen for states to make substantial changes?

 

First, federal rules must be relaxed so states can pass laws saying that employers who currently aren't contributing to health insurance must contribute some. States will need to decide what level of contributions must be made, what exemptions would be allowed and how fast the changes would be phased in.

 

Then there will have to be a good deal of federal money going to states, because that's the only source of adequate funding for the states that have the biggest numbers of uninsured.

 

Third, we will have to provide health services, if not health insurance, to the large numbers of new immigrants who have come to the country legally and illegally. Unfortunately, health care and immigration are volatile issues on their own, so if you put them together, it's an even more volatile issue.

 

How has the state of Wisconsin done in terms of trying to get affordable health care for everybody?

 

Wisconsin is one of the places in the country where we're seeing leadership and progress. Gov. Jim Doyle, who has been very committed to expanding Badger Care, has had the cooperation of both Republicans and Democrats in the state Legislature. Since last February, Badger Care has enrolled nearly 100,000 new members.

 

How will the budget shortfall affect the progress Wisconsin has made?

 

We have an immediate short-term threat to some of that success but we've got a game plan in place to continue to move towards affordable insurance for everybody in Wisconsin. With Democrats now having majority control of the Assembly and the Senate, and with a Democratic governor, I think that if they figure out how to solve the budget situation in a constructive way, there will be a more unified approach to moving new health reform options and decisions forward.

 

Why is health care reform such a challenge?

 

It's rocket science! You must consider factors such as: Who and where are the uninsured, what are the policies that will actually get them enrolled in coverage, which services and providers will be covered and, of course, how will we pay for it? There's not an easy answer to any of those issues.

 

That's why "a one-size-fits-all" model like Medicare or the one proposed in the Healthy Wisconsin legislation might work well. You wouldn't have to weigh who deserves coverage and who doesn't. You wouldn't need to consider age, employment status, size of employer, family composition, past illnesses or whether there are dependents.

 

All these choices have moral, legal, economic and practical consequences wrapped up in them, and it never stops. Still, many people are looking at all these factors and working them into models and trying to figure it all out.

 

Are you optimistic?

 

I am optimistic that there is a tremendous political opportunity to rethink what we are doing about health care needs in this country. I expect that there will be some forthcoming solutions for certain populations and certain kinds of strategies to expand coverage. But I think state budgets are in terrible shape, so to just keep the programs we already have, it's going to take a lot more money — and that can only come from the federal government.

The question is can people in the grassroots as well as our social and political leaders convince enough Americans that they are in this group that's getting progressively worse off. We are seeing this unique political and economic environment in which we might actually get people to say they're willing to share the risk a little bit more, to take a leap of faith, instead of fighting the same old politics of health care reform.

 

When we get out of the economic crisis, if we have a more stable and secure kind of health care system, we will all support that and be willing to commit to maintaining it over time.

 

This article appears in the winter 2009 issue of Quarterly.

 

Date Published: 02/16/2009