Government and Health Care: Be Not Afraid
One of the interesting dynamics in the current debate over health care reform is the number of people who are concerned about government involvement in health care. As someone who has been working in health care for more than 15 years, I have to say that the horses left the barn on that one a very long time ago.
First of all, federal and state governments are a direct provider of health insurance to a very large number of people. Medicare (a federal program) and Medicaid (a federal-state partnership) together provide health insurance to more than 100 million Americans. Taken together, these two programs—which have been around since the mid-1960s–provide almost half the revenue going to hospitals.
In addition to providing health insurance directly, federal, state and local governments also buy a lot of health insurance from private insurers. This is mostly to cover their employees (roughly 16 million FTEs), but the Children’s Health Insurance Program (another federal-state partnership) also purchases private health insurance for about 10 million children nationwide.
Federal and state governments are also major regulators of the health care sector and this, too, has been the case for a very long time. Hospitals are regulated at both the federal and state level, although hospitals accredited by the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) are usually deemed to have met many federal and state regulations. Physicians, nurses and other health care professionals must also comply with both state laws and the rules of their professional bodies.
In addition to regulating providers (e.g. hospitals, physicians), federal and state governments also regulate the business of insurance. This is primarily a state function. Here in California we actually have two bodies to do this, the Department of Insurance (which regulates all types of insurance, including health insurance) and the Department of Managed Health Care (which specifically regulates HMOs). Employers who self-insure are exempt from state insurance law, but are governed by a federal law called ERISA, the Employee Retirement Income Security Act.
Finally, while government plays a smaller role in the direct provision of health care services in the United States than in some other countries, its role is still significant. Public (non-federal) hospitals account for close to a quarter of all community hospitals in the United States, and many of these hospitals provide essential (but expensive) services that other hospitals have abandoned, such as trauma centers and burn units. The VA, of course, runs the largest integrated health care delivery systems in the country, with more than 1400 hospitals, clinics and nursing homes.
My point in recounting all this is merely to say that federal, state and local governments have been deeply involved in providing health care and health insurance—and in regulating these industries—for a very long time. Those of us who work in the industry sometimes chafe at this oversight, but we also respect, for example, the VA’s achievements in the area of patient safety and Medicare’s increasing sophistication about quality measurement and improvement.
The health care bills currently working their way through the Congress are very large and I’m sure almost everyone can find something in them that concerns them. We certainly need a deep and substantive debate over the details of this legislation. It should not be rushed through because of some artificial deadline. But angry rhetoric about the evils of “government controlled health care” is deeply disconnected from the reality of the health care system and the real challenges it faces, not least of which is the growing number of uninsured.