Health care reform: Is the process the outcome?Clin Ther, 2009
The Pharmaceutical Economics & Health Policy section of this journal features empiric articles, editorials, and occasional commentaries to support evidence-based communications, all of them peer reviewed for relevance, technical accuracy, clarity, and objectivity. However, despite the availability of objective information both here and elsewhere, objectivity does not seem to figure in much of the media coverage of the current health care reform debate. It is clearly not the cumulative objective evidence that has generated the extreme passions surrounding health care reform. National health expenditures per capita increased 123% between 1990 and 2004, 1 but it was not this that evoked such intensity. The numbers of the uninsured are substantial and have been increasing for years without arousing anything like the present turmoil. So, why is health care reform so contentious, and what is the role for evidence-based pharmaceutical economics and health policy? Rates of unemployment in the United States increased from 4.8% in February 2008 2 to 7.2% in December 2008 3 and 9.7% in August 2009, 4 a 102% increase in 18 months. Under a system of employment-based health insurance, this magnitude of unemployment threatens or eliminates health insurance for millions. However, the fact of employment no longer guarantees health benefits: the percentage of firms offering health benefits declined from a high of 69% in 2000 to 63% in 2008. 5 Americans' domestic concerns are now dominated by the economy (33%), health care (25%), unemployment and jobs (14%), and the federal debt (7%). 6 The Kaiser Family Foundation has estimated that each 1-point increase in the national unemployment rate produces an additional 1.1 million uninsured and an additional 1 million Medicaid and State Children's Health Insurance Program enrollees. 7 Trends in health care costs also pose a substantial threat to employers. From 16% of the gross domestic product in 2007, health care costs are projected to reach 25% by 2025, threatening the competitiveness of US businesses and the fiscal soundness of federal, state, and local governments. 8 Financial crises, declines in employmentbased health insurance for those still employed, and the loss of health insurance by those in the growing ranks of the unemployed have converged to make the health care status quo unacceptable to many citizens. Public Opinion Strategies, LLC, the firm whose research contributed to the "Harry and Louise" campaign that helped defeat the Clinton Administration's Health Security Act of 1993, reported that by June 2007, 36% of voters endorsed "the need for radical change in the U.S. health care system," and about half supported reform. 9 Support for radical change came from 45% of Democrats, 43% of Independents, and 20% of Republicans. In the 2008 presidential election, voters elected a candidate whose central campaign theme was change; however, the details of that change have been slower to emerge than the opposition to it. The clarity of the election results are in stark contrast to the melee that took place during the congressional recess, when McCarthy et al, 10 writing in the Congressional Quarterly, observed that "as politicians and interest groups try to shape the outcome of the healthcare overhaul, they've offered interpretations that are so wildly different that truth sometimes seems to be taking a vacation." Examining a dozen major talking points in the media coverage of health care reform, the authors concluded that 5 were demonstrably false, 6 were misleading, and 1 was true. An article in Newsweek magazine was more blunt, referring to "the five biggest lies in the health care debate." 11 When so much valid information is available from unbiased and peer-reviewed sources, why is the debate dominated by highamplitude but demonstrably false claims? Given the current approach to health policy and reform, the question posed by a 2004 editorial in this journal-"Evidence-or Opinion-Based Pharmaceutical Policy?" 12-remains relevant today. Paul Grenier, writing in The Baltimore Sun, has asserted that "what we need…are not labels, but analysis." 13 Political theater is taking the place of the genuine work of crisis resolution. Only incomplete health care reform legislation had been drafted by the end of July 2009. Separate House committees had issued 3 marked-up bills, and only 1 Senate committee had completed its work. 14 The remaining committee with jurisdiction, the Senate Finance Committee, was still negotiating as the August recess began. Plotted over time, health care costs form an
Edward Berkowitz
