UVM experts weigh in on the gravity of the passing of the health care reform bill.

President Obama signed into law a sweeping health care reform bill on March 23 considered the nation's most substantial social legislation in four decades. Debate leading to the passage of HR 3590 was intense and raised a number of questions about the effectiveness and affordability of the nearly $1 trillion plan.

The issue

The House and Senate passed the Patient Protection and Affordable Care Act with no Republican support in either chamber. A separate compromise package of changes was also passed by the House on March 21 and still needs to be approved by the Senate. If the compromise measure also becomes law, it would raise the total cost of the health care bill to $940 billion.

The plan is expected to provide insurance coverage to roughly 32 million additional Americans, in part by expanding Medicaid assistance to the poor while creating an insurance exchange to increase competition. Under the bill, most Americans will be required to have health insurance or pay a fine.

An opportunity for a healthier nation

Dr. Jan K. Carney, associate dean for public health and research professor of medicine, expects the reforms to improve the nation's overall collective health "by removing barriers to needed health care and preventive services, recognizing a broad definition of health that includes attention to mental health, dental health, and underserved populations, and creating incentives and funding for enhanced public health efforts."

Carney lists a number of examples including a national quality strategy to improve delivery of services and population health (an approach that aims to improve the health of an entire population), including community-based efforts to serve low-income populations. The Secretary of the Department of Health and Human Services will report on trends and progress in reducing health disparities. Incentives for worksite wellness and new requirements for restaurants to provide nutrition information to the public are also part of the new legislation, she says.

"A call to develop a national strategy for prevention, health promotion, and public health is accompanied by funding to strengthen prevention and public health programs," says Carney, who sees a multitude of missed opportunities for prevention in both clinical and community settings under the current system. "Many initiatives (in the new plan) are designed to impact health behaviors in positive ways, such as preventing diseases by reducing risks for preventable and costly chronic conditions. For individuals, there will be no cost sharing for science-based preventive services; people 65 and older can have individualized prevention plans based on their own health risks."

Carney says the bill is also expected to increase the number of physicians and nurses, especially in rural and underserved areas; provide health professional training that includes preventive medicine, public health, and training in cultural competence and innovative primary care delivery models; and provide funding to support additional community health centers, nurse-managed health clinics, school-based clinics, and an increase in the National Health Service Corps.

"In addition to providing health insurance and health care to millions of Americans, incentives and funding for both clinical prevention and public health create opportunities for a far healthier nation," says Carney.

Questions of economic sustainability

Art Woolf, associate professor in economics, says most economists agree that the health care plan is unsustainable without a major tax hike or serious cuts in large social programs such as Social Security, Medicaid or Medicare. Americans have paid taxes at a rate of around 19 percent of GDP for the past 40 years, he says, but would have to pay closer to 25 percent to pay for the new health care system. "This is beyond the level of tolerance Americans have for paying taxes."

Woolf also takes issue with the estimate by the Congressional Budget Office estimating that the legislation would yield a net reduction in deficits of $138 billion over the 10-year period.

"Those numbers are bogus," says Woolf, who also expects the bill to stifle medical innovation due in part to cost-control mechanisms. "They write it so it comes in where they want it. The numbers are based on estimates as they are written into the legislation." As an example, Woolf cites legislation that called for paying doctors 20 percent less. "They wrote in the law that this money would help pay for universal health care. That number is included in the CBO's estimate, but everyone knows that they postpone the law every year and don't save that amount. This cut is not going to happen, yet it's counted in the $138 billion net reduction."

The impact on Vermont

Steven Kappel, an adjunct professor who teaches Health Care Policy through the Master of Public Administration program, has been involved in health policy for more than 25 years and recently founded Policy Integrity, a company specializing in the development and evaluation of health policy. He says Vermont won't feel the impact of the legislation as much as other states for two primary reasons.

"First, our Medicaid program already has broader eligibility than the bill would require," says Kapell, who has provided policy and fiscal analysis to the state legislature on health care issues. "Second, our health insurance market is more tightly-regulated than most."

"More broadly, the bill builds on the American approach to health care reform, continuing to base coverage for the majority of people on private insurance, but making insurance look more and more like a public plan (mandated coverage, elimination of pre-existing condition exclusions, income-sensitive premium subsidies...)," he says.

Widening the political divide

According to Eileen Burgin, associate professor of political science who specializes in Congress and served as a professional staff member in the U.S. House of Representatives, the U.S. political system was designed to make incremental changes and sees the bill as a starting place.

"Many major, transformative pieces of domestic legislation pass with broad majorities and bipartisan support," says Burgin. "And while in general bipartisanship is a worthy goal, when a minority insists on complete obstructionism, policy making with just majority party support is preferable to stalemate, paralysis, and gridlock. Congress's action is not the end -- it is just the beginning on health care reform. As problems emerge, they will be addressed and policies will evolve."

Burgin reminds that Congress is an institution composed of individuals with personal relationships that have huge impacts on policy making. "What happens in informal meetings can be just as significant as what happens in more formal gatherings," she says."Whatever one thinks of President Obama's executive order that provided Bart Stupak and his anti-abortion colleagues with adequate political cover to support the legislation, one should remember that that compromise began to be discussed in the House gym -- Rahm Emanuel ran into Stupak in the House gym."

Anthony Gierzynski, associate professor of political science, says the health care bill goes as far as the current political climate in the U.S. would allow. "The nature of political polarization, the current media culture, and public opinion (including knowledge levels as well as attitudes) limited what could be done," he said. "That being said, what was accomplished was truly historic -- and maybe even more impressive -- given that climate, and the history of failed attempts at health care."

Gierzynski says he's convinced that as the news media start talking about the actual contents of the legislation -- something he thinks has been lost in all the "political game coverage" -- the majority of the public will see the legislation in a much more favorable light. As a consequence, he says, the Democrats may benefit come mid-term elections in November."

A social work perspective

George Liebowitz, assistant professor of social work whose research focuses on trauma among sexually abusive youth, delinquent youth and their families, says health care reform will go a long way in helping youth and their families address physical and mental health issues before they are beyond repair. Many of the temporary or "stop-gap" services currently in place act more as band-aids, ultimately costing taxpayers more as health care issues continually resurface, says Liebowitz.

"We still see people living in poverty as unworthy of services," he says. "The idea that they should be able to ride out their health care problems is unrealistic and ends up costing this country far more than if they had insurance and could address these issues earlier and when most needed. It's been proven that early access to care produces better outcomes, yet we've continued to re-arrange the deck chairs on the Titanic."

Legislative justice

Alex Zakaras, assistant professor of political science, sees the passage of the bill as the righting of an injustice.

"Despite its several flaws, the health care bill that President Obama just signed into law is an important moral victory; it helps address one of the most pervasive injustices in America today," he says. "Ours is, in many ways, an unjust society. The most important symptom of this injustice is the deep inequality that divides the wealthy from the poor, and that has grown dramatically since the Reagan presidency. America tolerates more inequality than any other modern industrialized country. This inequality extends not only to income and wealth, but also to the basic services, such as education and health care, that are so important in giving people a chance to live good lives.

"As of today, around forty million Americans cannot afford health care. For the simple reason that it makes health care affordable for over thirty million of those fellow citizens, this bill is cause for celebration."