Will Business Force Reform Back to the Drawing Board

By BRIAN KLEPPER and DAVID C. KIBBE

Until now, non-health care business has been noticeably absent from the health care reform proceedings , and quiet about the bills' impacts on their management of employee benefits, on cost, and on the larger issues of global competitiveness. Where have the voices been of the powerful business leaders who will pick up much of the tab?

They've finally surfaced, and now we'll see whether they have the will to bring reform back on track. They certainly have the strength. The question is whether this salvo by the business mainstream could force Democrats to reconsider and revise the content and structure of their proposals.

On October 29th, a powerful collaborative of major employer organizations sent a letter to Speaker Pelosi and Republican Leader Boehner asserting that the House legislation "falls short of the bipartisan goal of controlling costs and jeopardizes employer-sponsored coverage which now serves more than 160 million Americans." The same group sent a similar letter to Senate President Reid earlier that week.

It is important to note that the collaborative - the group includes the American Benefits Council, the Corporate Health Care Coalition, the ERISA Industry Committee, the U.S. Chamber of Commerce, the National Association of Manufacturers, the National Association of Wholesaler-Distributors, the National Coalition on Benefits, the National Retail Federation, the Retail Industry Leaders Association, the Business Roundtable and the National Business Group on Health - represents the mainstream of American business. In general, these associations' member firms have sponsored employee health coverage for decades, and understand the linkages between health, productivity, cost and competitiveness. Their very real stake in the outcome, their long term sponsorship and their sheer collective clout enable them to enter and change the terms of the discussion.

Then, Tuesday, Employee Benefit News published a list of 10 specific items prepared by National Business Group on Health President Helen Darling, a longstanding progressive voice in health benefits, that "should concern plan sponsors that provide health care benefits to their workers." The bill, she said:

1. Lacks meaningful ways to control health care costs;
2. Takes us down the road to even worse deficits and crushing national debt by not getting more savings from the health system and making the coverage more affordable;
3. Does not support strong evidence-based medicine or a way to make certain that we don’t pay for treatments that are not effective;
4. Does not establish a strong independent Commission that could help Congress make the politically hard, but obvious, good decisions to eliminate wasteful and harmful treatments and spending;
5. Does nothing to correct medical liability problems and related costly defensive medical practices;
6. Doesn’t expand employers’ ability to help employees to actively engage in wellness activities or achieve health goals;
7. Undermines ERISA and opens ERISA plans to unacceptable burdens;
8. Raises serious questions about the public plan and how it would operate;
9. Could require an employer who provides comprehensive benefits to still be subject to an 8% payroll tax if employees decline employer coverage because it costs more 12% of the employee’s income; and
10. Contains an outrageous requirement that would require employers still offering retiree medical coverage to continue it indefinitely, thereby hurting employers who have maintained retiree benefits in good faith.

Non-health care businesses comprise about six-sevenths of the economy - meaning they have six times the heft and influence of the health care industry - and financially sponsor coverage for more than half of Americans. Year after year, employers have borne the lion's share of onerous health care cost increases, 4 times general inflation over the last decade. Endless reports have described how health care, business' largest and most unpredictable benefit cost, has sapped America's global competitiveness and placed its employers at a severe disadvantage. An equal torrent of words has been spent on health care's excessive waste, at least 30% of our $2.6 trillion expenditure, or north of $800 billion annually. Even so, most business leaders are loathe to simply give up the health system they currently sponsor, its flaws notwithstanding, unless they can be confident the alternative can result in lower cost, improved quality, and an equally or more productive workforce.

Keep in mind that, at this point, health care reform has been a series of power plays between Congress and the health care industry (meaning the professionals, firms and associations representing health care's four major sectors: the supply chain, HIT, care delivery and insurance/finance).

Until now, the health care industry - those who seek dollars - has dominated, lobbying Congress and contributing enormous sums to election campaign coffers to make sure that the legislation doesn't impede health care profiteering and sends new funds their way. Meanwhile it has held its breath, apparently hoping that other interests with clout won't notice. As the bills come down to the wire, the air waves have NOT burned with cautionary and righteously indignant health care industry messages opposing them. That's because organizations in the health industry are reasonably certain they've won. They have been sitting tight until the deals are done.

And with good reason. As they stand now, the reform bills are very generous to the health care industry, facilitating, through mandate and/or subsidy, millions of new customers but, as we've recently pointed out, doing pathetically little to rectify the health care crisis' structural drivers. For example, the health plan sector can raise rates without restraint, and a significant chunk of Medicare dollars will be transferred to private sector control. The biotech industry gets a 12 year moratorium on generic competition. With only token progress away from fee-for-service reimbursement and toward primary care re-empowerment, the system will continue to make specialist excesses lucrative. The American Medical Association (AMA) and Medical Group Management Association (MGMA) couldn't be more enthusiastic, though both are now campaigning for H.R. 3961, which would eliminate the 21.2% drop in Medicare physician reimbursements scheduled to go into effect January 1, 2010. There are many more examples.

Commercial purchasers have waited to see how all this would play out. But now they're stirring, and not a moment too soon. Non-health care business leaders finally appear to be mobilizing against the weak cost control provisions of the current proposals.

What is needed now is an orchestrated, mobilized, highly visible campaign effort that features the faces and voices of well-known American CEOs, and that leverages the full force of business' leadership across industries, not just for their own interests, but for those of all Americans. The places to start are in the structural areas we and others have recently discussed: primary care, fee-for-service reimbursement and cost/quality performance transparency. Properly implemented, reforms in these approaches throughout health care could have profoundly positive impacts on both cost and quality, empowering the market to make health care far more affordable for businesses and working families.

It is possible that the entire health care reform process just changed tone and direction. If it did not, then we're no worse off than before. But if it did, then the ramifications for how American policy works - not just for health care but for all our issues - could have just entered a new and profoundly important paradigm.

Brian Klepper and David C. Kibbe write together on health care market dynamics, health IT, innovation and policy.