Nexus

The Wait Goes On

It’s Not Just ER Patients These Days. The Entire Healthcare System Is in Limbo.

Teen girl texting in hospital waiting room

It used to be that long lines in the emergency room were the worst part of waiting for American healthcare. Now we’re waiting for everything: health insurance to be available and affordable; primary care physicians to increase in number; politicians to stop bickering long enough to make some decisions about physician fees in Medicare; Supreme Court justices to decide whether Congress is allowed to do what it did in the Patient Protection and Affordable Healthcare Act.

You remember that goal of comprehensive reform? Cover everybody, improve the quality of healthcare services, lower costs? Before its passage, at least we knew what we were waiting for: a law that accomplished all these things. Now, in its anti-climactic aftermath, we are still waiting … not unlike the characters in Samuel Beckett’s Waiting for Godot, who know they have to remain waiting, but can’t recall why, or for whom, or what.

What’s our problem? Why is this so hard? Everyone knows a story about someone who needs healthcare but can’t afford it, or someone else who is suffering under the burden of healthcare costs. Why can’t America the Great just get its act together on this basic need?

There are several answers. The healthcare system is so complicated that most of us can barely understand it. The issue is so personally and politically charged that we can’t stop fighting about it. And healthcare is so expensive that we can’t afford it. The last answer encompasses a big “we”–everyone is poor these days–the federal government, state governments, the private sector, and patients.

The United States, in its embrace of a free market and no-entitlement-to-healthcare ideals, can boast of a system that is utterly complicated and totally broken. It is embarrassing to explain our regular failure to deliver appropriate care, our inability to control costs, and the converse incentives to providers that lead to inefficiencies that would never be acceptable in another industry. Not to mention the labyrinth that is the public and private investment in healthcare delivery, with so many overlapping federal, state, and corporate efforts intertwined in knots.

We Americans do not do well with complicated. Explaining the problems with the healthcare system takes a long time, let along taking a stab at some solutions. We like big-picture fixes like Herman Cain’s “9-9-9″ tax code (the candidate may have left the scene, but the dream goes on) or snappy, reductive slogans like “it’s the economy, stupid.”

Washington’s response to the complexity underlying the healthcare system is to compensate with simplistic, ideological, and polarizing quarrels around the issue. The same emotional factors–does Grandma live or die and so on–contribute to the coarsening of political discourse around healthcare. Take a position on any significant question on the future direction of the nation’s healthcare sector, and you’re likely to be labeled a raving socialist or a heartless capitalist.

Supporters of President Obama recently declared that he intends to launch a defense of the law on the campaign trail. Odd, no? The president’s posture is to defend a legislative victory? This lack of leadership in communicating and educating about the health law makes it impossible to tame its complexity. How can there be a shared political and cultural narrative around healthcare when one of the most professorial and clear-spoken of presidents is strangely unable, or unwilling, to recast healthcare as a comprehensible dinner conversation for American families? We need politicians to frame a solution in a way that we can digest so we know what makes us upset and what we want to do about it.

Polls indicate that many Americans disapprove of the health reform law overall but appreciate specific elements of it. If asked, people will say they like the elimination of coverage denials for pre-existing conditions or the provision allowing young adults to stay on their parents’ insurance plans until age 26.

Without the clear leadership of the president, the political landscape will only become more caustic and confusing, rife with uncertainty and this sense of being in limbo, waiting for something. This drift makes the future all the more frightening to unstable private markets, to state governments that are struggling to balance their budgets, and to Americans who avoid seeing the doctor or filling a prescription for fear of the costs.

On the ground in the states, leaders are not as focused on the bickering inside the Beltway in Washington. They are worried about making their health systems work at the local and community level, despite all the uncertainty emanating from Washington. Notwithstanding the anti-”Obamacare” rhetoric from governors’ offices, state governments have created task forces and are passing laws to create new insurance marketplaces–so that health insurance can be accessible to individuals and small businesses that cannot afford these benefits now.

With states facing the worst budget shortfall in 60 years, hundreds of millions of dollars have been distributed by the Department of Health and Human Services to help state governments build health information technology systems, help consumers find the best healthcare insurance, and keep insurance company premiums in check. And considerable efforts are being made to create a more streamlined determination of who is eligible for Medicaid or premium tax credits for private insurance.

The health reform law is not perfect, and it is not enough to solve the problems facing America’s healthcare system. But it does represent forward momentum at a time of transformation for the healthcare system.

The real world can’t wait for Washington to indulge in too many more political tantrums or in a protracted stalemate on healthcare matters. Whatever you think of the legislation that passed, the fact is that states need to prepare for a massive expansion of the Medicaid-eligible population and the development and launch of health insurance exchanges in the years leading up to 2014, along with a myriad of reforms to the individual and small group insurance markets already underway. Like so many people have opined before me, regardless of what the Supreme Court decides in the spring, the real world still needs to resolve the challenges of sustainable healthcare delivery and financing.

Unfortunately, as state and national political leaders and the American people wait for the outcome of the Supreme Court’s decision and the 2012 election, we’re likely to see very little movement over the next six to nine months. We’re waiting on healthcare, and we’re likely to keep waiting. With the American healthcare system in crisis, we have no time to waste. So are all the reasons we’re waiting really worth waiting for?

Julie Barnes is the director of the Health Policy Program at the Bipartisan Policy Center in Washington, D.C.

Photo courtesy of D. Sharon Pruitt.