Biography
Elizabeth Walker will complete her master of science in public health degree in health policy and management from the University of North Carolina (UNC) School of Public Health in May 2009. Prior to UNC, Liz worked in Washington, D.C. for former Centers for Medicare & Medicaid Services Administrator Mark McClellan and as a reporter and editor covering the pharmaceutical industry and Medicare Part D implementation. Last summer, she worked on evaluating state health programs for the North Carolina legislature. She is also a graduate research assistant at UNC’s Sheps Center for Health Services Research, where she supports a project that ranks the states based on public health indicators. Liz completed her undergraduate education at Oberlin College, majoring in politics and history.

During the 2008 presidential campaign, Barack Obama released a broad health care plan that included an extensive list of health reform goals. [1]  This campaign document left almost no area of the health care system unmentioned and included calls for more coordinated health care, increased insurance industry competition, generic drug regulation reforms, new tax credits, and greater disease prevention.

As President Obama moves to make comprehensive health reform a reality rather than just a campaign promise, he must focus and prioritize the elements of his campaign health proposal in a way that harnesses the political moment. The economic crisis creates an opportunity to quickly implement certain aspects of his plan but creates significant roadblocks for others. 

Prioritize Access
Candidate Obama’s health care plan grouped his laundry list of health reform goals into three categories: lowering health care costs, providing everyone with affordable and accessible health insurance options, and promoting prevention and public health. In the current environment of high unemployment and economic anxiety, President Obama must prioritize expanding access to affordable health insurance options. Central to his campaign plan were increasing availability of private health insurance options in a national “exchange” and tax credits to help some people pay for premiums.

There are compelling reasons to focus on expanding access in an economic crisis. With high unemployment, fewer people are in a position to access health insurance through their employers and many more are concerned about losing their job and their health insurance coverage. Families have fewer resources available to spend on health expenses, compounding existing concerns about the rising cost of health care. Businesses affected by the economic downturn are strapped by obligations to provide expensive health insurance to their employees.

There are explicit political reasons to prioritize expanding access to health insurance. In past reform efforts, the status quo was a powerful counterweight. Americans were generally satisfied with their own health insurance coverage and they were hesitant to risk reform that might affect their own coverage. However, with continued access to employer-sponsored coverage uncertain, the need to expand access to health insurance is now being felt personally by many Americans. A February 2009 Kaiser Family Foundation survey found that a third of those with existing health care coverage are “very concerned about losing it.” [2] 

Cost Control Challenges
If the economic crisis has opened up an opportunity for reform by increasing concerns about access to health insurance coverage, it has made addressing the issues of rising health care costs even more challenging. In any push to expand access to health insurance, the president must balance the difficulty of cost control measures in the current economic environment with weariness of large government spending and concerns about long term debt among the public and members of Congress.

Health care is a substantial part of the American economy, and this money is tied directly to employment for millions of people. It is also one of the few sectors of the economy that is still growing. [3] Ratcheting down spending on health care has the potential to harm a vital part of the economy.

In the face of massive spending commitments on the part of the federal government and existing concern over the burden of entitlement programs, however, Americans may be hesitant to support significant new long term spending commitments without cost control measures. In the February Kaiser survey, almost half of respondents felt that “making Medicare and Social Security more sound” should be a “top priority,” a topic that was second only to improving the economic situation. [4] An expansion of government obligations for funding health care coverage will be difficult to reconcile with pressure to bring down projected costs of existing entitlements. With employers bogged down by the cost of employee health insurance, their politically crucial support for reforms may hinge on effort to control costs.

To balance the need to expand coverage and address federal deficits without hurting this significant sector of the economy, President Obama will likely emphasize politically appealing measures intended to lower health care costs, such as investment in health information technology and disease management. However, if these are the only attempts to address costs, the long-term viability of expanded access is at risk. Despite the political appeal of these softer strategies, they require increases in spending in the short term and do little to address the root causes of high and rising health care costs. The recent health system reforms in Massachusetts – on which portions of Candidate Obama’s plan were based – demonstrate the difficult relationship between expanding access and controlling costs. The state succeeded in passing a health reform package that expanded access to health insurance but rising costs threaten the program’s effectiveness and political support. [5] 
 
Moving Forward
The economic crisis is creating a convergence of real need and political opportunity, and President Obama must move forward with expanding access to health insurance. As his administration works with Congress to develop health reform legislation, he must be constantly aware of the current political and economic environment. The instability in the economy has sharpened the need to expand access to health insurance coverage and may provide the necessary political opening to pass such reforms. However, the economic situation has made implementing serious methods of cost control more challenging. The role of the health care sector in the economy is more important than ever, but expanded access to health insurance will be unsustainable in the long run without measures to keep cost growth in check.

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[1] “Barack Obama and Joe Biden’s Plan to Lower Health Care Costs and Ensure Affordable, Accessible Health Coverage for All.” Available from http://www.barackobama.com/pdf/issues/HealthCareFullPlan.pdf. Accessed February 27, 2009.
[2] Kaiser Health Tracking Poll, February 2009. Available at http://www.kff.org/kaiserpolls/upload/7866.pdf. Accessed February 27, 2009.
[3] Reinhardt, UE. “In Defense of a Giant (and Growing) Health Care Industry.” Available from http://economix.blogs.nytimes.com/2008/09/26/in-defense-of-a-giant-and-growing-health-care-industry/. Accessed February 27, 2009.
[4] Kaiser Health Tracking Poll, February 2009. Available at http://www.kff.org/kaiserpolls/upload/7866.pdf. Accessed February 27, 2009. 
[5] Steinbrook, R. “Health Care Reform in Massachusetts – Expanding Coverage, Escalating Costs.” New England Journal of Medicine. 26(2008) 2757-2760.