So, the Baucus “gang-of-three-out-of-six” bill has been released, and it is clear that policy makers are no longer talking about health-care reform, but are instead focused on health-insurance reform. As has been done for decades in education, where many “education reformers” work around the edges to find a different way to pay more for an educational delivery system that is fundamentally flawed, it appears that now the “health care reformers” are working around the edges to figure out a new way to pay for a health-care delivery system that is similarly fundamentally flawed.
I agree that we need to make sure that more people have access to a means to pay for health-care services, which means that more people need access to health insurance, but if we decouple the debate about insurance reform from the debate about delivery reform, we simply enable more people to pay for a system that is less than optimal with results that are increasingly questionable. Even those of us who are happy with the care we receive recognize the inefficiencies and shortcomings of the system that must be addressed if we are to contain our personal health-care spending and improve results.
We have a health-care system that, on average, spends more money on people in the last two years of life than it does on those in the first two years. We DO need outside experts, and not just the treating physicians, to help patients and families navigate difficult end-of-life care and treatment decisions. I have helped manage the care of three grandparents and one parent who died slow, painful deaths as the result of chronic illnesses. They each wanted to stop the treatments, and had written directives to do so, but their doctors insisted on long lists of additional tests and procedures, largely because compassionate physicians have relationships with their patients that make it hard for them to say, as it is for us to hear, that nothing more can be done. Patients who want to try “one more treatment” should certainly be allowed to do so, and insurance should pay, but my personal experience shows that at least some who are terminally ill would like to accept their fate without pushing the limits of medical science — and without being made to feel guilty, or wimpy, or less spiritual for coming to that decision.
Unlike our current system, we need a health-care delivery system that rewards health-care providers and hospitals for being accessible to patients, and for taking the time to coordinate patient care, rather than focusing on the number of people they can see and the number of treatments they can deliver in a day. We need to reduce overtreatment without rationing care, and while we do need better practice standards, we need to view these as minimal care standards (that offer legal protection) without overriding physician judgment when it comes to developing an individual’s treatment plan.
We need to focus on what patients want, which sometimes may be a higher quality of life, but not necessarily a longer life. We need to put more responsibility where it belongs, which is on patients themselves. Doctors and hospitals can do only so much if patients don’t follow directions and don’t take personal responsibility for their health and well-being. We need to give patients more information about the risks and benefits of medical procedures and treatments, so that they can make informed decisions, and we need to include some appropriate level of cost sharing so that each person thinks hard before requesting yet another (perhaps unnecessary) intervention. And we absolutely need to give physicians and the public relief from the sort of CYA medicine that drives up costs, reduces quality, and exposes patients to additional and unnecessary risks. I don’t see much focus on any of these issues in the bills we have before us.
We also need to dial down the rhetoric and gimmicks. While it may be politically correct on both sides of the aisle to assure Americans that illegal immigrants will not be included in the new plan, people in Washington seem to be ignoring the fact that illegal immigrants will continue to show up in emergency rooms across the country, and will continue to receive the care they need (hospitals are, after all, compassionate places), and somebody will continue to have to pay for that care. Or maybe I’ve just missed the provision in the bill that requires hospitals to use their health care IT dollars to install a SEVIS-like database, to use the system to confirm the residency status of their patients, and to deny care to those who are here illegally. If we aren’t prohibiting the delivery of care, then we had better start talking about who is going to pay.
As a person who once lost insurance coverage because I got sick, I am delighted that the bill would prevent others in the future from suffering the same fate, but it is silly to pretend that we can have our proverbial cake and eat it, too. We are likely to all pay higher premiums for the added security this provision of the bill provides, and for the fees that will be imposed on health-care companies and some insurance plans to help pay for the sum total of the proposed legislation. The American people need to receive an honest assessment of how much the plan will cost them, and not just how much the proposed bill will cost the government. Much of what leads to budget neutrality in the Congressional Budget Office analysis will definitely not be felt as budget neutrality in most households. As Americans, we might be willing to pay more for care that is managed and delivered in a better way, but so far we are being told that we will be getting more while paying less, and that just seems impossible if we aren’t also talking about reform of health-care delivery.
The biggest gimmick of them all, however, is the fact that much of cost of the current bill won’t be felt by individuals, families and taxpayers until 2013 — after the next general election. If the bill is so good, wouldn’t you think that its supporters would want to implement it right away so that they could be rewarded at the polls in 2012?
7 Responses to Honest Talk on Health Care
suomynona - September 17, 2009 at 8:06 pm
1) We need to think of health care as a right, like many other rights we enjoy in a privileged nation. It is absurd that we have a constitutionally protected right to bear arms, but no right to health care. If that’s too polemical a point (like a point of critique of a given health care bill based on immigration policy rather than health care policy), let me start over. We have a right of habeas corpus, but no right to care to keep that precious body healthy.2) What about the rest of the rhetoric? Are you not concerned with all the rest of the political demagoguery surrounding health care reform? Not concerned about an entire party suggesting that health care reform is a plot to ration care for the elderly; to kill women with breat cancer; to allow the government access to our private bank accounts; to socialize health care so that it can only be provided for Democrats? If you want to “stop the rhetoric” then why haven’t you taken on the bulk of the rhetoric surrounding the issue?
wjprice - September 18, 2009 at 10:31 am
A right? Really? How does that help the situation? It still has to be paid for, which is the real issue behind all of this. There are a couple of separate issues involved with this entire scheme that have nothing to do with the rhetoric. 1) “If you like your health care then you can keep it.” While the President is correct — nothing I’ve heard so far forces people to change their plan — to think that the issue is solved is naive. With a public option available what incentive do employers have to maintain their employees health insurance? The penalty for not providing this benefit is less than the benefit. If I were an employer I’d drop the benefit and let my employees go for the public option. For most, the only way they can keep their healt care is if their employer keeps providing it, a choice the employee has no voice in.2) Increase competition. Here’s a way to increase competition without the public option. Allow anyone to buy insurance anywhere they want. The stranglehold that some companies have (in cooperation with states) would end overnight.3) Stop presenting the pre-existing condition problem as if it’s a product of evil insurance companies. To deny coverage for pre-existing conditions makes perfect business sense. To outlaw it is ridiculous. BUT we have to come up with a way to effectively deal with it. I haven’t heard any solutions yet.
suomynona - September 18, 2009 at 12:22 pm
“A right? Really? How does that help the situation?”Because before we get into issues of financing, we should understand why (or why not) health care should (or should not) be financed in the first place. Your final comment about restrictions for those with pre-existing conditions being both “not a product of the evil insurance companies” and “perfect business sense” would seem to speak directly to the value of deciding whether health care is a right first and foremost. For if health care is a right, then it’s perfectly understandable to view a “perfect business sense” decision to deprive someone of a basic human right as, quite frankly, an “evil” product of an “evil” industry operating with an “evil” sensibility. No?The whole point of guaranteed rights is so that whatever gets in the way of them, be it a market occurence, a change of government, a war, etc., the rights remain. This can only come to be when a society takes the trouble to decide what inalienable rights its citizens should have. Now that systematic life-changing and life-sustaining health care is a reality (unlike, say, in the late 18th century), it’s time, now, to reevaluate where this fits in our spectrum of rights.
wjprice - September 18, 2009 at 4:25 pm
Suomynona’s view, health care as a right, is one way to look at it. But it’s not the way that health care exists in the US. To get to this point would take far more than what is being debated in Washington right now.Just to use the pre-existing condition as an example of where I think this thing turns wacky, why would an insurance company want to stay in business if they had to sell insurance to clients who were already sick and in dire need of care. This is a business decision as well as a humanitarian one. To require insurance companies to take clients with pre-existing conditions is like forcing car insurers to insure people after they’ve already had a crash and expect the company to pay for the repairs. It doesn’t make business sense.You can argue that this is the wrong way to look at it but if any kind of reform is to be had in the next few years this is the way we have to look at it. Considering it a right is an evolutionary change that will not happen any time soon.
suomynona - September 18, 2009 at 7:29 pm
Well, it’s one way to look at it, and it’s also the way most of the developed world looks at it. I have no problems with arguing for an ideal that is no less utopian than the idea that both the free market and our caring, helpful neighbors will somehow patch together enough to fund basic care for our least fortunate citizens of their own collective free will.To require insurance companies to take clients with pre-existing conditions is nothing like forcing car insurers to insure people after the’ve already had a crash, because paying to sustain the life of an automobile is a very different thing than paying to sustain the life of a human being. This is precisely why many other wealthy countries throughout the world don’t subject health care nakedly to the dictates of a free, unregulated market: because there is no moral imperative in business, whereas some think providing basic health care for people is a moral issue. Lots of things make ‘busness sense,’ but of course ‘business sense’ is exactly what landed us in this global economic predicament. It doesn’t make ‘business sense’ to bail out Wall St. firms and insurance firms and failing automobile makers, but we do that anyway because we find some larger civic value in it. Why not health care? Can we not see some larger civic value in basic health care?An evolutionary change? As in a change from a social Darwinist perspective to an understanding among human beings that we should care for the weakest among us? I hate to break it to you, but many other countries have ‘evolved’ away from your perspective. Please don’t evoke evolutionary arguments as apologia for American political culture.
11218946 - September 18, 2009 at 9:32 pm
What “rights”, aside from being represented by a lawyer if you cannot afford one, require the services of someone else?
suomynona - September 19, 2009 at 2:26 pm
Um, all of them. Apparently the irony of your ‘aside from being represented by a lawyer’ exception escapes you, because as it happens many very expensive lawyers and judges toil every day to uphold or evaluate every single right we have. Rights don’t support themselves; they need a guarenteur. Do you think free speech, for example, is merely a function of us opening our mouths? Wrong. It’s incredibly expensive to provide citizens unversal protections, and to enforce universal rights. That’s why we have an incredibly expensive thing called a government to protect certain rights. Do you think that without the services of people like police officers, soldiers, and other executive agents in the government’s employ any of our rights would last very long?Like they say, freedom ain’t free. That’s right, it costs a hell of a lot of time and money. And yes, taxes.