Update from the day after: Just so that everyone knows, I’m not singling out any specific people or any particular party. I’m only angry at Congress and the pundits who are more concerned with scoring political points than with improving an obviously broken, expensive system. It’s true that I was angry when I wrote this, but it was an anger born of systemic frustration and not any specific interaction I’ve had. My anger was not directed in a partisan fashion; it’s a truly bipartisan emotion, with enough for each party. But now that I’ve railed, I can get back to the nonpartisan task of looking at all sides of this topic. As always, I welcome practical political dialogue — even of a partisan nature — with anyone and everyone interested in an honest discussion about what’s possible and what the trade-offs of these choices might be. Stay well!
I’m going to take a short break from my usually nonpartisan, constructive mode of looking at healthcare costs and reform. Please forgive me.
The fact that I might be inclined towards partisanship here is not something I relish. Sure, I have my political opinions. (Oh, do I have opinions!) But I’ve changed affiliations a couple times, so I believe that I have a little standing when it comes to understanding the opposing viewpoint. I don’t think either side is the enemy or stupid or destroying America or whatever mean thing one side says about the other. (Yes, it’s sad that’s what gets passed off as political debate at the present time.) So I do believe there’s more than just simple partisanship going on in Congress and around the water-cooler; I can understand why each side is deeply suspicious of the principles that underlie the other’s position.
But I am so very, very angry about what is *not* happening to get the legislation passed. And don’t even get me started about the weak content of the proposals and the counterproposals.
And when I say that I’m “angry,” I don’t mean rhetorical anger. I don’t have the luxury of rhetorical anger. Well, that’s not exactly true; unlike the under-insured, I do have very good coverage, and I live in a place with multiple care-providers for the same condition. But I do have a disease, and I use a lot of healthcare relative to the majority of the population. I don’t want to spend ever more money out of my own pocket each year for something that isn’t going away anytime soon. Worse, I strongly believe that a good portion of each dollar spent on my healthcare does not actually go very far toward providing a better chronic illness experience. And I suspect — but could probably never prove — that if we were able to spend less on disease management, we could probably invest enough of what we might save into actually finding the cure for diabetes and other expensive long-term illnesses.
I also have a nagging fear that I’m only one unfortunate life-event away from being in a truly terrible place with healthcare. If we’ve learned anything over the last couple years — and I’m not sure we have — it’s that even the “good jobs” aren’t always secure and that our wellness depends on being well-employed, which is somewhat out of our control. That’s unconscionable. In fact, it actually sounds un-American to me; and I think that if you disagree with that statement, then you and I have such vastly different notions of the American dream and our possibilities that I wonder whether we actually live in the same country, whether we were taught the same things about who we are as a people, whether we actually are or can be the great nation that we claim to be.
Why am I so angry? After all, I had planned to keep posting rational, dispassionate, argument-by-argument analyses of the different aspects of healthcare and insurance reform, building up to a convincing argument about why we should make a particular set of changes. So what’s happened to make today the day that I lose my composure and get ahead of myself?
It seems that after today’s White House-organized bipartisan healthcare summit, returning to an honest discussion about the need for changes and putting aside ideological differences seems unlikely to happen. So I’m going to be a little petty and then try to redeem myself with some realistic, practical suggestions that ought to be able to get bipartisan support. But right now, I’m angry.
In my black heart, what I really want is (a) for half of Congress to be without health insurance until a law actually fixes what’s broken with American healthcare delivery and spending and (b) for the other half to pay the same percentage of their income for healthcare as the 12% of Americans who pay completely out of pocket. Deep down in that dark place I don’t talk about at parties, I want to take this group of 535 people who are mostly beyond middle age and tell them this: “You haven’t been working, so you’re fired. You don’t have health insurance anymore except what you can get through COBRA (which was passed via reconciliation, I might add). And many of you will have pre-existing conditions so good luck getting reinsured under a generous plan. And since you don’t like governmental influence in the health system, we’re going to deny you Medicare or Medicaid — and SCHIP, too. (Because as rotten as you have been to us for the last few years, you deserve to worry about your whole family, too.) And you have to go home to your district for healthcare; I hope you live in a big city with lots of services, because you’re going to need them eventually. Some of you won’t be very lucky. If these new circumstances bankrupt any of you, I don’t care. Now you can suffer with the rest of us.”
I know, I know . . . it’s petty. But the social justice and humanitarian arguments have been ineffective in moving us toward consensus. Nor have purely economic arguments.* I don’t feel like I’m being hyperbolic when I say I believe healthcare reform is a matter of national survival. If the well-being of the nation isn’t enough to move the Congress forward, then I suspect greedy self-interest is our last hope to get meaningful reform passed. And right now Congress isn’t feeling any pain.
What do I think is “meaningful reform?” Without tipping my hand too much about what it could look like or how it might get implemented — I would like to continue investigating the various aspects of healthcare spending without favoring or dismissing any particular idea — here’s a broad outline of what I would very much like to see:
- Insure every American by mandate. You can refuse treatments if you want. That’s your business. But you can’t refuse to pay for insurance and/or healthcare. This is the very basis of insurance: Share the economic risk as broadly as possible so that over our lifetimes we pay the lowest possible amount.
- Ensure that no American can be denied insurance coverage, be dropped from any plan, or be forced to pay more than they can afford. Again, the goal is two-fold: everybody pays a reasonable amount at the same time that everyone has access to healthcare. (BTW, you can’t have this without an individual mandate. Universal coverage requires a universal mandate.)
- Reduce the administrative costs of private sector health insurance — if we keep that system — to the same level as government run programs (currently 2%).
- Discourage the use of the E.R. for routine care. For example, we might encourage producing more primary care physicians. We might also need to build more community-based, 24-hour primary care clinics for non-emergent care.
- Aggressively target the elimination of preventable chronic illnesses. Chronic illnesses — preventable or not — constitute up to 85% of all medical spending.
- Incentivize the use of evidence-based medicine. This means doctors and hospitals should get bonuses when patients do well and costs are low.
- Focus on waste reduction. In medicine this means choosing lower cost options (such as generic drugs and older scanners) whenever the outcomes are the same; lowering administrative costs; preventing medical mistakes; reducing the number of unnecessary, duplicated, and purely defensive tests; using electronic medical records that are shared by all healthcare providers; etc.
- Establish a national health strategy. We lack systemic coordination and goals. Ideas for goals include making wellness more prominent in policy, reducing preventable illnesses by encouraging positive lifestyle choices, improving rural medical access, implementing electronic health records, creating high-quality protocols, etc.
- Do some one-time changes that are politically palatable but won’t really do very much to lower costs: prohibit companies from advertising prescription drugs on television, over the radio, and in non-medical publications; reform medical malpractice; etc.
- Create a panel of medical professionals who can set reimbursement rates and maximum costs for all providers and insurers.
I am purposefully steering clear of issues where I think there are multiple good solutions. I don’t know enough about the potential costs, revenues, and savings of the choices. Maybe a single-payer system will make implementation of these goals easiest. Perhaps interstate competition between private insurers will lead to lower costs. If so, how would different states handle different requirements for covered services? Should we eliminate antitrust exemptions for insurance companies? Encourage co-ops? Create public plans? What role should the individual states play? I suspect there’s a place for federalism, with states as laboratories for innovation, but how much? Should we tax Lexus Cadillac healthcare plans? Reasonable people can come up with different conclusions on all these proposals.**
There’s one big, lingering, completely untouched question: “How much healthcare do we really need?” I won’t propose an answer. Everyone wants their healthcare completely covered, whether that’s continuous glucose monitoring supplies, fertility treatment, or experimental therapies for a rare disease. It’s something I grapple with myself. Unfortunately, it’s also the issue that led to the first (tragically) effective attempts to derail reform. (Remember “death panels?”) From a selfish perspective, I would also like to see a system where the chronically ill aren’t forced into higher cost plans.
And for most Americans that’s what it all comes down to: “What’s in it for me?” For Congress it’s a political game. For all the rest of us, it’s our health.
* — Healthcare costs are higher in the US than in any other developed nation. In fact, healthcare spending as a percentage of GDP is 50% higher in the US than in other countries, limiting what companies can pay employees and what individuals can spend and invest. Healthcare costs employers more than $2 per hour per employee, harming US competitiveness. And it’s only getting worse; by the end of the decade, spending will account for 20% of GDP. One out of every five dollars spent in the US will be go toward returning us to health or keeping us well. And on top of all that, Medicare will be insolvent by the end of the decade at current levels of spending, requiring higher taxes or reduced services if costs don’t come down.
** — Simply saying something is “socialism” is not a reasonable counter-argument. Show me why it’s bad. Prove to me that socialized health systems in other democracies have worse outcomes than the United States — because they don’t, and they’re less expensive. If you’re just “red baiting,” then perhaps you should stop, take a moment to reflect, and grow up. I’m back to being civil now; so let’s carry on our conversation without poisoning the well any further, shall we?
