Saturday, October 10, 2009

Are We Serious About Health Care Reform?

Doctors get asked from time to time what we think of health care reform. (We also get asked about swine flu, and spend a considerable amount of time explaining that you cannot contract the disease from Sweet and Sour Pork.) I used to try to follow the debate to the letter, but realized it was silly to do so when nobody making the policy actually did, either. So here’s what I understand as of now:

Health care reform was intended to give every American full access to the health care system. It was intended to stabilize or decrease health care costs while enhancing the quality of care. It was intended to reform the health insurance industry, and to make the lives of physicians and other health care providers easier by decreasing paperwork and releasing them from the burdens of unrealistic expectations and medicolegal fear. The net effect of the entire effort was to improve the overall health status of the nation. These are all laudable, important, and urgently required goals.

But so far, what we’ve got is a proposal that forces all Americans not already covered by Medicare or an expanded Medicaid to purchase an “affordable” health insurance policy or face a federally imposed fine. In order to help lower-income families purchase insurance, we will be using government money to support the purchase of polices from the same insurance companies that have been the leaders in denying, restricting and raising the costs of health care coverage so that administrative costs now represent a third of our health care dollar. Yes, we will allow public co-ops to develop insurance plans as well, but these will operate in the same mode as traditional insurance companies and will, in essence, differ only in ownership and profit margins. (In fairness to the co-ops, there is a model that works for them. It’s called Medicare). The out-of-pocket deductibles for low income families purchasing insurance, and the choice of using family dollars to buy insurance or pay a fine likely smaller than in the coverage costs, even with a subsidy? Not even a whisper of a question.

Physicians, of course, will not be finding their workloads eased nor have more time for quality patient care. While all Americans may be insured, the paperwork per patient stays the same, and there is still no relief from the lawsuits that result when the physician is unable to meet the consumer demands irregardless of the quality of care provided. Reimbursement still favors procedures rather than thought, technology instead of counseling, and the drive towards increased specialization and a reliance of testing rather than clinical insight remains unabated. (Oh, wait a minute; there’s going to be a panel. That’ll make it all better.) That is, of course, assuming that these newly enrolled patients have physicians to see them: Many physicians already decline to see Medicaid patients (or see them only when required to do so, as when “on call”) due to perceptions of patient compliance and medicolegal risk. There is no reason to believe a new flood of Medicaid patients will be greeted by enthusiastic doctors and hospitals, and those who do assume the burdens of care will do so facing declining reimbursements despite increased demands for accountability.

Am I missing something?

It seems to me that if we’re serious about health care reform, let’s do it seriously. If the underlying principle is that all Americans should have access to a baseline level of health care, then we should design health care reform as we would any other program that delivers basic services to which everyone should be entitled. If we view health care as a fundamental benefit of living in this country (the question of health care as a “right” or a “privilege” is temporarily shelved for another day), then we need to determine the appropriate level of entitlement, institutionalize it, and provide it without cost to all citizens of the United States. Those who can afford more certainly have the privilege of doing so, but are still responsible for their share of the common good.

The public schools can serve as an example of this precedent. American society has determined that education of our children through at least age 16 (10th Grade) serves a social good of such import that we require all children to receive this benefit. Granted, individual schools may differ in quality, but we have as a collective body decided that every child has a right to an education, and we have institutionalized this right through school statues, infrastructure, and funding sources. Those who opt out of the baseline benefit (sending a child to public school) can choose to do so at their own expense, but are still required to contribute to the general welfare. To make it more plain (and put it in a health context), we have determined that within the United States, every person should have access to clean water for drinking. We institutionalize this belief through laws, regulations, and infrastructure such as sewer pipes and water treatment plants. This baseline level of service doesn’t stop anyone from spending a few extra dollars for a water softener or filter, but those with own systems are still responsible for supporting the public works.

So if we’re serious about health care reform, let’s be serious about it and build reform around the fundamental desires and goals of the effort rather than what can get past the lobbyists. Let’s take the time to determine what clinically represents the baseline level of care that should be expected by every American, and let’s find ways to build in a set of responsibilities for each beneficiary to match the entitlement they’ve been granted. Lets’ change reimbursement patterns to reward primary and preventive care. Let’s revamp he system of medical justice. Let’s invest powerfully in information technology to allow doctors and hospitals to “talk” to each other within a secure framework of patient care.

But let’s not go as far as to restrict health care to a single payer system, thus denying those who can desire and afford further benefits to obtain them. The advent of a public benefit will likely be in competition with private insurance plans, and the latter may lose some business. But it also provides them with an opportunity to streamline their corporate structures, revise and enhance their product lines, adapt marketing strategies to maintain their volume and market share and, in the process, make health insurance truly affordable for all. It seems to me that’s essentially a “conservative,” free market idea that co-exists quite nicely with the more “liberal” agenda. (I believe that the idea I‘m discussing is fundamentally different than a “public option” insurance plan…the difference between a public and a private option coverage is simply a matter of where you send the bucks. Nonetheless, establishing a defined minimum level of benefit for all citizens will likely result in some of the same competitive challenges and opportunities for the private sector.)

Of course, if a fundamental shift in how our system works is not what anyone was actually thinking…well, as Miss Emily Litella used to say, “Never mind.”

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