Pie in the Sky

Despite lengthy closed-door negotiations in a subcommittee, Max Baucus (D, Montana) released his “Baucus Bill” to the larger Senate Finance Committee last week with no Republican support from his panel. Both the Left and the Right have declared this version of health care reform a disaster.  The Right doesn’t seem to want any health care reform during this administration. The Left is concerned that the bill is a giveaway to health insurance companies and that it doesn’t include a public option. Already the bill has attracted nearly 600 amendments, many aimed to slow down the progress of the bill. If votes on the amendments proceed at the pace they started, it will be months before the bill will make it to the Senate floor.

At the moment, instead of jumping into this briar patch, I’m going to sit back and approach health care reform from a different angle: what is it that I think I really want our system to look like?  Sure it’s pie in the sky, but sometimes figuring out our dreams, even if they can easily be labeled unrealistic, is a good exercise.  So I’ll tell you my dreams, and I’d love it if you’d tell me yours. Use the comment feature—please!

Pie in My Sky

1. Set an overall goal of the best health for each person with the greatest choice for the least cost.

2. Make health care universal since it is a basic human right. I’ve written about this on August 28 and August 27. 

3. Make health care reform about much more than insurance, which is currently the focus of discussion.

4. Share the responsibility for health. More can be done to encourage people to be educated health consumers. Providers have a responsibility to be honest and respectful presenters of options.

5. Put great brains to work on how to deliver health care efficiently. Dr. Jim Yong Kim at Dartmouth says, “In my view, the rocket science in health and health care is how we deliver it.”

6. Rebuild medical education. We need enough doctors, especially primary care doctors, meaning that we somehow need to make being a primary care doctor as attractive as being a specialist.  Hand in hand with this, we need to figure out how to make medical education less expensive.

7. Revamp the way doctors are paid. We need doctors who are not penalized for taking time with patients, who are encouraged to work preventatively, and who,when faced with problem cases, can think outside the box. This may mean finding alternatives to the current fee-for-service system, which often results in cramming as many patients as possible into a doctor’s day.  We need providers who are rewarded for their success at keeping or making patients well, requiring more thought about the whole person instead of just malfunctioning parts.

8. Figure out a better balance between overuse of expensive hospital services on the one hand and the rights of individuals to the best possible diagnostic, preventive and treatment options. Experts on health care reform are now kicking around the term, “Supply-driven health care,” saying that when facilities have all those expensive machines and procedures available, the tendency is to use them even when they may not need to be used. Yet a patient struggling with a complex problem will want no stone left unturned. This may be the toughest health care finance problem of all to solve.


9. Maintain market incentives for research and development while enabling serious negotiation on the cost of life-saving products. At present, there are huge rewards for coming up with something that can be patented—a drug, a device, a bio-solution, a material.  That’s been a driving force behind research and innovation. We don’t want to lose that capitalistic motivation. However, use of these products may be untenable if there is no way to cap costs. Also, when providers automatically turn to patented solutions rather than considering less costly alternatives such as supplements, dietary changes, or physical therapies, the cost of medical care obviously rises.

10. Sever the financial links between manufacturers of drugs and equipment and the providers who are rewarded for using these products. This would include eliminating company-sponsored continuing education hours for providers.

11. Share responsibility for costs of health care, deciding payment by income. Those who can pay more should. Those who can only pay a little should. We have tremendous inequities in wealth and earning power in the U.S., so this is the only way I can see universal care working. People who become ill or have an accident should not be penalized financially. A reformed universal care system will, I believe, still cost the average taxpayer less than is projected for our current unreformed system.

In addition, consumers should know up front how much visits and procedures will cost. In no other arena are consumers so uninformed about prices.

12. Sever the link between employment and health insurance. One of the reasons companies are in so much trouble in the U.S. right now is because of the burgeoning cost of health insurance. Companies should still bear some of the cost burden, but this could be done more equitably with taxes (Oh, dreaded word!) In the long run, under a reformed insurance system, companies would probably pay less in tax than they are presently paying in premiums. If health insurance were not tied to employment, it would also give employees more flexibility about changing jobs and could add to their job satisfaction.

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As you can see, I haven’t laid out solutions so much as raised problems—problems that mostly remain unaddressed by any of the health care reform proposals in Congress. 

I’m not sure that the pie in my sky could even begin to be achieved by anything other than a single-payer system like Medicare—along with a number of other reforms. For instance, isn’t there a fundamental conflict of interest between insurers, whose goal is profit, and my number one goal? The conflict is not in keeping people healthy—insurers profit if people don’t get sick. The conflict is in keeping costs down, providing choice, and making sure that people aren’t penalized when they need help the most.

That’s a nutshell version of my utopian health care dreams. What do you like and dislike about this? What’s your vision? Do you have any great ideas about how some of these problems can be solved?


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Cartoon of the day

Health Care Reform and the Word Game

In politics as in Scrabble, whoever controls the language controls the game. The most powerful words and phrases in the health care reform debate right now are coming from those opposed to reform: “rationing,” “death panels,” “kill granny,” “big government,” “government takeover,” “socialism,” “socialized medicine.”

Fear words like these are related to a common human phenomenon psychologists call “loss aversion.” Human beings tend to worry about changes. No matter how bad things may be, no matter how inadequate our present condition, there's always a chance it could be worse. Change may mean loss.

People who have health insurance, even expensive, inadequate health insurance, are worried that they might lose it or the medical care itself. This fear is most visceral with the “death panels” and “kill granny” phrases. I hope the claims behind these phrases have been thoroughly debunked in recent weeks, and I hope that people are beginning to realize that we already have rationing by insurance companies. It’s the last four terms--“big government,” “government takeover,” “socialism,” and “socialized medicine”-- that seem to have the most staying power, turning up again and again over the decades.

All four phrases reflect a divide in political philosophy in the United States about the role government should play in our lives. However, powerful as they are, none of these phrases is being applied accurately to the health care reform debate.

 “Socialized medicine”  is a system where the hospitals, pharmaceutical manufacture, and equipment manufacture are owned and operated by the government and where providers such as doctors are employed by the government. The U.K. has some of these features. Veteran’s health care has some of these features.

“Socialism” is a system of governance in which everything is owned and operated by the government and everyone is an employee of the government—hardly descriptive of our capitalist system.

A “government takeover” of medicine would mean that “socialized medicine” would be put in place. That is absolutely not under discussion under any plan before Congress or the President. Nor is it being considered even by the most radical liberals in Congress.

“Big government” is perhaps the phrase with the most credibility in this discussion.  Yet all it means is that whoever is using the term thinks government should not be regulating or funding whatever area of our lives is under consideration. Do we ever hear the term "big government" in connection with huge farm subsidies to corporate farmers? In connection with defense spending? In connection with regulating people's private lives? Curious, isn't it? Is it only "big government" when social programs are involved?

Repeated often enough and with enough volume, these phrases can be highly effective in prompting the fear of change.

Is there anything in any of the bills that remotely resembles “socialized medicine”? The short answer is no.

Some members of Congress would like a “single payer system.” That is not socialized medicine. The government would not own the hospitals or the drug companies or employ the doctors. It would simply be the insurer, as it is now in Medicare.

“Single payer” is not on the table. A “public option” is. This would make the government one among many insurers. If you don’t like your current insurer’s offering, you could choose the government as your insurer. If you don’t have an insurer, you still have the government’s plan. That’s in no way “socialized medicine” or a “government takeover.”

Whether it’s “Big Government” to set things up so that health care costs are contained and people are able to afford the care they need is a matter of perspective.



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Cartoon for the day