The promise of universal health care - offered in one form or another by almost every presidential candidate - is looking more and more like a big lie. Give us a break. If neither the president nor congress could even bring themselves to expand moderately a highly successful federal health insurance scheme for poor children, how are we ever going to find the money and the political will to join the rest of the developed world and cover everybody?
In the October 25, 2007, New England Journal of Medicine, policy scholar Jonathan Oberlander wrote, "No matter how much momentum it seems to have, no matter how many signs point to change, there is nothing inevitable about health care reform in the United States." He inventories the armory of the status quo: providers' economic self-interest is too great, most people are too content (even if they're not delighted) with what they have, government projects are too suspect, attention spans are too short, Congress is too divided, and nobody can figure out where the money will come from.
Some states look like counter-examples - Massachusetts, California, Vermont, and a few others - by declaring their intention to assure universal health care insurance. In fact, Massachusetts has already solved almost half of its problem, covering over 200,000 more people in less than two years since passing its law. These state-level initiatives likely reflect some important and stable desires in the body politic: to have care for everybody that is both good and affordable. But, we fear, these bold commitments are headed for the same rocks on which national reform has foundered so far.
It's sad, and even sadder because it is unnecessary. No candidate, no political leader, no courageous state coalition, and few, if any, payers have yet realized or (if they realize it) found a way to make salable to the public a scientific fact: the apparent deadlock between assuring the care we need and finding the resources to give it is an illusion. It dissolves, or nearly so, when one understands what "quality" is in health care. The best way to make universal coverage affordable is not to reduce care but to enhance it. More precisely, it is to promise all the care that helps, BUT only the care that helps.
That's because so much of the medical care we give and get today is pure waste - it does not help any recipient, hurts many, and costs a ton. It is technocracy with no benefit, indeed, often with harm. For example, Dartmouth researchers Elliott Fisher and Jack Wennberg have shown that the top fifth of American regions in health care costs per capita spend $3000 per year per Medicare beneficiary more than the bottom fifth, but the highest cost areas have worse outcomes and poorer satisfaction for both patients and doctors than the lowest cost areas.
We estimate that at least 30% of the health care that we pay for today does not work. It shows up as tests and surgical and other procedures we don't need, errors in care that then need correction, complex medications when simple ones or none would do fine, unwanted intensive care at the end of life, avoidable hospitalizations for chronic illness, using doctors for tasks that nurses and others could do even better, and failing to use simple and convenient alternatives to office visits, like email, web-based supports, and the telephone. A lot of the waste is concentrated in care for the chronically ill, the 10% of Americans who use 70% of the care. Patients and families often don't see this as waste. For them, it takes the form of bad experiences: hassles, out-of-pocket costs, complications, dropped balls in their care, and confusion. But, it's all the same: the high financial toll of poor quality - a "lose-lose" proposition. And, when the waste is swept into promises for universality, it all adds up to unaffordability.
Of course, linking quality improvement to universal coverage won't disarm the proponents of the status quo entirely. What is waste for a patient is often income for someone else, and the structures that benefit from Fisher and Wennberg's $3000 of non-value won't go down without a fight. But, surely aiming for excellence, not ineffective excess, can help us get to the social justice and equity that behoove a great nation. We need proponents of universal coverage to realize that, and then we need them to explain to our public that all Americans can have the health care they truly need at a price our nation can afford, if (and maybe only if) we extract and end habits of error, defect, and overuse that help patients not at all.
Donald M. Berwick, MD, MPP, is President & CEO of the Institute for Healthcare Improvement. Howard Hiatt, MD, is Senior Physician at the Brigham and Women's Hospital and former Dean of the Harvard School of Public Health.