04/14/2011 11:40 am ET Updated Jun 14, 2011

The Health Speech Obama Skipped

For the past two years, I've been trying to ignore criticism suggesting that President Obama did an inadequate sell-job on health reform and should have spoken to the American people more directly and candidly about what he was up to. Until now I've contested these comments, responding that the very complexity of the issue and the secret war against over-consumption made such a speech impossible. Despite my best efforts, the criticism keeps coming. So I've responded with a draft of what an honest recital of the issues would have sounded like. I invite reader comment on whether this would have made the sale. -- JJ

My fellow Americans. A lot has changed in the century since Congress first began debating legislation to provide adequate and affordable medical care for all of us. It is time to finish the job. But before we can take the final steps forward, there's a need to take stock of how far we've come and appreciate not only the many problems our efforts have solved, but candidly assess some of the new obstacles our initiatives have created.

During this period, American life expectancy has increased by more than 50 percent. Modern medicine is one reason that trend continues today. Diseases that used to be killers can now be cured. We've seen revolutionary changes in the roles played by doctors, who can see into the body and diagnose and reverse conditions that their predecessors only vaguely understood. And we've seen hospitals transformed from feared institutions where people only went to die to hopeful places that typically extend life.

Not so incidentally, we've also created a health insurance system that didn't exist at the beginning of this period, providing a way to pay for modern medicine whose growing sophistication has increased costs to a point where many of us simply can't afford to directly pay for the care we require when we become sick.

On balance, I would characterize today's system as one we can all be proud of. Not just the doctors and nurses and X-ray technicians who directly provide the care, but also the employers who help insure most of us and even the politicians who created programs like Medicare and medicaid that help pay for the care needed to cure us when we become ill. But these elements created in the 20th century are not meshing well in the 21st.

We can build on this structure to make our system even better -- both more affordable and more accessible -- by using American ingenuity that has built the world's most vibrant economy to streamline and rationalize the way we deliver health care. But to do so, we have to also acknowledge today's defects.

It would be irresponsible of me to end my description here without describing the other side of the coin. A large and growing minority of Americans lack health insurance, which puts them in a very vulnerable position if they get sick. They may be denied the care they need.

The cost of care is rising much faster than other prices to a point where it threatens to crowd out our ability to pay for other necessities. This is a growing issue for government at all levels that drives much of our political debate. But that's only an echo of something employers who provide insurance learned a few years ago, and growing number of individuals are beginning to realize now.

The fact is that there's no health fairy who'll pay all our bills. Ultimately we'll have to, either directly or through broader programs. And there's no evil dragon responsible for driving the bills up who can be slain in a dramatic, liberating battle. Instead there are a lot of well-meaning individuals and institutions who don't work together as well as they should, and often ignore the costs they're creating by ascribing responsibility for them to someone else.

Red warning flags quickly pop up when you consider some numbers:

The cost of medical care chronically rises twice as fast as the consumer price index. If you graph that trend, you'll quickly understand why that's unsustainable and why medical costs are starting to squeeze other priorities.

Medicare's cost per beneficiary more than doubles between high-cost areas like Miami and low-cost areas like Minneapolis but patients entering the system in the expensive regions are neither sicker when they enter the system nor healthier when they exit it. If we could make practice patterns in the more efficient areas the norm, Medicare cost pressures would virtually disappear.

Every year the intensity of care -- that means the number of tests and procedures done for a given diagnosis -- increases, but there's no commensurate improvement in health status. In other words, we're spending more money and inducing more discomfort without making patients any healthier.

We spend an extraordinary amount of money on patients during their last months of life while they're suffering from an irreversible condition. Physicians understand that both a long life and a good death are important goals. Despite medical advances, we cannot live forever.

Because the odd historic way the payment system is organized, patients are often unaware of how much things cost and providers can maximize their incomes by doing more.

Only 20 percent of what doctors do is based on strong scientific evidence. Many of their decisions are based on no evidence at all beyond personal experience. We need to know more about what works when, so we can create optimal treatment plans. Medicare has made a beginning by refusing to pay for unproven care or innovations that increase costs without improving health.

These are difficult challenges, but they are hardly impossible in a nation as flexible and sophisticated as America. They'll require everyone in the system to change the way they're operating and we all have a natural tendency to resist change. And while I can't paint you a picture of precisely what the new improved system will look like, I can sketch its outlines.

First, we need to do a lot more research on what works best and then find a way to more quickly drive newer, better, more efficient ways of doing things into common use, and acknowledge that the latest and most expensive option isn't always the best one -- in fact, often the old way is safer and better.

Next, we need a payment system that makes things more affordable by getting away from the a la carte system where we pay for each procedure, pill and test and replace it with payment for incident, a successful system Medicare already uses for hospital stays. Allowing those who provide services to maximize their income by maximizing what they do leads to over-consumption and inefficiency.

And finally, we have to change the broader environment. That means encouraging our families to eat more wisely and exercise more. It means providing universal insurance coverage so that those with coverage aren't hit with a big invisible tax to fund care that would otherwise be uncompensated, and use our movement toward evidence-based medicine as an opportunity to move away from today's medical malpractice system that encourages defensive medicine that eats up resources in a way that protects providers without healing those who are sick.

These are all proven principles that can provide the basis for a real system -- like many today I think the menu of services we offer is far too disorganized to deserve definition as a system at all -- that delivers all the care we need at a price we can afford.

(Originally posted to Additional analysis of health reform at