Health Care Reform: Now or Never

Media reports indicate that later this week the White House will be holding a summit on health care reform. We also know that Sen. Kennedy has been holding meetings every other week since last fall with many "stakeholders" sitting around his table. And, President Obama also said during his "unofficial" state of the union address last week that health care reform is on its way. So, let's assume that money were no object in fixing what ails the delivery and cost for health care -- like we have a googol worth of money for this (for those of you who don't know what a googol is, it is the number 10 raised to the power of 100 (=1 followed by 100 zeros) -- which would make the currently proposed $3.6 trillion budget over 10 years look like a paltry sum).

First of all, do we need a restructuring to our health care system? To answer this question requires one to believe in the notion that all Americans (including those immigrants actively seeking this status) have a right to health care. We should maintain that health care is a right because, without it, we cannot be productive to ourselves, our families, our community, our jobs (assuming we still have one), and thus also to the economy. If we are ill or sick, we become an expense and burden that the economy can not afford.

Next, if we do not reform healthcare now, a catastrophe will slowly and inevitably be cast over a system already in a crisis -- like, for example, the plague that descended upon the lives of the first born in Egypt as described in the Old Testament (and in the flick with Charleton Heston as Moses). Is everyone for change now? Undoubtedly; even the corporate types, large and small, which cannot afford to pay for health insurance premiums for employees any longer.

Should health care reform be incremental, such as has been suggested by the noted Harvard physician-author, Atul Gawande, M.D. ("Getting There From Here")? No, because what has worked in the past has no place in the present. There is too much calamity daily in delivering and paying for health care that tweaking the system as has been done in days past will simply not work. And the situation will, and is, only getting worse -- the more layoffs occur in an ever weakening economy, the more Americans will have no insurance to pay for sickness and disease -- thus adding to the roles of the 45-50 million folks uninsured, underinsured, and who have been forced into bankruptcy due to an inability to pay skyrocketing medical bills. Concomitantly, however, change that President Obama is talking about should be phased in over time. To do a restructuring of the system over night would be a culture shock that Americans should not have to endure.

So what should we change in our present system?

1. There should be health care coverage for every American provided through a public-private partnership. The first layer would be funded with tax dollars; any additional coverage would be paid for privately through individuals or through the employer base. The base level could be provided through a mechanism similar to a Universal Health Care Voucher system advanced by Ezkiel Emanuel (the brother of Obama's Chief of Staff) and Victor Fuchs. See: "Solved." The point here, though, is that we as a nation are not ready to have a totally nationalized system, like we see in Britain or Canada. Having just said this, one must wonder why those approaching the age for Medicare can't wait to get into the system -- thus, what's so wrong with socialized medicine?

2. Any health care coverage would be portable, across state lines.

3. Pre-existing conditions would not bar coverage.

4. Much waste exist administratively, and duplication and unnecessary procedures abound in the present system. This must be eliminated.

5. We must motivate health care providers to stay in practice, and provide the motivation to those who wish to become health care providers. This includes doing what is necessary to stem the tide of the nursing shortage in this country.

6. Any health care reform must provide for wellness and prevention too. But, Americans must also be motivated to stay healthy; being a country that is continuing to produce, for example, overweight folks is not the sine qua non of health. How about considering a tax credit for being healthy on an annual basis?

7. And, any discussion of health care reform should include the immigrant question, since our country cannot afford to treat those who come across our borders who are not seeking to become citizens in earnest. Our system is just too broken to do this.

Let's see what happens with the White House summit. But in the end, it is fourth down in the last quarter of the game with seconds left on the clock. It is now or never for health care reform; sure hope the "Hail Mary" pass called change in health care is caught in the end-zone for a touchdown.

Comments

[OutsidetheBoxDC]

The fundamental issue with the health care system in the USA is that the financial incentives of those in the system are not aligned towards the final objective - the improvement of the health status of the American population. I disagree that the system cannot work while profit remains a motive - we just have to align the incentives so that the companies contributing to the objective are rewarded.

For example, I would expand point 3). Everybody should be covered regardless of so called pre-existing conditions, AND all approved treatments should be covered. This combination would mean that insurance companies could no longer deny coverage and, as a result, would have a financial incentive to keep their covered lives as healthy as possible. This would shift resources away from coverage denial and into patient support programs and incentives for people to lead healthier lifestyles. Insurance premium discounts could be provided to those who kept their weight under control, stopped smoking, drank less, and so forth. Tax incentives won't work here (a lot of the least healthy are in the lower income groups), but discounts on premiums could certainly work.

There are more details behind this and other approaches that would align the incentives for all players in the system, but space does not permit a comprehensive listing. Major reform is possible without destroying the best of what we have. A smart combination of legislation and regulation can do the job.

[RoloTomassi]

'Major reform is possible without destroying the best of what we have."

Removing the profit motive will destroy nothing other than the obscene profits that big pharma and health insurance companies are indulged with.

For example: it is absurd and morally reprehensible that we allow pharmaceutical companies to take such extreme advantage of US citizens; there is no sound reason to allow these companies to drugs in the US at an overinflated price--if they can sell to Canada & Australia [and many other nations] for a much lower, neogotiated price and make a profit, then they should be forced to do the same here in the US.

And that is just one out of many unreasonable pricing schemes that we are subjected to.

[OutsidetheBoxDC]

I am not suggesting that we remove the profit motive; We should modify the regulations so that profit is only made when companies are improveing the health outcomes of patients.

As to pharmaceutical pricing, it is essential that we align their incentives so that safer and more effective treatments are encouraged and me-too products are discouraged. Price controls based on international pricing comparisons is fraught with many dangers. The pricing argument should be managed in the context of the US health care system.

Pharmaceutical profits should be linked to performance, whilst retaining the ability to incentivize development of more effective and safer products. We should not consider health and profit to be contradictory, but we must ensure that profit is only made where value is added.

I am no pharmaceutical sympathizer - there are many practices in that industry that I find most unattractive. However, we can be sure that they will not continue to advance medicine unless there is a profit motive involved. Like the insurance companies, I think that a mechanism can be put in place allowing these big players to make a profit but ONLY if they are adding value by keeping people healthier. For drugs this means that no added value equals generic level prices, no innovation means smaller margins - but real innovations are rewarded by higher prices and better margins. Set the incentives so that the innovative companies make more profit and you will see significant shifts in behavior.

[milesz]

Very insightful observation, viz, aligning incentives - - - such as eliminating the barrier of pre-existing conditions with ensuring that all insureds be as healthy as possible. Thanks for your comments.

Miles Zaremski
3-10-09

[James Floyd, M.D. - Huffpost Blogger]

I have to disagree with you, especially as points 1 and 4 are contradictory.

Much waste does exist in our current system. About 30% of all health care dollars are spent on administration, and about half of that waste generated by private insurers that adds no value. There is no way to eliminate this waste without eliminating private insurance. These cost savings have been achieved in the rest of the industrialized world, and it was done only by moving to a public system of financing.

I've looked closely at Emmanuel's idea of vouchers funded by taxes to pay for private insurance, as I'm sure you have. The costly middlemen (private insurers) are left in place, and administrative waste is left untouched. There is a much more efficient (and less regressive) way to guarantee universal coverage - through a single-payer system of national health insurance.

As far as the public not being ready to support a nationalized financing of health care - I don't buy that argument either, although its a popular one with our politicians and within the mainstream media. Most national polls show that a majority of Americans (usually around 60%) want a national health insurance program, funded by taxes, that covers everyone.

[milesz]

I could not agree with you more Dr. Floyd regarding the wasteful spending in administering health care programs. I would also add that just as there is waste administratively, so, too, is there waste in having unnecessary medical/surgical care - - - just, I suspect, to boost profits and the bottom line for the medical juggernauts within our present healthcare system. But who is going to be the policeperson to decide what is waste or not?; what is medical necessary care or not? - - - the medical and insurance communities - - - which may be like asking the fox guarding the chicken coop to undertake these tasks.

[tompoe]

I see you found a detail, a small amount of so-called "waste" to rebut Dr. Floyd on single payer healthcare. Regardless of whether you can truly demonstrate your argument, you still need to come back to the point. Why reject single payer healthcare? Are you shilling for the insurance industry?

[foreffectivegovernment]

HR 676 is the answer. We need Universal Healthcare, not Universal Health Insurance.
Let the Insurance Companies go back to selling Life and Accident Insurance instead of determining life or death.
When you have life insurance, the Insurance Company is betting you will die and you are betting you will live. When they control your access to Healthcare, they have the odds in their favor.

[TimDanMick]

The bottom line is that the US pays 17% of GDP on healthcare which does not cover all and which leaves rich Americans as the sickest rich people in the world.
Other advanced nations pay 9% of GDP on healthcare and cover everyone.
Tinkering with the system will only make it more expensive and it may be that a future impoverished US may not be able to afford the luxury.
Public control of the police and army is acceptable to most people. Why would efficient public healthcare cause such fear.

[RoloTomassi]

What I cannot imagine is how managing all of these medical industry vultures will avoid self-fulfilling predictions of failure brought about by the very people and organizations Obama is trying to work with on this issue. They are by no means trustworthy, and will surely sabbotage streamlining efforts in the future, if this actually gets off the ground.

For me, Conyers HR 676 bill is the only thing that makes sense, and sooner or later we will have to face the fact that healthcare based on profit bottom lines will never live up to the benefits of a single-payer, true UHC system.

At some point we will have to have a leader that is willing to sacrifice political longevity for the greater good and CRAMP a real UHC system down the throats of conservatives and healthcare corporatists.

I fear we are on a road of never-ending complications and setbacks, and not because what Obama is attempting can't be done, but because the corporatist element involved are not sincere and are never going to willingly give up their insane profits.

[satyriasis]

It really is now or never for health care and more people need to be reminded of that. Urgency needs to be emphasized......

If it doesn't happen this year it won't happen at all.

[milesz]

You are right on the point. Another element why health care reform hsould come about is (now) Sir Edward Kennedy's failing health and how such reform will be his lasting legacy.

[Jimmy1920]

I think you miss the mark.

I agree with five of your seven points. But those five are inconsequential. Although I'm sure many will think your last point is the most controversial.

No, I take exception to points one and four. Not because they are wrong, but because they are the heart of the problem and you spend so little effort on them.

You start off strong. "There should be health care coverage for every American provided through a public-private partnership." But then you confuse a centralized system like Britain's where doctors are public servants, with Canada's decentralized and much more privatized system. I suspect the only thing they have in common is some sort of unifying national legislation. Like we have here with Medicare, and with the VA, and with the Indian Health Service, and with SCHIP.

Did you say the US is not ready for national legislation on health care?

If there is a topic to be treated seriously, it is your point four and you dismiss it in a single sentence. In fact you combine two momentous concepts - administrative waste and unnecessary medical procedures into a single passing remark.

I do agree that it is now or never for health care reform. I also believe in incremental reform. Start with the single payer proposal. Over time we can address the fragmented delivery system, payment reform, population wellness and prevention, medical education, infant mortality, life expectancy, medical errors and theother issues that plague our system.

[milesz]

You are quite insightful with your observations. One comment in reply. though. When I spoke of Britain and Canada, I use them as but in microcosm for the perception of a system completely taken over by the government, which would be a perception to be held by most of us Americans if our system were completely "nationalized".. Perception, as you know, can be everything. Also, I do not speak of incremental change, but an overhaul phased in over time. These are two different matters. Thanks again for taking the time to reply and engage in this important conversation about changing our health care system.

[FightingTheRight]

We need to educate our fellow citizens on the alternatives available, beyond the British and Canadian systems, that are usually put up as examples.

The French healthcare system being one that addresses many of the concerns, found with other single payer systems.

We cannot keep letting the oposition, narrow the arguement down to creating a system, based on the worst that is out there.

[PlaceboStudman]

I have to strongly disagree with your priorities. Population wellness and prevention should come first and foremost, and should come at any cost. Until issues like childhood cancer and lukemia and the millions of children who are born with critical disabilities such as MD, MS, CP, and Spina Bifida are treated and those diseases found cures for and preventions for, THEN we can talk about Single payer system that is primarily set up so that someone with a broken arm or a stubbed toe can get treatment at the lowest possible cost

[RoloTomassi]

NO; sorry, I realize you are [or at least see yourself] as a special case, and advocate primarily for the special case, but waiting for those kinds of breakthroughs to advance to a single-payer system is absurd, selfish, and shortsighted.

What you really need to realize about the current situation in research [a what would continue regardless of how healthcare is reformed] is that the NIH is the primary and most reliable resource for medical research. All of the crap you've been fed about a single-payer system detracting from research efforts is just plain nonsensical propaganda.

[Jimmy1920]

Your second sentence betrays your message. "At any cost?" Who pays that cost? How does that money get into the system? Taxes? Payroll deductions? Premiums payments? How do people get into this system?

You first have to get people into the sytem before you can treat them. I had a father call our Plan one day. He had just learned that his daughter, who lived with her mother, had no health insurance. She was prepped for surgery to remove a tumor and was sent home from the hospital when they learned she had no health insurance.

Do you think that father understands about open enrollment rules, or Qualified Medical Child Support Orders? He just wants to get his daughter into the system.

We need to make that process as simple as absolutely possible. We have a maze of health care silos that frustrates too many people. We need to eliminate barriers.

[Janet Wees]

I am a Canadian, and have been using our "socialized" medical system since its inception in Saskatchewan in the early '60's. I don't pay premiums, I don't pay when I go to the doctor's office, I don't pay for operations, or visits to specialists.
Yes, it costs us in taxes, but it saves us money in the long run. We are healthier than the USA, our infant mortality is lower, our life expectancy higher. Our cost is lower.
Using the fact that some Canadians go elsewhere for treatment is an interesting tack, but it is not a big percentage. In Alberta there was a pilot program which revamped the system for joint replacement whereby the average wait time for surgery was 4.7 weeks.
Sure there are problems, as there are with any larger systems. In my city, three hospitals were imploded or closed, and our population almost doubled afterward, so there is much complaining here about lack of beds, emergency services etc. But the bottom line is that we can have access to our medical treatment with no insurance companies dictating what and where we can go. How can you allow this to happen in your country?