POLICY: Why Is Fixing American Health Care So Difficult?

Das KapitalABC News is running a special on health care this week and they asked two bloggers to stick in our 2c.  I’m up asking Why Is Fixing American Health Care So Difficult? David Williams from The Health Business Blog pens an article about IT and transparency that is slightly more optimistic.

Feel free to come back here and comment.

Almost all the problems with the American
health care system boil down to two questions. How do we create a
system that ensures that all citizens, and perhaps residents, have
access to health insurance? And how do we contain the huge cost

Of course, behind these questions lies the question of how to reform
the nation’s largest industry that serves and richly rewards many
powerful interests. Continue.

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77 replies »

  1. Everything in healthcare is changing almost daily. very few people knows what is happening behind the scene.
    The best bet is to go to uncle sam & use his websites. I am sure that it would give us the most authentic info.
    here is one to start with – https://www.healthcare.gov
    Check it out before anything else. I think all the content stems from this one.


  2. Hello,
    My name is Jake Waring and I am an acting student and Central School of Speech and Drama in London, England.
    We are devising a piece of theatre based on the American Healthcare System.
    I am researching this and would like to hear real people’s stories and experiences about the system. No matter how insignificant things may seem, everything is very valuable to my research, as actual human encounters give me a better view than simply reading facts and figures on the internet.
    It would be greatly appreciated if you could email me even the smallest details or stories you have, whether it be good or bad experiences with hospitals, insurance companies etc.
    I am also looking to get actual interviews over the phone/Skype so if you feel you have more you would like to tell me or just to have a chat that would be amazing.
    My email address is jake.waring@cssd.ac.uk
    Facebook: Jake Bare Tiffin Waring
    Skype: jake waring
    Thank you for your time,

  3. Terrific blog — thanks very much for it!
    I am troubled by some of the word choices, though, especially since I see them so often in discussions such as these. You write: “How do we create a system that ensures that all citizens… have access to health insurance?” This wording conflates the insurance with the health care. It isn’t the insurance we need, it’s the health care. So the question ought to be: “How do we create a system that ensures that all citizens have health care?”
    Let’s not build-in the assumption that these expensive middlemen are necessarily part of the package… They’re not!
    Thanks again for a great blog.
    — Dan Keller

  4. You know I just watched a video of what the right wing idiots are doing and saying about kids and there health care. Ya know its sad when a single man who doesnt make enough to afford health care cant even get Medicaid but when they start attacking kids thats absolutely freakin rediculous. They wanna send death threats to these children and there families? Who in there right mind couldnt threaten a child? That is just plain sick. If they wanna start threatening people let them threaten someone who doesnt give a rats a** about what they think. They have already screwed up our lives enough the worst they can do is throw us in jail. They have already made our lives miserable and allowed us to have a astronomical medical debt. Which when looked at by companies that do credit check to see if your worth the money to give a real job to doesnt look all that well so we are left to working for someone who doesnt pay worth a damn and has no medical benefits. You say your all for your country but I say no your all for as much money and as much pain as you can cause the little guy just for your pure enjoyment. People wonder why Americans are starting to leave this great country and move else where. Well when you have a government that cant get its head out of its own butt long enough to see we need to to quit worrying about whats goin on with our neighbors and worry about our own people first it stands to reason why they leave. We need to get a government in office that is gonna care about us and not just what is going to line there own pockets. They dont understand that what they are slowly starting is going to end up as a war on our own soil and it will be there own fault.

  5. I recently left a job and got the COBRA letter from my employer. I was in a state of shock so I started doing some research.
    If you have ever left a job where you had group health insurance, you probably have been asked if you want to continue your COBRA benefits. A common reaction in this situation is to take a look at the price of the plan, and balk because it is so expensive. Many people seek out individual and short term health insurance quotes but end up wasting a lot of time online looking around for affordable health insurance to fit their needs.
    Before you look for health insurance quotes, take a look at this resource about COBRA and COBRA alternatives. It can help you understand if you should continue your COBRA benefits. It details in what situations it might be a good idea to consider keeping your COBRA coverage.
    If you’ve been chronically ill, or you take expensive medications, a COBRA alternative may not be right for you. You might be very happy with your benefits and want to keep them. Or you may have been declined for insurance recently. All of these factors might make you decide to keep your COBRA coverage.

  6. Why is fixing American HealthCare so difficult? Perhaps becasue the powers that be are composed of Pharmaceutical Company interest, like the FDA, the AMA and all our paid off politicians who are asleep or controlled at the wheel. Pharmaceitucal Industry’s political control is far sweeping as in an intigral part of the WTO and those who would have a NWO.
    Harmonization – a political philosophy coming to a government near you soon! That will regulate your healthcare options especially in your choices in Dietary Supplements. The pharmaceutical industry wants full control of dietary supplements. Soon you will be seeing telivision advertisements for a wide variety of supplements produced by pharmaceutical industry as they work to put small manufactures out of business and to require supplements to have a prescription from a medical doctor, their controlled and paid drug pushers.
    weblink:www.stopthenorthamericanunion.com/videos/EuropeanUnion.html weblink:www.youtube.com/watch?v=3tg8suvwS3o&mode=related&search=
    Although the above video is about the European Union I strongly recommend that you watch it and when you are done click on “About the NAU” in the left hand column. This website and video was recently brought to my attention. It draws together a number of historical incidents and puts it into a very distrubing light. I am not saying that everything here is absolutely correct but it certainly is food for thought.
    The biggest question is – Is the United States going by way that England did? Is our fate to loose jurisdiction of our nation and our own back yard. Will we too loose civil liberties under Codex Harmonization and International rule through the WTO? This information will tell you exactly why our supplements are in jeopardy, what it has to do with NAFTA and CAFTA and the WTO.
    I’m not going to get into bickering about the specific issues on this forum. I’m just posting it because I think in large part much of it is true. Do your own edification, make your own judgements. And when you see the reality coming down the pike perhaps you will remember that you were warned of things to come.
    Do I think that there is anything we can do to stop it? I don’t know. I do think that our next election will be of paramount importance. And no I’m not for Hillary. We must seek out a strong Constitutionalist that will stand up against legistation that will suck us into the NWO through international trade agreements or that intends to dissolve international borders.

  7. Jim… here is your statement:
    “The problem is that the cost of health care is so high that we cannot afford it on a “pay as you go” basis – like we do with every other basic human need (food, housing, clothing, transportation, etc.)”
    If designer jeans cost over $100, 6 CD’s cost over $100, if an auto repair bill runs over $200, a vet bill for FiFi runs over $150, Dinner for 4 runs over $100, one ticket to a major league sporting event w/parking & snacks cost over $100, 2 concert tickets cost over $150, a DVD player costs over $100, one months rent costs over $600….
    When a physician gets paid $50 (including your copay)from your health insurance company or Medicare, for an office visit – which must be split to pay for the building, utililities, staff salaries & benefits, medications and supplies, phones & computers w/electronic medical records, malpractice and other insurance, taxes, loan payments, equipment lease payments…
    AND a person goes only once or twice a year… Even at List Price, that’s only $200 a year. How much do you spend on CD’s? The movies? Your social life? Snacks?
    What about healthcare is unaffordable? You can’t stand the doctor getting paid between $4 and $8 a visit???
    Not to mention, the doctor having to work 6-7 days a week and pull Call Duty.
    It’s probably less than YOU make on a per hour basis – and significantly more work.
    “Profit” is what a doctor calls his paycheck, to feed his family. Oh… maybe we aren’t supposed to have one of those either.

  8. Why keep trying to come up with a rational model healthcare model supporting irrational values?
    Attempting to defeat nature’s design and intentions through massive $100,000 healthcare subsidies at the end of life stage is ultimately futile & a waste of money.
    Spending the same $ 100,000 investing in our society, including the future of young children and young adults will generate far greater rewards to a vibrant society.
    Assuming the “education” of a largly uninformed and illiterate public that prefers watching the Jerry Springer Show and Maury Povich’s “Who’s my Daddy?” expose’s rather than critical reading and debate is an exercise in wishful thinking.
    “things may have to get worse before the public demands to be educated and heard, especially since the general public is unaware how bad things are.” Perhaps because, in general, for most people – things are pretty good – especially their health care.
    What people are worried about, and businesses are worried about is the cost of their health insurance-not the cost of healthcare.
    These are TWO DIFFERENT ISSUES. Offer affordable Major Medical policies with Chronic Condition Coverage and specific disease riders (based upon family history) and discard the bloated, overly expensive, “We Cover Everything, kind of, sort of, with pre approval, minus certain conditions” that is being sold today
    – and the problem is solved. The golden question:
    Bankruptcy has been the only recourse of a fair number of people without health insurance and having a major hospital stay or dealing with a chronic health condition, such as renal failure.
    The goal should be $200 a month insurance per person policy. The pricing should encourage LONG TERM HOLDING, like 20 year term insurance or a 30 year mortgage to make it viable to the health insurance industry. Why?
    Flipping policies every year or two makes health insurance a game of roulette. Get the money now and pass the cost to someone else tomorrow. Long term commitments makes each client more valuable and lest risky. Like term insurance, the cost will increase over time – because as we age, we need more health services, and the type of care we need gets more expensive.
    What will should it buy? Make the health insurance battle over the quality of their service and product offerings. Define a minimum and let the insurance industry, to differentiate and sell their product, add their own extras and incentives to make a better product.
    Keep it simple people and it will work. It will be understandable. Identify AFFORDABLE and don’t confuse the effort with one size fits all vision of EQUALITY to force some realignment of society to conform to some utopian ideal…
    It doesn’t work.
    People need different coverage options, because we each have our own biochemical & genetic makeup, and our own personal health practices – which will affect the policy that we purchase for ourselves and our families.
    Just as importantly, just because the solution is in place, don’t assume that people will voluntarily spend their money on affordable health insurance. Car insurance is already MANDATORY – and ignored on a large scale. That’s why You & I have Uninsured Motorist Coverage. There has to be a better enforcement mechanism. (While you are at it – solve the motorist w/no insurance problem too!!!)
    The Problem is simply the high cost of health insurance. The rest of the health care industry will adjust accordingly to the new reality.
    Pick a base amount and allow the flexibility of options. Mandate the availability of the coverage by all insurance companies in all 50 states and DC. Each state needs to be involved to tailor the policy costs to tailer them to their Cost of Living situation – a New York policy will cost more than a South Dakota policy, because the cost of living in NY is higher than SD.
    Remember that insurance is designed to protect against catastrophic loss – NOT expected and usual expenses.
    The example is the auto industry – insurance pays if the vehicle is stolen or damaged by a storm or auto accident. It does not pay for maintenance repairs, new tires, or your subscription to satellite radio. IT keeps Auto premiums LOW.
    Costs go down dramatically when the probability of expense (loss to insurance company) goes down. Period.
    Give people a GOOD alternative and they will support it.

  9. Per Tony:
    “If we choose to live in a society then we are by definition a part of that society. If we are part of that society and we are free and equal, then we are equally responsible for everything that happens in that society. No society is perfect so we can expect some members to be disenfranchised.
    Do we have a responsibility to these individuals? If we are part of that society and reaping its advantages, of course we do. ”
    A corresponding thought which we NEVER hear from the Universal Healthcare advocates – and those of the Leftist Persuasion – but is absolutely vital to the success of any society…
    === What is the responsibility of ALL members to contribute to the benefit of society ????
    Why are portions of our society consistantly and falsely portrayed as victims with no accountability for their prior actions and corresponding circumstances – and therefore no responsibility to make a positive social and/or financial contribution to the success of that society??? E.g. we hear of RIGHTS, but no corresponding RESPONSIBILITIES. The responsibilities always seem to belong to someone else. The sacrifice must be made by someone else. WHY?
    If there is to be a discussion of free and equal, then that discussion must include equal, personal responsibility.
    Interestingly enough, in this anniversary of the Jamestown landing, the Jamestown colony was origionally established as a holding in common, where everyone received an equal share of the bounty.
    Jamestown’s colonists were starving, susceptible to disease, and vulnerable to attacks from native american tribes.
    To save the colony, the holding in common economic model was changed – due to the lazy, indolent, and slothful behavior of others, not planting and producing enough food or their FAIR SHARE of the work. To force ALL colonists to contribute, colonists were given individual plots of land to tend. Put another way, some worked and contributed to the survival of Jamestown. Others wanted a free ride – a parasitic relationship to society.
    By changing the rules, and enforcing all members of society to produce and protect the interest of society, Jamestown survived.
    The same could be said for healthcare and many of the ills bedeviling our society today.
    The Victimized, Excuse Society has to come to an end.
    To quote an American icon, Robert F. Kennedy, “Ask not what your country can do for you, but what YOU can do for your country”.

  10. I have just finished reading the excellent article by Matt, and the extensive comments.
    I would offer some reflections:
    As a retired Family Practice Physician I can attest to the statement that 1/3rd to 2/3rds of all medical care is unecessary or without benefit.
    I spent the last 10 years working in an Urgent Care clinic. Mamy patients presented with self limited problems, such as viral respiratory infections, etc.
    Competition among insurance companies makes them offer great benefits in order to attract patients and generate large amounts of revenue. It is too easy for a patient to go to an Urgent Care clinic and pay $5.00 rather than explore options to self treat or make them aware of what point in the llness requires an evaluation by a physician. Even then, they may not accept that their illness is self limited, can be treated with simple solutions, but will often demand an antibiotic pill or injection to “nip the problem in the bud”.
    Part of the solution to improving health care in this country involves much improved patient education. I am not sure how to best accomplish this, but this must be part of the answer to this complex problem.
    The article by Matt talks about involving patients in the process of improving patient care. When I was in training, one topic discussed frequently was “how does a patient select a personal physician”?
    Patients generally select a physician based on the 3As. The first A stands for availability. How easy is it for the patient to be seen quickly by the physician, the most important factor. A number 2 is affability. How do I and the physician get along. Is he pleasant, kind, caring, attentive to me or distant, disinterested, rude, etc. The factor of least importance is Ability. Patients most often do not have access to information that allows them to judge the ability of a physician. I realize this is a simplification, and that the internet now allows access to information regarding success rates of surgery, rate of infection in hospitals, etc. But most patients don’t want to spend the time exploring the info, they just want ready, easy access to a physician of their choice. This is becoming harder and harder to find. Many patients are going to the system of finding a physician, paying a fixed amount of money per month and having that physician be available to them 24 hours a day. Physicians are also finding this a less stressful way of practicing, with the headaches of dealing with any insurance paperwork. I don’t think this is the answer to our health care crisis, but it is one approach.
    It does not matter what type of plan we come up with, there are some simple facts. 80% of the health care dollars are spent on 20% of the patients. Poor, elderly, those at high risk because of their lifestyle, i.e., obese, smokers, alcohol and drug abuse, etc. This will never change. Is their a way to work this into the equation? I do not have the answer. So do we accept a socialistic appoach and say that the have’s must take care of the have nots?
    Let us talk about single payer healthcare. We already have an example of that system in the multiple HMO’s and medicare advantage plans created by our government. These plans, as they relate to Medicare patients, function in this manner. They hire recruiters during the open enrollment period of Oct to Dec. These recruiters flood the nursing homes, retirement homes, senior centers and sponser seminars to explain their plans and to try to recuit as many new subscribers or converts from other plans as they can. Each new subscriber results in the medicare withholding of $98.50, plus an amount up to 5 or 6 hundred dollars from the government for each patient.
    These plans are often over-loaded with patients to the point of long waits for appointments, or more commonly, long waits for tests or procedures such as hip replacement, cataract surgery, diagnostic testing such as ultrasounds or CT scans or MRIs. There may be withholding of procedures such as colon cancer screening. There may be lack of time in the busy schedule of the physician to adequately explain the risk and benefit of certain procedures. The elderly patient with hearing or mental problems may not truly receive “Informed Consent” regarding the need to do a procedure.
    These HMO’s receive large amounts of money. If there is a surplus left over at the end of the year, there may be some sort of “bonus” paid to phsicians. In some cases this may give them an incentive to withhold care or testing.
    A single payer system could result in most people, not our Congressmen and Senators of course, into this type of HMO. Limited resources could result in withholding of care from many people.
    Asking patients to decide what constitutes a good system does not make sense. There are many experts out there who could address the problems, once they are defined. This in itself is a huge problem. Deciding how to correct the system is also a hard decision. We could throw money at the problem, and eventually we would be in the same boat as social security. Not enough people paying into the system to suppost those who are taking money out of the system.

  11. If you drop a piece of fine china and it shatters into a million pieces you don’t run for the glue to get your piece of china back. American health care is that broke.(no pun intended)
    We need to start over. Our premises have been wrong from the beginning. The concept “Lets base our system on the free market economy” is easily the worst possible methodology for a health care system.
    Under this concept, we charge people who want to be healers a fortune to learn the craft, whether it is a community or private educational center. Yes teaching Medicine is expensive but future healers should not bear these costs.
    Of course if it has cost a fortune to get your education you may feel that legitimizes you charging a “fortune” for your services. The snobbery that comes from the idea that “I paid a lot for my education” also seems to
    support the idea that I can charge more (Lawyers are another example, by the way) Of course, your community may not be willing to pay you what you think you deserve so you will choose to provide less than excellent care and make it up in “volume” “I will lower my charges and just see more patients” Rarely, it appears, is the option to make less money. (I see absolutely no physicians driving an average car and living in an apartment despite their “high calling”). However I hear many, if not most, physicians espouse how their goals are altruistic and and their thoughts pure.
    Our society has never said lets provide an inexpensive education to healers and insist they take care of our people at a reasonable price. Why? because somehow another we have decided that limits freedom. Whose freedom? Certainly not the healer’s freedom but definitely the freedom of everyone else. Shouldn’t good health should be everyones right?. (One of those unalienable rights, I think, that our leaders espouse?)
    Of course physicians are not the only problem.
    We decided from the beginning of our history that health care is a business. If you have a health care problem you have to pay to get it fixed. (Even if the problem is related to your communities poor ability to solve its other problems: bad air. bad water, poor working conditions, accidents etc).
    So, the physical ills living in this society place on us are not the societies responsibility as a whole but only our personal responsibility (because we are so free?)
    Maybe the largest problem we have is HEALTHY people. It appears that healthy people don’t want to pay in anyway for health care for unhealthy people in this society. The elderly and the poor are frequently the most unhealthy and it seems healthy people feel they have no responsibility in this society for providing any part of the unhealthy’s HEALTH care. Even if these people are in their employ, are members of their socieity, relatives, victims of disasters or whatever.
    “They are not my responsibility they are someone else’s.
    If the premise is that healthy people think this, then obviously only the unhealthy are responsible for the unhealthy.
    Of course many of the healthy are the wealthy or it least, “unpoor”. Most of the “unpoor” (the wealthy included) are involved in disenfranchisement of the poor.
    Whether you pay an “illegal” to mow your yard because he works cheap, or you employ skilled labor but pay them inadequately because you can, you are disenfranchising people who then have a greater chance of becoming unhealthy without any ability to pay for their health care.
    Its hard to imagine that disenfranchising such people gives you permission not to take some responsibility for their health care.
    If we choose to live in a society then we are by definition a part of that society. If we are part of that society and we are free and equal, then we are equally responsible for everything that happens in that society. No society is perfect so we can expect some members to be disenfranchised.
    Do we have a responsibility to these individuals? If we are part of that society and reaping its advantages, of course we do.
    Where am I going? If this society is responsible for all of is members then our health care system has to provide for all. If we make that premise then we need to start over, and create health care for everyone.
    Let’s level the playing field from the top to the bottom.
    Physicians get cheap excellent education and are required to see limited number of patients and charge reasonable rates. Profits from developing medical equipment, new drugs, advanced procedures are all limited, (not great for our great free economy but great for our people) If big business is frustrated with their limited profits,they should develop MORE medical advances. Instead of a lot of profit for a few ideas how bout a little profit for each of a LOT of ideas. (Yes this is backward, but reasonable thinking) I am assuming all stock holders have all ready have health insurance.
    Hospitals are required to treat everyone and charge exactly the same rates to everyone for every service despite their financial status, insurance or no insurance, wealthy or poor.
    Who they charge might be up for grabs. Charge the government, the insurance company the employer the patient but NEVER anyone who has no ability to pay.
    Of course this WILL NEVER HAPPEN, but what will probably happen if this is explored is a dialog that may result in a national health insurance program. Would that work? You betcha, but only if everyone in the society exercises their responsibilities as a member of a society to take care of all its members. Martha stated above that health care in Canada is a political scam. I do not know. What I do know is that if it is, it is because of special interests or lack of interest not because it will not work. Society has always solved every problem it ever completely invested in. Polio, Small Pox TB are slowly disappearing. Slavery is an anathema, Women’s suffrage is evaporating in the free world. We have created technological advances that have changed the entire world. All of these things have required great ambition, energy and most of all, dedication.
    Health care for everyone is entirely possible but everyone has to want it and take the responsibility as a member of society to assure it. As soon as this society will elect leaders and support a move in this direction it will appear. We may spend decades refining it but as long as we put the needs of society before our own selfish needs it will work. Only then are we truly free and equal.
    I know many comments in this blog are more realistic and are related to improving the existing system. Forget it
    We need a clean slate, fresh chalk, and a desire to rise above ourselves and create a new paradigm.


  13. The problem is not the lack of or cost of health insurance. The problem is that the cost of health care is so high that we cannot afford it on a “pay as you go” basis – like we do with every other basic human need (food, housing, clothing, transportation, etc.) First and foremost, we have to decide health care is a basic “right” for our citizens and to what level of quality that right extends. If we decide that health care is a basic right, like a public education, then all bets are off with respect to our current system of delivering health care. You cannot have a workable system of government subsidizing or sponsoring health care without a balanced regulation of the health care industry. That means, regulating (limiting) physicians fees, drug costs, etc. and eliminating profit from the system.
    If we truly wish to make health care available and affordable then perhaps the government should get into the health care business directly – just as it address the national defense, law enforcement, and most other governmental services. Establish a national health service, with medical clinics, hospitals, etc. in every community where we have a post office. Pay the costs of medical education, physician training, etc. in exchange for 5 years service in the National Health Service (such as we do for Military officers in ROTC). A national health service would provide competition to the health care industry, as well. In most communities there is little, if any, choice in hospitals or specialized health services. The health care consumer cannot “shop” for even the most basic health care needs. This alone drives the high costs inherent in our current system of high demand, low supply.
    If we are determined to use the taxpayers money in an effort to provide quality health care to all Americans, then lets go all the way…a basic level of care, paid for by our tax dollars, free to every citizen – just as we get our police & fire protection, national defense, etc. Those who want more or better quality health care than the system provides can pay for it themselves.

  14. I must be nuts. This blog starts with the notion that we must decide or answer “How do we create a system that ensures that all citizens, and perhaps residents, have access to health insurance? And how do we contain the huge cost increases?”
    Says who? Believe it or not, I don’t want any individual or collective “you” deciding how I gain access to either insurance or health care. And, I have no desire to accept individual or collective responsibility for how anyone else accesses either insurance or healthcare. It seems to me the first questions ought to be whether freedom or control should be presumed.
    If you take just a glance at the U.S. system, you notice that the feds control:
    1) nearly every step in the process of becoming a doctor or pharmacist;
    2) nearly every step in the process of obtaining insurance, whether through your employer or even purchasing it individually;
    3) nearly every step in the pharmaceutical delivery process; and,
    4) through the silly income tax system, the feds disguise and distort the consequences of many healthcare choices made either individually or by one’s employer.
    Clearly, there’s not been a “free market” in the healthcare system for a long time, at least not in the U.S. Am I to blithely presume then that there must be some good reason to let politicians control it all?
    Can anyone tell me three things politicians, especially at the federal level do well?
    I see nothing that suggests coerced collective solutions to this (or any) problem work better than solutions reached by individuals left free to decide where, when and how much property ($$) they want to exchange for someone else’s services (Drs.) or products (drugs).
    The “starting point” set out above burdens me to prove I’m entitled to my individual freedoms, when those of you who want to rob me of my freedom should have the burden of proof.
    I’ll ask again – what evidence suggests that the politicians in D.C. are wise enough to control any aspect of the healthcare system? And, for those of you who say “but look at Canada” or any other collective system, I ask you to tell me how many pharmaceuticals have been developed in Canada?
    Mr Lohman says that meds “should be developed by the NIH. Breathtaking idea. Please, tell me what prevents the NIH from doing just that? And, what/who allows those “detestable” pharmaceuticals” to make those “rip offs?” Duh, the very same politicians you expect to save you?
    It seems to me that if you would enslave me, YOU (individually and collectively) should first have the burden of proving a principled reason, and that I shouldn’t be burdened with proving that I am entitled to my freedoms. Again, if I’m not free to chose when, where and how much of my own property I’m willing to exchange with someone else for their property or services, then I am little more than a slave, as my freedoms then depend solely on someone/something else telling just how much or little freedom I am to have. What a sorry notion. And for so little in return.

  15. On top of it we are allowing the pharmaceutical industry to contibue its massive rip-off of the public. Meds should be developed by the NIH and licensed out to multiple manufacturers. THAT would be a true free market! But follow the money. It will never happen.

  16. We are victims of our own free market economy. Standards of care are being driven though the marketing relationships of biomedical companies and providers. Hospitals and physicians do not sit in strategic planning meetings and discuss a vision of healing all who are directed to the facility. Like most businesses, they focus on how to achieve a profit, which in all other industry sectors is important. Therefore, the discussion in the meeting is how to differentiate the enterprise from its competitors in order to grow market share. This is primarily achieved through offering the most cutting edge arsenal of medical services. The downside is that these services are always more expensive to the consumer and the medical outcomes and benefits may not be any better. Patient convenience seems to be the primary measure, not cure. That fact of the matter is we need to establish a national benefit plan which spells out the benfits that will be paid, period.

  17. FYI – I summarized this conversation on another blog focused on finding ways to get the public involved in transforming our healthcare system at the grass-roots level and, at the same time, helping the elderly, handicapped, infirmed, and their families and care-givers deal with daunting challenges imposed by the complex, fractured system we have today. The conversation evolved into an exploration of patient advocacy.
    Anyone interested in getting involved with us at the ground-level as we discuss, openly and honestly, how to accomplish these goals through creation and activities of a community-based not-for-profit organization.
    Please join us here.

  18. America’s healthcare system operates in definace of fundamental good business practices and basic economics, not to mention common sense.
    The antiquated and broken system can never be fixed without efficiency, for starters. Infomatics administrators and physicians are at loggerheads. IT systems can’t be implemented unless there are universal standards. We don’t even have universal billing codes, much less diagnosis, treatments, anything. No resources go into prevention or efficiency, it’s all going into research and education.
    It’s a problem with a solution, but there are too many that profit from the current status quo. Until the consumers in America finally demand improvements, they’re not going to come. It’s going to take a consumer uprising.

  19. We are not going to have a universal “medicare for all” system here in the United States, at least not in my lifetime.
    The root cause of the REAL problem is slowly being fixed, and all the while the “experts” are predicting… forecasting… even giving into… socialized medicine.
    I don’t see it happening. Everyone needs to wake up, see the problem for what it is, and take charge.
    As I sit typing this, the lsrgest carrier in the U.S. is on the hook for anti-trust, price fixing, collusion, and restraint of trade. They’ve been caught redhanded and are going to go down, along with all the brokers who followed suit. The carriers and large brokers have all bilked the consumers out of trillions of dollars collectively, and it’s going to stop. It has to stop. It will stop. Well informed consumers understand this, and are looking at all their options, many of which they have been told aren’t really available to them, which is criminal.
    The only crisis is that people have been ripped off for so long, they are just accustomed to it. Now, everyone is starting to reach a point where “business as usual” just isn’t an affordable option, much less a wise business decision.

  20. I agree 100% with “simple,” and the simplest is Medicare-for-all. But even Medicare needs some fine-tuning to eliminate waste.
    We are going to have a universal system in 10 years. The only thing standing in the way are the moneyed interests trying to make it 20 years. But they surely must see the handwriting on the wall, but whatever delay they can inject adds to their bottom line.

  21. R.Oakley – Are you saying (as I paraphrase you post) that (a) key to solving our healthcare problems are clinical models fostering patients and their providers to promote wellness (keep well and make well safely, effectively, and efficiently) and (b) our economic models, which focus on how the care is paid and profits accrued, are a big part of the problem because they interfere with the promotion of wellness?

  22. I must drop in my $.02.
    1) Patients see healthcare as something to be “delivered.” They’ve been taught to expect this by…
    2) An insurance industry looking for efficiencies and cost-cutting beyond muscle and deep into bone, taking a page out of MacDonald’s book by treating healthcare as a fungible “product,” while
    3) Free-marketers insist that the problem is with patients who refuse to take “personal responsibility” for their health – as though their children never fall off a bicycle
    I sensed a spindly thread in somewhere in here that says we go back to the basics. Patient. Doctor.
    Now we add on: Outside testing facilities. Hospital for accute care.
    Ok. How much would this cost?
    How much of our problem is an industry bent on taking premiums and investing them to keep a company’s books looking fat and happy and not actually producing the “product” we’re expecting? How much of this is just a perverse form of speculative banking?
    I know this is simplistic, but I’m an IT guy. I like simple. Simple doesn’t break. Simple may not be the flashiest, but it is unbeatable at producing the core result: Broken people who get fixed. Non-broken people who stay that way. The end.

  23. “If the Congressional Budget Office can be set up as a totally nonpartisan agency, why can’t we establish one for health care.”
    And the answer?
    “Elect Democrats”
    Goodbye, Jack.

  24. Elect Democrats, because it is a 100% political issue and the Republicans are in the pocket of the health care industry (and I say that as a lifelong Republican that voted for Bush twice).

  25. “If the Congressional Budget Office can be set up as a totally nonpartisan agency, why can’t we establish one for health care.”
    Good question! How would you answer it?

  26. If the Congressional Budget Office can be set up as a totally nonpartisan agency, why can’t we establish one for health care. Actually, I’d like all of them set up that way, or follow the model of the federal reserve board where members serve 10 year terms.

  27. I believe most people would accept control by governmental agencies – or at least a coordinating role — if trustworthy, non-partisan watchdog groups monitor their activities.
    As far as innovation goes, having putting every healthcare invention in the public domain will probably stifle creativity in a capitalistic economy. An alternative is to “share” intellectual property through licensing or building it into products for sale. This isn’t free sharing, of course, but it does get the innovation into the hands of anyone willing to pay for it, pays for the inventers’ work and investments, and encourages more innovations.

  28. “Do you believe our government has the ability and integrity to do this devoid of politically-influenced hidden agendas? Do you think our government would embrace and support valid, unbiased science that conflicts with the economic motives of powerful special interests?”
    Oh, yeah, probably – as much as I trust any other federal health-related organizations such as CDC, or the public health service or Medicare or the National Center for Health Statistics Research (I think its name has changed – you know the organzation) etc. Anyway, the alternative is to have those very private-sector companies and interests you mention control the research. I think it’s a push. And universities are not exactly pristine either.
    An important factor has to be the answer to this question: what happens to breakthroughs? In the private sector there will be innovations but they will not be shared. In the public sector innovations will be shared – provided there are any.
    Pick yer poison.

  29. “Wouldn’t it make more sense to designate one federal agency to collect and analyze national health care data and be responsible for policy recommendations based on the analyses?”
    Hmmm. Healthcare researcher in many universities and other non-government institutions are funded by government grants. So, in a sense, some of that’s being done. Going one step further, and giving the Feds the responsibility for transforming the research results into evolving evidence-based guidelines that are disseminated nation-wide is an interesting possibility that could help promote better healthcare. Do you believe our government has the ability and integrity to do this devoid of politically-influenced hidden agendas? Do you think our government would embrace and support valid, unbiased science that conflicts with the economic motives of powerful special interests?

  30. “We do need standardization, at least one area: A universal data set”
    Wouldn’t it make more sense to designate one federal agency to collect and analyze national health care data and be responsible for policy recommendations based on the analyses? This would require that finally there be agreement on a uniform data set & that would be mostly for the good.

  31. You make good points, Jack. If there weren’t already dozens of EHRs/EMRs being used in many places, if VistA has the flexibility to be transformed into something that addresses the needs of all practitioners (from PCP to surgeon to oncologist to chiropractor to psychotherapist to nutritionist to acupuncturist, etc.), and/or if having a mish-mash of different products made nation-wide data sharing (interoperability) too difficult, then I’d agree whole-heartedly. Even though this is not the care as I see it, I do agree with you about several things:
    1. VistA ought to be seriously considered by any appropriate provider who lacks an EHR or who wants to switch to a different one.
    2. We do need standardization, at least one area: A universal data set that includes every possible piece of data related to every possible: (a) diagnostic factor (including genetics, demographics, concomitant conditions, as well as biological, psychological, and mind-body symptoms); (b) treatment method/procedure/technique/process/guideline/protocol/regimen; (c) prevention/wellness strategy; (d) side-effect and complication; and (e) clinical and financial outcomes.
    We’ve also addressed the need for a “universal translator” that takes any piece of data from any software system or any technical term in any message, which is being sent from a provider to other providers or patients, and translates that data so it can easily be stored in the recipients’ databases, or translates those terms so the message can be easily understood by the people receiving it.

  32. Steve, VistA software is only an example I gave to demonstrate that it is already paid for by the public, is open source, and is an excellent starting point. It can be expanded to do all of the things it does not yet do, but I’d rather see that than 10 other parallel efforts and a mish-mash of efforts. This single-source doesn’t have to stifle innovation, like open-source Linux outside companies can still have input and make their money on support services.

  33. Jack – VistA software is good, but as far as I know, all EHR systems have their own strengths and weaknesses. For example, does VistA accommodate the needs of all primary care physicians and specialists in independent practice and in small group practices better than HIT systems specifically designed for them? And is a client-server system better than a peer-to-peer system? And what about the need for other non-EHR HIT tools having capabilities VistA doesn’t offer (e.g., advanced clinical decision systems and clinical model building & exchange systems)? And doesn’t reliance on a single software application stifle innovation? Well, if the free-market encouraged and supported development of disruptive technologies by small vendors, radically new innovations would emerge and cost of HIT would decline.
    ”should public policy permit private companies to compete on developing health care treatment protocols?” I suggest that, IF the clinical models ( protocols/guidelines/pathways) are evidence-based, then competing with them makes sense. This is because clinical model development is only in its infancy and a great deal of work/research must be done to develop new ones and revise existing ones. We could come a long way forward in improving care quality and controlling costs if clinician and researcher teams were encouraged to discover the most effective ways to treat their patients and the most efficiently ways to deliver that care, as long as they are held accountable for their actions and decisions and gain competitive advantage for good results. I don’t know if you would call this a free-market approach or not? Anyway, uniformity would come in the future by identifying the clinical models that consistently prove significantly superior for narrowly defined patient types. At that point, they become commodities and the original developers loose their competitive advantage, but could gain financial remuneration at that time I suppose. Just brain-storming here guys.

  34. Steve, Jack –
    I think a core principle is that sometimes, public policy is best served by prohibiting private-market competition on certain goods and services. Accountability for those decisions should rest entirely in the hands of public officials who can lose their jobs if they make a big mistake.
    In this case, the question is: should public policy permit private companies to compete on developing health care treatment protocols? [Note: this is a cousin to asking whether private physicians should be permitted to practice as they see fit. I am not going there.]
    I agree with Jack on protocols – the answer is “no, not if we want health care administered under national, uniform protocols.” Benefits come from uniformity. The downside to uniformity is a system less amenable to change. [You didn’t expect all good and no bad?]
    However, it is no condemnation of market principles to decide that some specific activities e.g., development of medical evidence and treatment guidelines, should be excluded from market competition – provided always that important wrong decisions can cost the decision-makers their jobs. This is how a “mixed” economy – our economy – actually works. Of course there are things outside, or not entirely inside, the private sphere – which, it must be noted, has not brought on Judgement Day. Examples include the postal system, the Coast Guard, printing money, the Federal Reserve System, TVA, international diplomacy, the federal judiciary, the National Park System, etc etc etc – all activities not subject to private-market competition.
    So I think another core principle is to ensure the desired balance between private freedoms and societal restraints. That balance is not carved in stone anywhere but reflects how society wants itself regulated over time – and therefore the balance can change. Isn’t that what elections and laws and courts are for? I say yes. Would you have it any other way? I would not – at least, not so long as the decision-makers can lose their jobs for important mistakes.
    Hmmm, I feel like Michael J. Fox in Back to the Future when he was playing Johhny B Goode and suddenly noticed everyone had stopped dancing. Sorry.

  35. Steve, I think all-of-the-above is possible, but it blows my mind that we are so frightened by “Big Government” that we would be willing to spend ten times the amount of dollars it would take to establish “data guidelines” for ten competitors to develop ten systems with interchangeability, all of which its costs would ultimately be added to the health care system, as opposed to simply using the VistA software that has already been paid for by the public. But then….
    The only competition the free market has spawned is when physicians pulled high profitability tests out of the hospital, and this resulted in higher costs, not lower.

  36. “Unfortunately the free-market doesn’t want anything to do with sharing their work with competitors.”
    Jack, John: It seems to me that there are different ways to view the issue of “work sharing” between competitors.
    One type of work sharing that is very doable and useful in healthcare is sharing of patient information between the providers treating a patient using shared HIT tools. Since this doesn’t involve trade secrets, I can see no affect on competition. Another type of non-competitive sharing involves compiling clinical data (diagnostic, process, and outcomes) into central data warehouses, stripped of patient identifiers, for aggregate analyses and scientific scrutiny by all. I consider these things as fundamental services of a well-designed RHIO.
    Where I see competition and work sharing as being related issues is in the development of practice guidelines (i.e., models of care delivery for particular health conditions). For example, a collaborative multidisciplinary team of providers and researchers collects and analyzes patient data and uses them to develop evolving evidence-based best practice guidelines. Competing teams do the same and compete with each other based on the results of implementing their respective guidelines: “My guideline is better than yours.” In this way, each team’s best practice guidelines can be viewed as trade secrets. This gives providers with better guidelines a competitive advantage. It is possible, of course, for a team to share its own guidelines with competitors for a price (such as collecting a royalties or commodity sales). There can even be a “model sharing ecology,” whereby competing guidelines are exchanged and examined by multiple competitors, their comparative effectiveness and efficiency are measured, and the better ones are sold at a higher rate. And if they want, competitors can even join forces to develop guidelines collaboratively.
    Switching focus, I don’t see the need for a “national IT system” if we act wisely. That is, if different IT systems are interoperable, then patient data can be shared among them and the IT vendors can compete on the value proposition they present to potential customers. I do have a personal bias here, however, because I know how to simplify and dramatically reduce the cost of interoperability between disparate IT systems, but it requires inclusion of disruptive technologies with certain proprietary features I’ve helped develop.
    Anyway, I suppose if we can agree that our “free-market” system is truly “free” in terms of fostering competition on a level playing field devoid of political manipulation by special interests, then a free-market approach might work. But debating this issue seems to be a whole topic in itself.
    What are your thoughts?

  37. “Unless a national IT system like the VA’s VistA (or like) is mandated and funded by Medicare, it is not going to get done . . . the point is that it will not be solved by free market competitors”
    Wouldn’t it make more sense to designate one federal agency to collect and analyze national health care data and be responsible for policy recommendations based on the analyses? This would require that finally there be agreement on a uniform data set & that would be mostly for the good.

  38. We didn’t have an anti-trust issue, John, the FBI ultimately caught wind of the rip-offs and charged the company owners with felony fraud, and one insurance company has sued for $40 million to recover its losses. But industry groups do (and we did) tiptoe carefully and avoided “conspiring.” A federal effort to provide a universal IT system would certainly not violate laws.
    There are many ways to skin this cat, John, but the point is that it will not be solved by free market competitors. If we are of the mind that the government can’t do anything right, as I’ve said before, outsource it to Halliburton.

  39. Jack,
    I think you’ve explained everything but the part about antitrust law and the part about competitors conspiring against the public. Apparently even in your business, some competitors conspired against the public. I think giving competitors legal license to share competitive information – or mandating that they do so – doesn’t seem wise.
    Wouldn’t it make more sense to designate one federal agency to collect and analyze national health care data and be responsible for policy recommendations based on the analyses?
    This would require that finally there be agreement on a uniform data set & that would be mostly for the good. Medicare already collects data for their population and Medicare could do the same for the population under age 65 but I think it doesn’t really matter which federal agency were designated for this purpose – e.g., it could be NCHSR or its successor.
    This approach would (1) avoid the political awkwardness of mandating that competitors share competitively-sensitive information among themselves, (2) avoid the appearance (and likely the fact) of promoting collusion among competitors, (3) avoid conflicts with antitrust law, (4) promote the development of evidence-based health care policy recommendations (5) not require anything be shoved down anyone’s throats, and (6) not require an extended and likely fruitless search for someone in government with balls.

  40. When I ran my business, John, I spearheaded an industry association amongst my competitors for the purpose of reigning in maverick competitors that were illegally ripping off the system, but I didn’t give them data that would allow them to improve their service over mine. And that is exactly my point. Unless a national IT system like the VA’s VistA (or like) is mandated and funded by Medicare, it is not going to get done. Period!

  41. “Unfortunately the free-market doesn’t want anything to do with sharing their work with competitors.”
    Well, hmmm. They ARE competitors. When you ran your business, how much information, and how often, did you share with your competitors ? To what purpose?
    Adam Smith observed two centuries ago that “people of the same trade seldom meet together but the conversation ends in conspiracy against the public.” It is a compelling comment because it reflects human nature that after all, has not changed.
    So, will the corrupt and greedy businesses cooperate first to get the politicians who are on the take to repeal the antitrust laws? And after that, will the companies share their secrets with one another in order to reform the system into one that will truly work to their distinct disadvantage? And if they do not, will the government led by corrupt politicians on the take from these very companies, force them to?
    Is that the plan?

  42. Steve, given our current free-market competition (???) I do not believe there will *ever* be nation-wide colaboration between competitors. That’s why we need the government to force the decision. The free-marketers have shown us their incentives, and they don’t include us.

  43. Steve, I think one of the most valuable investments we could make is in a national IT system as I’ve seen you write about. Best practices, prescription checking, ER access, etc, are all the reasons we need it. Unfortunately the free-market doesn’t want anything to do with sharing their work with competitors. Somebody is going to have to have the balls to shove a nationalized system down the industry’s throat.

  44. John wrote: “The past 40 years is Exhibit A how easy it is to underestimate the difficulty of doing this … the larger risk lies in implementing some ‘universal’ solution that inadvertently makes things worse … I favor state-level demonstrations and incremental changes rather than universal solutions.”
    The difficulties of the past 40 years can actually help the process move forward by pointing out reasons for earlier failures, and an incremental approach could come from innovative RHIOs, which are patient-centric and community-focused. I do think, however, that having deep dialogue about the problems and potential solutions from multiple points of view will enable emergence of a big picture view of the current situation and its causes (As Is model), which can then be evaluated in terms of the likely futures resulting from different scenarios (using What If models). The scenarios promising the most desirable futures based on reasonable processes would then be defined as solutions worth pursuing (To Be models). Building, discussing, comparing, and evaluating different As Is, What If and To Be models — e.g., by challenging models’ assumptions and predictions — is one possible method for consensus-building.
    Bringing the public “up to speed” so they can engage intelligently in this kind of discourse, however, requires education and motivation. On another blog, a health educator RN offered the following good ideas, which include the media, advocacy groups, and use of retired healthcare professional as educators:
    “First, the Newsweek of Oct. 16 ran a series of articles on healthcare issues that I feel was very well written. I intend to use them to continue to promote consumer education. If more articles like these can be provided for the public we have a chance to educate and empower the consumers to demand and expect change.
    I would like to see healthcare consumer advocacy groups that address individual concerns as well as promoting seminars or general training for the public. Word of mouth and teaching one to teach more is a great grassroots system (just slower than most of us would like).
    The use of retired nurses, physicians and hospital billing personal would be great sources of information to resolve concerns and to educate the public. They would truly have no agendas to push except promotion of better quality healthcare.”
    Jack’s post reflects what we’re up against: “our future direction will be controlled by the for-profit health care interests that want to see the system remain exactly as it is; chaotic and profitable. And they are willing to put their money where their mouth is … to corrupt politicians in Washington … Much of what I’ve read here involves an increase in spending … the problem will have to get much worse before it gets better”.
    Well, I’d like to see more spending on collaborative scientific research to help answer the questions: (a) What prevention and treatment approaches and the safest, highest quality, and most affordable for the particular patient/consumer — i.e., what is likely to result in the greatest health benefit, with least risk, for least cost for a person with a specific set of symptoms, risk factors, genetic makeup, and preferences; and (b) Which (multidisciplinary teams of) providers are likely to deliver that care in the most effective and efficient manner across the entire care cycle (episode of care) as evidenced by valid clinical and financial outcomes data. Armed with these answers through support for transparency, care quality will continually improve and overall cost decline; as Porter and Tiesberg say in their new book, it’s possible to transform American healthcare into a non-zero sum system.
    And yes, things may have to get worse before the public demands to be educated and heard, especially since the general public is unaware how bad things are. So, how much worse do things have to get before people wake up, and is it acceptable to sit back in the mean time and wait (or to game the system for personal gain) before it collapses? Apparently, positive things can and are being done today.

  45. I may be beating an old horse (though not a dead one), but it amazes me that (a) our group of intelligent, diverse and (sometimes) financially interested blog participants are spending so much time arguing the pluses and minuses of this approach versus that approach to solving our health care problem, when in fact (b) our future direction will be controlled by the for-profit health care interests that want to see the system remain exactly as it is; chaotic and profitable. And they are willing to put their money where their mouth is, that is, by sending $100 million per year to corrupt politicians in Washington, all to forestall a political correction to the system that will cost them profits.
    Much of what I’ve read here involves an increase in spending, some justified yet promise a return on investment (like a national IT system), and some that will have unintended consequences (like P4P and transparency).
    Twenty years from now we’ll have a universal health care system either like that in Canada or the UK, or some combination thereof. But the problem will have to get much worse before it gets better, and I predict the costs to reach 20-25% of GDP before public outrage forces a political decision. My cynical advice: make your money and run. It isn’t going to last.

  46. Steve, if I had answers to the questions you raise, I would have more money than Bill McGuire – and I would be WORTH it.
    “I believe this is very doable.”
    The past 40 years is Exhibit A how easy it is to underestimate the difficulty of doing this.
    Yes, I believe there are teachers (and not teachers only) with integrity, objectivity, critical thinking, and courage. I also fear that these are the very people that others in our society are comfortable scorning and ignoring when in disagreement with their ideas. American society does such a fine job of challenging authority (and such a poor job of teaching real critical thinking) that we can’t seem to find authoritative voices when they are needed.
    Certainly there is great risk in doing nothing. There is also great risk in doing something, when there is scant assurance that the something is the right something – or close enough. Perhaps I’m just expressing my own fear of the unknown when I say the larger risk lies in implementing some “universal” solution that inadvertantly makes things worse – or, in one of my favorite phrases – will have us “running thru hell in gasoline pants.” Anyway, that is why, in part, I favor state-level demonstrations and incremental changes rather than universal solutions.
    But now – World Series Game 1.

  47. Yup … Not easy! Some questions follow:
    “there are no voices that have emerged as leadership opinions or that command clear respect. Too many pundits and politicians are overly invested in debunking rival ideas vs. working with others to devise practical compromises where ideas differ.”
    What would it take for such leadership voices to emerge and for “those in the know” to focus on compromise as a path to resolving their differences and establish a unified path forward?
    These leaders not only have to be able to teach, but also to foster consensus (and it need not be unanimous) among disparate groups. If the overriding goal is safer, more effective (high quality) care delivered competently and efficiently to everyone in need, then it gives us criteria by which to judge alternative solutions. Strategies focused on enabling, supporting, and empowering patients and providers to continually improving outcomes (including quality of life, as well as quantity of life) and efficiencies through the development, evolution, and implementation of cost-effective processes would have priority over strategies that don’t. One of the first things to do is define the critical success factors and key performance indicators against which alternate solutions are judged. I believe this is very doable.
    “I still don’t see where true [trustworthy] educational leadership is going to come from.”
    Do you think our society has become so imbued with duplicity to cover up biases (hidden agendas) that it’s just too difficult to find teachers with integrity, objectivity, critical thinking, and courage?
    If such teachers do exist, where might they be found and how do you discern their level of integrity and objective knowledge? If they don’t exist, then what would it take to create them?

  48. Steve, you say that “non-profit, non-partisan, consumer watchdog/advocacy groups focusing on healthcare reform would be my choice for authoritative leadership”
    Maybe you’re right. I said before that I agree with the goals that you outlined, I just see no clear road to reach them. Regardless, I’ll support education and the other initiatives you suggest, because I think they will help me, and others, toward a better grasp of the facts. I am much less confident that such efforts will help people toward a more unified idea of what to do.
    Why am I doubtful?
    First, because there are so many competing ideas, and there are no voices that have emerged as leadership opinions or that command clear respect. Too many pundits and politicians are overly invested in debunking rival ideas vs. working with others to devise practical compromises where ideas differ.
    Second I still don’t see where true educational leadership is going to come from. People from non-profit organizations don’t seem to me any more trustworthy than people from business or people from government, which is to say, not all that trustworthy. In the same way, advocacy groups by definition have their own agendas – and bias is bias is bias. Individuals claiming to be non-partisan are generally regarded with mistrust by partisans and for that reason tend to be ignored.
    By comparison, Diogenes had it easy – and he failed.

  49. I can certainly see why someone would by cynical, John; these are daunting issues.
    You said “mass media is one of the players that push their own agenda … There has to be authoritative leadership.”
    I suppose every for-profit organization has an “agenda” to sell something. They may be honest, ethical and impartial, thus trustworthy, but the veil of suspicion can never be fully lifted. That’s why non-profit, non-partisan, consumer watchdog/advocacy groups focusing on healthcare reform would be my choice for authoritative leadership.
    There’s ”no practical consensus about what ‘the problem’ is”
    A primary reason for that is the complex and intertwined problems affective healthcare today, including economic (cost, coverage & efficiency), clinical (practice/process, research, QI, etc.), and emotional/psychological factors. So, how can we make sense of it all and share these insights with the public in an understandable way to promote the generation of rational solutions?
    I believe the place to start is by constructing a “big picture” view that defines and describes the key factors and interactions contributing to our healthcare crisis. Trying to make sense of such incredibly complexity is a grueling task, which my colleagues and I are currently attempting to do, and we plan to present our results for peer review and feedback. If processes like this help stimulate constructive collaboration to clarify the problems, it will enable folks to prioritize the problems, which will focus them on developing rational strategies for continuous quality improvement, cost reduction, and enhanced patient trust and provider confidence. I would consider this taking steps in the right direction.
    “how long will it take for the public to absorb sufficient factual information about health care”
    I suppose it depends on how well (clearly, interestingly, understandably) the information is presented and how focused, motivated, and aware the public is. These variables, in turn, relate to such things as people’s intelligence, existing base of knowledge, fear and despair vs. courage and hope, degree of economic pain, past experiences as a patient or family care-giver, sense of hope and trust, community spirit, willingness to collaborate, etc. I know one thing: The only way to answer this question with confidence is by doing it, and in the process our methods would improve and public learning will accelerate.

  50. Eric, my post above is not a response to yours, but to that earlier blitz of trash spam that has now been removed.
    Matt, if you would be so kind also to remove this post and the one immediately above, I would appreciate it. They are both space-wasters now.

  51. John– I think you slightly misunderstand. As I have promoted previously, we need to move away from a concept of wages + compensation to the concept of ‘total compensation’.
    Businesses do not hide the cost of COBRA per se, they just do not always make it clear what the exact value of benefits are; ie. the total cost of an employee.
    There are exceptions- and if your company promotes total disclosure you should be commended. But it is rare.
    Businesses do not want employees who do not get health insurance through the company demanding more money to get them on par with employees that do. Some companies have even gone to pay their employees to NOT be on health insurance. What the employees do not reallize is that they are coming out behind, because the extra pay does not come close to covering the cost of insurance.

  52. “An example of the insanity that could be solved easily — the absolute horror we all have when we try to get COBRA insurance.”
    COBRA is hard to get? I think it’s easy. It’s just expensive. If the cost of COBRA is what you mean by the horror, then I agree with you. Is that it? If so what is the easy solution you have in mind to this insanity?
    “Employers because the employees who do NOT get health insurance through the company would (and rightly so) demand more compensation to keep up with their peers.”
    Eric, I manage a large corporate plan (over 10,000 subscribers), and I try to use COBRA at every opportunity to show people what their plan actually costs – because the company pays 80% of the tab. We include the COBRA rates in our annual enrollment materials (which are “out there” right now). I want us to get credit for the 80% that we pay. We don’t. People complain about their 20% and they complain about the $10 OV copay and they complain about the $15 Rx copay. Complain, complain complain. I’m required to listen to 4 hours of complaints per business day, or my stock options won’t be back-dated any more. :-/
    We have some people (consultants who are not employees and part-timers who work less than 20 hours per week) who cannot sign up for insurance. Every other employee is eligible. I don’t worry about compensation equity issues – if one arises, I tell them to sign up for insurance like everyone else. If they aren’t eligible I shrug my shoulders – that’s the employment deal they have.
    When someone terminates and is not eligible for the post-retirement medical plan, COBRA comes out of the desk. I sure can’t hide that. It’s in my interest for that not to be a surprise.
    What could possibly be my motive to hide the cost of COBRA?

  53. The broken record of people taking some more responsibility for their own health always seems to be lacking…
    Note that I said health and not healthcare.
    Common sense behaviors work– smoking, diet, exercise.
    So many want to dive right into the double-secret complex facets of medical bills. You are all so right when you say it is hard to find out costs– then many of you lambast and oppose those physicians who shed the complex billing procedures for simple cash (or equivalent) transactions without insurance.
    An example of the insanity that could be solved easily — the absolute horror we all have when we try to get COBRA insurance. This number is merely the ACTUAL COST of the insurance we have been receiving all along, but amazingly employers, unions, and government do not want you to realize it.
    Employers because the employees who do NOT get health insurance through the company would (and rightly so) demand more compensation to keep up with their peers. Unions because they depend upon employee ignorance to promote so many of their policies. And the government because the public might not like the regressive tax implications of employer sponsored insurance.
    Many on the left would do well to recognize that when people behave badly, at some point they must be held accountable and that government is not the solution to our problems, but they won’t.
    Many on the right would do well to recognize that a ‘free market’ that is really rigged with so many perks to certain businesses creates a business-consumer relationship with a power differential rivalling that between, oh let’s say, a President and an intern. But they won’t.
    So that leaves efforts of both sides to convince the public and the legislatures of the country to take steps that naturally lead to one another to reform the system.
    Mandatory insurance with employer and employee ‘mandates’ and a government run ‘connector’ is a step toward a single-pool system.
    The Health Care Choice Act, Association Health Plans, HSAs, ‘cash’ and ‘concierge’ medical practices, are steps away from that vision.
    Medicare Part B is failing. Guarantee — a 10 day ‘pay holiday’ for Medicare this year will be longer next. A ‘no cut this year’ in exchange for amorphous pay for performance requirements in medicare is a bad bargain. Medicine, the Congress, and the country are better off letting the cuts go through this year and the next and see where the consequences take us.

  54. “use the mass media (especially TV and the Internet) to bring to the public different various points of view”
    Steve, I understand what you want to accomplish and I agree with the goal – but the mass media is one of the players that push their own agenda and so do not/will not fairly present the various points of view.
    “Once the public understands the problem”
    You come at this in a rational way, and rationally your approach makes sense and should work. But. There has to be authoritative leadership. I don’t know who or what can fill that need. I dont think the public trusts anyone – not government, not business, not pundits, not physicians; not academicians. We’ve done such a fine job of challenging authority that we don’t have it when we need it.
    Besides, I think there is no practical consensus about what “the problem” is. Health care thought-leaders are like the seven blind swamis trying to explain to the rest of us blind folks what an elephant looks like. Or perhaps more accurately, we are all blind mathematics illiterates trying to understand mandelbrot sets.
    Anyway how long will it take for the public to absorb sufficient factual information about health care, despite the spinning of the parties involved, and when even college-educated folks e.g., in San Francisco, don’t know simple things like who is the Speaker of the House? I can’t count the years. Certainly not in my lifetime. OK, we have to start somewhere. But how to start? Who will lead? And who will follow?
    I used to think Jay Leno’s “Jaywalking” segments were scripted. I don’t think that any more.
    I hate to sound so cynical. I don’t feel that way. It just comes out that way. One of Mark Twain’s more brilliant remarks was “I hope it, but I doubt it.” Yeah, me, too.

  55. Excellent points, John.
    One possible way to start is to use the mass media (especially TV and the Internet) to bring to the public different points of view about the problems with healthcare today, and to encourage public discussion/debate about which problems are most important and vote on what to make the priorities. If nothing else, this will help enlighten then as the seriousness of the situation and thereby help motivate them to act. The ABC News program and Matt’s article are good examples of how to educate the public.
    Once the public understands the problem and identifies the priorities, different potential solutions addressing them would be presented and critically evaluated through public discussions and a policy platform for change built on some degree of consensus would emerge.
    The details of this proposed process must be defined and its feasibility determined. A detailed strategy for reaching the most people and motivating them for informed action at a grass roots level is needed. While this isn’t an area of my expertise, I’m willing to participate in efforts to stimulate community knowledge and involvement. There are, for example, several Consumer Watchdog and Advocacy Groups that focus on healthcare.

  56. Thanks for writing a fantastic article.
    I’m trying to become a better consumer of healthcare by finding out the prices of common procedures, but it is very difficult.
    Would any of you know where to find a “menu”, that tells me how much it would cost to get a heart bypass, overnight hospital stay…etc?
    I know there’s a list here for Medicare, but if anyone has more information on prices, I’d really appreciate it if you can email me or come comment on my blog about this particular topic.

  57. “rallying the public first requires educating them”
    Who will decide the curriculum and who will do the educating?
    I think there is no answer to these questions that does not immediately encounter the following:
    There are so many competing solutions that none can gain support from the majority of influence-leaders most of whom see different problems to solve, and thus tout their own solutions.
    It’s a good idea to educate the public – don’t get me wrong. But the curriculum and teachers i.e. the thought-leadership on this subject – first must reach a much better consensus on whatever it is will be taught. I don’t think there is sufficient consensus yet and one need not read further than this blog to begn finding examples. In the absence of that I don’t see education being able to bring about unity of purpose.

  58. Good article, Matt!
    If the American public is to ever stand up and demand meaningful change, they would need a sensible rallying point, something they can understand and support, and something that is powerful enough to withstand the push-back from the mighty self-interests gaining from the status quo who will resist such change. So, what particular deliverables might they demand and what tactics might they endorse that would will propel such transformation?
    I think one of the most important things to patients/consumers is to feel secure in the belief that they do/will receive the best possible care — tailored to their particular needs, characteristics, and preferences — which is delivered in a safe, timely, and efficient (cost-effective) manner.
    This is an emotional issue related to having trust and confidence in (a) the knowledge and competence of their providers, (b) the safety of the healthcare delivery system, and (c) the ability for the system to be prepared and respond effectively in emergencies (bioterrorism, pandemics, natural disasters, etc.).
    An informed consumer would likely feel quite insecure considering the knowledge void problem, safety and quality problems, our insane economic and competition models, and the split between sick-care and well-care and between mind and body care, which reflect today’s healthcare environment.
    If I’m correct, rallying the public first requires educating them about why feeling insecure about their health and finances is the most rational reaction to the current healthcare system. They then have to debate what changes are necessary to transform the system, which requires further education, along with good collaborative communication for discussing and evaluating ideas. Emerging from this dialogue would be a transformational model detailing the strategies and tactics necessary to make them feel more secure. It will likely include recommendations for policies, practices, models and processes designed to help their providers deliver continually improving care quality and reward them for doing it efficiently and effectively, to monitor populations for outbreaks and have responding to emergencies, as well as ways to make universal coverage a reality.
    Does this process make sense? If so, what is the best way to accomplish this type of focused consumer movement?

  59. If the only thing holding your older emplyees to the company is healthcare then there is something wrong with your company. I ran into this with an old time company I was employed by. The industry was in the consolication process to increase market share and this company was loosing out. The only employees to stay, the ones who had the least vision for success, were the older ones (who got us there) clinging to their pension and accumulated vacation. That company did not survive. A universal system provides portability for workers and a level playing field for smaller competitive companies who cannot afford health insurance. People buy home insurance because their lender forces them to, they buy car insurance because the state forces them to. If the government forces you to have health insurance then it needs to give you something in return – cost control and affordability. As soon as we cut this crap about this pool or that pool, which are all about business plans not about healthcare, and realize we all have a stake to be ONE pool, and then reduce utilization and costs in that pool, we will begin to get control of healthcare. But Tom is right – Fat chance.

  60. I’ll start off with a comment/criticism of Matthew’s piece, and then agree with the main thrust of it. Because I am not foolishly consistent.
    Matthew said:
    > any attempt to provide insurance to people who are
    > sick means, by definition, that people who are well
    > are going to pay more for their insurance than they’ll
    > need or use.
    People who know they face a better lifetime risk profile than average might under a community rating scheme pay more for more insurance than they need. True enough. How they might know at birth their lifetime risk profile is beyond my expertise.
    To speak of insurance as being a transfer of wealth from the well to the sick completely misrepresents the concept of insurance, and only serves to make people even more suspicious than they are. It is right to speak of buying insurance for the poor as a transfer of wealth from the rich to the poor. Ditto when the rich buy services for the poor unlucky enough to become seriously ill. But this is an entirely different concept. The distinction is difficult perhaps for people who think primarily in terms of social insurance rather than in terms of mutual insurance.
    We use the fire insurance on our homes by living in them, taking steps to prevent fires and praying we never have one. In the same way, we use health insurance by living, not by getting medical treatments.
    I harp on this because I constantly hear people, even my relatives, say they don’t buy insurance because they have never spent as much on medical services in a year as the premiums cost. They see insurance as a sort of “discount club” for buying medical services, not as a payment to someone else to take on the risk they’ll get sick next year (or the year after that).
    So that’s the comment.
    And this is on topic here, I suppose.
    About four weeks ago, the Missouri Healthcare Executives Group (an independent chapter of the ACHE) or which I am secretary hosted in cooperation with the local chapter of the Healthcare Financial Management Association a panel discussion on the topic “The Future of Healthcare Finance”. About 150 people attended.
    Panelists were recruited to “represent” various points of view.
    Of particular interest to me anyway were Louise Probst of the St. Louis Area Business Health Coalition, and
    Dennis Matheis Vice President of Anthem Blue Cross and Blue Shield.
    Ms. Probst was supposed to represent the “businessman’s” view of health insurance, mostly medium-sized to large employers’ view. Mr. Matheis’ point of view should be obvious. They’re on the same side.
    Listening to Mr. Matheis, insurance companies provide “patient choice”. He harped over and over again about the failed managed care experiment of the 1990s and about how patients hated having their choices restricted and about how they got their legislators to outlaw restrictions, so now insurance companies give patients exactly what they want: choice. At employers’ expense, of course. But (up to a point at least) the employers don’t care, because…
    According to Ms. Probst said, employers see health insurance strictly as a retention tool. She essentially defended medical underwriting saying “Younger workers prefer other forms of compensation to a rich health insurance benefit, and older workers prefer richer health benefits to other forms of compensation”. She sees offering health benefits as a way to arbitrage the preferences of different employees to give them more of what they want at a lesser cost than a cash equivalent, and as a way to retain talent (i.e. middle aged workers who might go elsewhere but for their increasing uninsurability). At least some employers like and benefit from the current situation. Pope Leo XIII called this condition “Wage Slavery”. In 1891.
    Any sort of “Medicare for All” plan hurts the employer-insurer alliance: Ms. Probst’s clients couldn’t use health insurance as a “retention tool” anymore, and Mr. Matheis would be reduced mostly to the level of any other CMS contractor that processes enrollments and claims. Any insurance business he gets would be in the “buy up” packages he might sell to the especially risk averse. And in a way, this business is barely insurance.
    And so, Matthew is right. Nothing will happen until the patients demand something be done, and submit themselves to the opinions of the officials who run the thing. Fat chance of that happening any time soon.

  61. Absolutely. I am. The mercantilists who run the country are the ones who don’t believe their Adam Smith!

  62. Natalie–you’re stepping on the line between opinionating and advertising. If you want to advertise, you can but it costs money and it appears in a speciic place. If not, please step back from the line.

  63. BlueCross BlueShield of Minnesota suggested that Minnesotans should be required by law to have health insurance…..
    Visit http://www.aishealth.com/GNOW/101606.html#gnowten for more information
    Now This makes me chuckle. Next you’ll see life insurers making life insurance mandatory.
    The bottom line is that the market will decide what services consumers will have at their disposal and by whom! Health insurers expect america to pay 13,500 for a healthy family of four in 2006?? This will pay for an hour wait to see a nurse, by the way. Why not utilize a PersonalPediatrics affiliate pediatrician and recieve house calls by a doctor who actually will see you and give you the time of day?? Combine this with a high deductible and receive personalized service for less money!! Take a look at http://www.personalpediatrics and watch our story as it unfolds. Natalie Hodge MD

  64. John — Thanks for that clarification. It was manadatory pools that I had in mind. One advantage that large, employer based self-funded plans have is that they can offer high deductible plans and still guarantee coverage for all of the high cost cases in their group. Assuming they don’t fund an HSA but just shift some of the risk to the employee in exchange for a lower contribution toward the premium, they will likely save money on balance. For employers that don’t offer health coverage, they probably need to be required to pay something in the range of 8%-10% of payroll to cover the cost of alternative group coverage. The individual market is uneconomic because of high administrative costs, inferior benefits, and medical underwriting. I also wonder if it would make sense for the government to offer optional reinsurance for an actuarially sound price per member to cover costs above $250K per case, and, if so, what that price might be.

  65. Multiple pools are fine so long as a) it’s compulsory to join a pool (no free riders, and we need the healthy for cross subsidization) and b)all the benefits are the same (e.g. we need a NICE too) so that a cheapo pool won’t skim off the “healthies”.
    Then the “pools” will compete on service and cost-effectiveness (doing the same thing better, not doing different things)
    This is the core of the original Enthoven proposal, of course.

  66. “I think Association Health Plans would be a good idea for pooling risks, but they are vehemently opposed by the Blues among others.”
    Barry, there is a serious underwriting problem with association-type plans if participation is voluntary. When healthier people leave (or don’t sign up for) a voluntary health plan, it’s called adverse selection because the remaining participants’ overall health status is poorer than the original group. Adverse selection drives up the cost of a voluntary plan. Worse, as the voluntary plan increases its premium in response to adverse selection, the higher premium induces still more participants to leave the association – those who are healthiest at the margin and who are best able to find a better deal – and this requires yet another premium increase, leading to still more participants leaving the plan, etc, etc. Voluntary associations are not stable because they are especially vulnerable to adverse selection leading to the cycle indicated above, usually called “the death spiral”.
    Of course, the government could very well adopt the approach you suggest by creating smaller mandatory pools (e.g. geographic) that are large enough to command economy of scale.
    However, I think the bigger problem will be that the government hasn’t the political capital to push thru such a plan – or any plan for that matter.

  67. I’m not convinced we have to put everyone in one giant risk pool. We could have hundreds of risk pools that were each large enough to eliminate the need for medical underwriting and drive administrative costs down to 4%-5% of expenses which is about what large self-funded plans pay today.
    I think Association Health Plans would be a good idea for pooling risks, but they are vehemently opposed by the Blues among others. Maybe it’s time to strip away most of the state coverage manadates which self-funded plans don’t have to comply with because they are governed by ERISA rules.
    I also agree that there is tremendous potential for information technology to improve efficiency, reduce costs, make consumers smarter and more cost conscious, and bring about convergence in practice patterns between the high utilizers and the best practicers.
    We also need something similar to the UK’s NICE to just say no to very expensive, marginally beneficial treatments. If people want to pay for them out of pocket, they can.
    Finally, using health courts to settle medical disputes could bring more fairness and objectivity to the litigation system and, hopefully and over time, reduce the incidence of defensive medicine which needlessly drives up costs.

  68. “That’s why I still have my Canadian citizenship.”
    Fortunately or unfortunately.

  69. “Fortunately or unfortunately, the private sector won’t resolve this – not in my lifetime anyway.”
    That’s why I still have my Canadian citizenship.

  70. Why so difficult?
    I like most everything I read in your abc article including your conclusions – nice job, by the way. My ideas boil down to these three:
    First, there are so many competing solutions that none can gain support from the majority of influence-leaders all of whom tout their own solutions.
    Second, and as you and many others also point out, people make their living and institutions get their revenue from charges made to sick people who are insured. Reducing the public’s cost of health care means reducing these charges which means health care incomes must drop. Predictably, there is massive resistance. Besides, who wants a fight with their doctor over money? Fortunately or unfortunately, the private sector won’t resolve this – not in my lifetime anyway.
    Finally, how many libertarians does it take to change a light bulb? Only one – but you have to get him to show up. Advocacy for federal takeover of 15% of the US economy tends to galvanize resistance, not support. The libertarians show up in force, and they have many allies on this issue who show up with them. The government is simply not trusted, and I do not believe that any election will dissipate the mistrust. This country is so deeply polarized that I cannot imagine either a powerful president of either party, or a Congress that holds strong public opinion. Can you? Many factors not even related to health care contribute to this lack of public trust in government. That’s not all bad. But I think the public’s trust in government has eroded so signficantly over the past 40 years that the political power to achieve progress on health care will not be present in the foreseeable future, no matter who is elected.
    So I think we’re a long way from the end game, and for the time being can only continue to watch as marginal improvements evolve in the “system” that we have. That’s not a satisfactory answer for people who believe in action and that there is always an immediate action leading to a solution. However, I think it’s realistic.

  71. The solution to healthcare cost and quality are indeed very complex. Matt, I think that you have supplied a very good capsule of the ills of the system. I do know of some cases where the improvement of quality resulted in higher income. For instance, see the results for Mt. Sinai in New York City described in the June 22, 2006 Wall Stree Journal, “How a Hospital Stumbled Across an Rx for Medicaid.”