Fostering an adult conversation about health reform

Zeke Emanuel and Shannon Brownlee have an op-ed in Sunday’s Washington Post that should be required reading for anyone interested in health care reform.

The title is, “5 Myths About Our Ailing Health Care System.”

They suggest the “5 Myths” are:

  1. America has the best health care in the world.
  2. Somebody else is paying for your health insurance.
  3. We would save a lot if we could cut the administrative waste of private insurance.
  4. Health-care reform is going to cost a bundle.
  5. Americans aren’t ready for a major overhaul of the health–care system.

At one level I can disagree with many of their points and at another I can agree with all of them — but they are right on all counts.

For example, as I have argued on this blog before, Americans are nowhere near ready enough for health care reform because most in the middle class who vote have good health insurance paid for by their employer.

As a result, voters don’t have a big reason for change in this regard—no matter the real costs of health care. But, as the authors point out, our people are in fact paying for their health care through lower wages and higher taxes.

What Emanuel and Brownlee are doing is having the kind of adult conversation with the public that our national leadership really needs to have in order to be able to build the necessary underlying consensus for health care change.

Without that kind of conversation, continuing with the same example, our people will never understand that the employer support for their health insurance costs they are enjoying is in fact illusionary. Until that, and so many of these other points are broadly understood, we will never have the consensus we will need for successful reform—getting it passed or doing it right.

Our health care access problems are symptoms of the real problems—uncontrolled costs and inadequate quality.

Today in Washington, most of the political discussion is heading toward a big expensive comprehensive Massachusetts-like package that really wouldn’t change anything, would probably make underlying costs worse, and would likely not even pass—falling of its own weight before the year is over. But the current effort does address many of the superficial political problems our health care system presents—particularly on access—while more often only giving cursory attention to the underlying cost and quality issues that are driving the access problem in the first place.

To build the kind of broad public consensus for the health care change we really need, it will be important to build a solid foundation that addresses the more politically problematic cost and quality issues as a priority at least equal to the access challenge.

To build that foundation, our leaders need to start addressing these more problematic challenges. They need to do that with facts, get beyond the simplistic myth-filled discussion we are used to that often drives the debate, and take the time to build the consensus required for any real reform.

We don’t have time? We are about to waste 2009 and have little or nothing to show for it at the rate we are going.

As the authors put it, "Now is not the time to think small, to cover a few million Americans and leave the bigger job of controlling costs and improving quality for another day."

Now if we could just figure out a way to get Zeke an audience with the new administration…

Robert Laszewski is a long-time Washington health policy insider. He writes the nonpartisan blog, Health Policy Marketplace & Review, where this post first appeared.

8 replies »

  1. Thank you very much for this valuable and important post. This is the type of post we are looking for our post. It provides information and education regarding health care to us. So once again thanks for this fabulous post.

  2. I am glad to see Dr. Emmanuel getting a broader audience. His book – Healthcare, Guaranteed – was outstanding.
    I was really dismayed during the recent election campaign to hear both candidate spouting dumbed-down nonsense about healthcare reform (although at the end of the day I felt better realizing that their proposals were both so stupid that neither would ever be enacted).
    I think that it’s important to keep the debate going, and keep getting these ideas out there.

  3. jd – The biggest downside to that approach is the fact that you would be increasing access to a system that is costly and does not have the primary care capacity (or morale) to handle it. It sounds too much like a political “workaround”. We shouldn’t dance around our problems because that will only cost the taxpayers more money. Obama needs to show that he has a backbone to make the tough decisions, which will cause those that profited from our broken system to give something back. If we do it any other way, we are using a broken political system to fix a broken healthcare system.

  4. in social terms, health calamity is the experience of relatively few of us. Health inconvenience is far more common. Current healthcare delivery modes too often treat conditions generating the latter as if they were the former, for a variety of reasons. That practice almost ensures that more of the former types of events occur than might otherwise.
    Because inconvenience affects so many – unlike calamity, which “happens to others” – broad swaths of the populace can be enlisted in support of reducing healthcare inconvenience (the inconvenience of routine checkups, innoculations, etc). If adroitly coupled with steps to broaden access, broad swaths of people begin to get the ‘habit’ of preferring convenient, effective, proactive health care, avoiding greater #s of calamities, which should motivate those in the calamity-amelioration business to remodel their activities too.
    As jd notes, much of healthcare reform resembles the organization & execution of a military retreat, the hardest of martial maneuvers. Any path is hard; at very least maybe we can reduce the extent it inconveniences us all.

  5. As a matter of policy, I agree with Mr. Laszewski that we need a cold, blunt assessment of our problems and we need a comprehensive solution that solves the cost/quality riddle. As a matter of politics: fat chance we’re getting that now.
    The recession certainly makes it easier to get some concessions in the way of value-based payment, or lowering specialist incomes to improve primary care incomes, etc. But I see no indication that we can do anything that really makes a big dent in the price of care in the next two years.
    Reforming the system to generate lower costs means wrenching changes in how millions of people do their jobs. It means lower pay for people and institutions that collectively have over 2 trillion in income. It may mean a lot of people lose their jobs due to greater efficiencies, and these people work for organizations that are among the largest and best paying in their communities. How many Congressfolk have hospitals among the largest employers in their districts? Almost all.
    For all these reasons, I don’t think we can even freeze costs at the current levels. The best we can hope for in 2009 and 2010 is to keep growth in costs in line with overall economic growth and inflation, and even that will take several significant and hard fought reforms to the payment system.
    Part of the reason I am so convinced of this is that I watched Eliot Spitzer, when he was at the peak of his power and good-will among New Yorkers, get absolutely flayed by the hospitals and SEIU when he proposed cuts to reimbursements. It may be hard to remember now, but this was in the days when Spitzer was calling himself the M-F’in steamroller….and it was like the steamroller ran into an avalanche.
    Physicians and hospitals still find it very easy to mobilize public opinion. All that pharma, device manufacturers and insurance have to throw around is money and the ability to play off of the Republicans’ sense of ideology and self-preservation. Physicians and hospitals also have money, but they can present themselves as on the side of the little guy to win not just sympathy but righteous anger in opposition to cuts.
    To repeat: it is a bad strategy to try to fundamentally reform the delivery and reimbursement of care at the same time you expand the access to care to cover all. You can reach a majority for the latter if you do not push too hard on the former. Do not try to fight all your enemies at once. In fact, far better to get AMA, AHA and AHIP on your side for universal care legislation that isn’t very good on cost/quality grounds, then turn around and go after some of the sacred cows of each in turn.
    Once you have universal health care, it is locked in. No one is going to take that away and the focus instead will be how to pay for it, just as is happening now in Massachusetts. More free-market Republicans will begin to turn their attention away from defending the bloated delivery system (we’re the best in the world! Government cost controls just make it worse!) to criticizing it (how wasteful!). More liberals will turn their attention away from universal health care (we got it!) to reducing the costs of bloated corporations. I do not think it is an accident that this excellent article appeared in the Boston Globe recently. And don’t be surprised if $500,000 surgeon salaries become a lot less invisible to the public, whether left, right or center. Once tax dollars are seen as propping up more of the system, the average Joe (Joe the Taxpayer!) will become more conscious of the expense….especially in the first few years.
    But none of that change of focus happens quickly if you don’t get universal health care first.
    Even with a change of focus, reforming the delivery system is not likely to be quick or clean. It’s going to occur over many iterations as consensus builds over various parts of the problem. I would expect Obama to still be working at it in the 6th and 7th years of his presidency, and the work would continue on into the next administration, because it must. In contrast, universal healthcare can and should come quickly. Just get it over with, even if you have to put up with a clunky mixed model that is partly employer-based, partly an individual market with an insurance exchange, and partly government-run health plans. You can always streamline later. We need to look at universal healthcare in 2009 as the starting point of a better system.
    A lot of smart people disagree with me. There may be good reasons why they are paid to opine and advise about health care policy while I am not.

  6. I agree that we are “paying” for our health insurance. The problem is, someone else is “purchasing” it so we don’t know we’re paying for it. That’s the same as someone else paying for it and it’s providing the “insulation” many of us are talking about.
    You’re speaking my language when you talk about addressing the real cost drivers instead of focusing on covering all citizens and reducing insurance company waste.

  7. Given that Zeke is Rahm Emanuel’s brother, my guess is that his thinking has an audience in the Obama administration.

  8. 10-21-2008 Health Care by: Everyone who has been to a doctor in the last year. The most important economic issue of 2008
    To paraphrase Senator McCain, the loose tax dollars in Washington DC have turned good statesmen into corrupt politicians. But, his statement is just the tip of the iceberg. Not only has it turned good statesman into corrupt politicians, but it has turned kind and caring doctors into parasitical thieves. Money is not the root of all evil, but the Love of money is the basis of most corruption. In years past, if you found a man hanging from the edge of a cliff and you made him give you his wallet before pulling him to safety, you would be considered a thief! Today in order to get medical help you must give your insurance card and sign away everything you own or will ever earn in the future, to pay for medical costs not covered by insurance. We can set term limits on politicians to reduce their power holds, we can give the President the line item veto to reduce kick backs through ear marks and we can change campaign finance laws to cut down the bribery of our politicians. But solving the National Health Care Problem will be more difficult. The trick is to maintain the diversity of cutting edge free enterprise while at the same time maintaining an affordable universal health care program available to everyone. Let’s look at the present system while considering some possible solutions.
    National Health Care –Medicare and Medicaid were set up by taxing the general population to pay for the health care of those citizens that could not afford their own health care, the problem was that the program did not control what the Doctors and Hospital would charge and medical costs inflated at a geometric pace. Greed is a driving force of inflationary medical costs and the government soon found that it could not raise taxes fast enough to satisfy the greed of the doctors and hospitals. Without competition and the government paying the bills, the problem was out of control. The government put in place caps and tried to promote supplemental insurance to cover the difference in the doctor’s charges and the government’s ability to pay. In order to appease the doctors, the caps were partly based on what was usually and customarily charged by the doctors. Doctors are not dumb or at least I would hope not, they soon realized that by charging a higher rate to everyone even if they never saw a dime from some of the poorer people the next year the government limits would raise based on what they usually and customarily charged. Anything they lost from uncollectable charges would soon be made up for by increased government payments.
    We now understand that the rising average charge of what is usual and customary, driven by the greed of doctors and hospital is the major cause of rising hospital cost. But compounding the problem is the high cost of medical insurance for malpractice. Any National Health Care Program will have to address both inflationary factors, so let’s take a look at a possible solution.
    First in order to control the wages of the medical staff, the government would pay for the education of any students qualifying for medical or nursing school. These graduating students would then serve in the military as doctors and nurses for a period of 15-20 years at which time they could stay or go into private practice. This would leave freedom of choice for the patient, free health care to the general public, government control for planning and organizing the health care side of home land security. At the same time forces private doctors and hospitals to be competitive by attempting to give better service than can be provided by the government hospitals at an affordable rate. The government would still pay for Medicare and Medicaid costs but instead of going directly to the hospitals and doctors it would go back into the health care fund and the doctors and hospital staff would be paid the same as any other military medical staff. This way the general public would only need a supplemental insurance and they could choose a government hospital or a private hospital just like vouchers for a private school or public schools. This would also allow the time for the government to implement a nationwide health care program without a noticeable disruption of health care services to the public.
    Second where would all these new doctors practice? I would start by placing them in the many local County Hospital all over the nation. These county hospitals would serve both the public and veterans. Using county hospitals would save veterans from traveling long distances to find a VA Hospital and it would insure the survival of many local hospitals, most of which are having financial problems and staffing problems because they cannot afford the doctors and the insurance. This brings us to the second main inflationary force of medical malpractice Insurance.
    A cap must be placed on medical liability insurance. That cap should be similar to a person on social security disability from the government at the present time. To be quite frank, I do not believe any civilian accident that is truly unintentional should ever be awarded a higher settlement than what is given to our men and women in the military service. If doctors are truly incompetent, they should be barred from practicing medicine. If doctors are criminal in nature, they should be prosecuted in the criminal judicial system. Paying out multimillion dollar settlements and then having the insurance companies charge high insurance rate to protect against such loses, is similar to the mob sending out a thief to rob several stores and then to send out an extortionist to collect protection fees. In this scenario the thief would be the lawyers and the extortionist would be the insurance companies. Lawyers and insurance companies are a necessary part of our society, but I feel that to make an entire nation pay extortion fees so that a few individuals can become overnight millionaires is just wrong!
    Both parties talk about how to pay for the insurance to pay the extravagant charges of the Doctors and Hospitals. But neither addresses the true problem of how to control the costs. Pick a state like Iowa and do a trial run, if it works expand the system nationwide. I am normally against socialized programs except when it concerns national security such as the military, transportation through our road system, and in this case the health of our country. But if you notice, I have left room for competition between private health and public health just like there is room for both public and private education.
    If you have a better idea please put it on the internet, if you like my idea please let others know. If you like parts of my ideas, but can improve on other parts make the changes and pass it on. I am not looking for this to be a final draft; I am looking for an answer to the inflationary health costs. Let’s start a movement and put pressure on congress and the senate.

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