Matthew Holt

Two rules by which to judge a health reform bill

Right now we have sausage-making going on in DC and lots of uninformed opinions and outright lies being strewn across the front pages and on cable from newly declared experts. I sat in an airport last night and heard 5 Wall Street pundits spewing rubbish about health reform on one cable show. It even included an aging upper-class British twit declaring that government health care was more expensive than private systems. Clearly he’d managed to miss comparing the 8% of GDP his (and my) original homeland spends on health care versus the 17% we spend here. Later on CNN had 4 random people including Christine Hefner—yes one of those Hefners—talking about it. I suspect that if you know something about health care and your name’s not Michael Cannon you’re just not allowed on cable TV.

But all the hot air aside, even those of us in the punditocracy who know something about the subject matter (i.e. anyone reading THCB) seem to be so deep in the weeds that we have lost the basics about what we should be looking for from a health care bill. So it’s time to make that very clear, and here in my not so humble opinion are the rules by which to judge reform.

Rule 1 A health care reform bill needs to guarantee that no
one should find themselves unable to get care simply because they
cannot afford it. Neither should anyone find themselves financially
compromised (or worse) because they have received care.

Rule 2 A health care reform bill needs to limit the amount of
GDP that is going to health care to its current level, with an overall
aim of reducing the share of health care going to GDP.

Everything else (quality, safety, care integration, patient satisfaction, malpractice, primary care, etc) is about rule 7 onwards. Of course a good reform bill would fix all that too. But we have a bought & paid for Congress so we’re not getting that.

Incidentally I just read an interesting biography of Sidney Garfield, the MD who founded Kaiser Permanente. He made the point that once workers were paying into his pre-paid medical plans in southern California and Washington, then patients came in for preventative care that they had been putting off because they couldn’t afford it. Garfield was also—despite years of being accused of being a communist by the AMA—vehemently opposed to socialized medicine and thought pre-paid salaried group practice was the only logical alternative to it, in that it could cover everyone and in the long run do it cheaper because of its emphasis on long-term prevention. And he was more or less right.

Seventy years later the story is the same. We need to get everyone in the system, and figure out how to do it cheaper.

So when you look at the legislation coming out of Congress, it appears to be making a five-eighth's effort at Rule 1.

All of the bills seem to be improving access to freedom from ruinous costs for most people, and increasing costs in a trivial way. So although I’ve said that this reform seems to be trivial and small, it is in its small way potentially going to incrementally improve things.

Sadly it’s ignoring Rule 2, but Rule 1 is more important. Because when we get Rule 1 fixed, Rule 2 will eventually follow.