Photo credit: www.rossink.com
I must get the team who made Obamaville to film this story of intrusive government and spunky citizens yearning and fighting for an equitable, all-American healthcare system.
Then again, if I want truth, I better try writing it myself. So here goes. In the prequel, I wrote how some board in the Obama administration (set up by ACA) had mandated contraceptive coverage in employee health insurance policies. There ensued a long discussion on health insurance, which I will try to summarize without introducing too many inaccuracies, and throw in some additional points too.
Homework Problem Set--Solve the issues in bold
The American healthcare system suffers from the problem of 'other people's money,' which is the opposite of self-pay or 'skin-in-the-game.'Interests are not always aligned. Your doctor may, or may not, have your health as his top interest. You may not have your health as your top interest. Your insurance company may not have your health as its top interest.
There's an absence of knowledge of what procedures you need, how much they cost here versus elsewhere, and whether they are cost-effective. Defining 'cost-effective' as it pertains to healthcare is difficult because it's hard to cost all the concerns--the cost of the procedure, the risk to life or disability if you don't have the procedure, what to do if you don't have the money for a life-saving treating, etc.
The situation with cost-efficiency is the same as interest alignment. The doctor probably doesn't have cost-efficiency as a top interest --he doesn't know what procedures or medicines cost, but that's not surprising considering the multiplicity of insurance plans. The doctor may also have a financial interest in ordering more tests. Patients aren't concerned with cost-efficiency when they're spending other people's money either. Insurance companies aren't even cost-efficient because they pass costs on to employers. Employers don't demand cost-efficiency because there are a limited number of health insurance providers and many follow current defacto standards of care that aren't cost-efficient.
If consumers, when they pay directly, can impose cost-efficiency, they may also take undue risks by not getting the medical care they should have. Who is good at evaluating risk? Laymen generally aren't. But even professional panels evaluating risks may put too high or too low a value on lives lost, the pain of treatment at an advanced stage, inconvenience, and anxiety caused by false positives. (Case in point, the panel recommending changes to mammography frequency.)
Ideally we'd like to have a system where cost-efficiency is built in, through competition or some other mechanism. However, if that's not possible, should we impose cost containment by fiat? Lower reimbursements and best practices standards can contain costs if the doctors don't or can't rebel. However, these measures can also inhibit doctors from accepting patients from underpaying groups and inhibit extra care that a doctor deems necessary.
One new issue that I've noticed: the temptation to design a healthcare system that works selfishly for 'me' but is ineffective for other major groups. Healthcare is not one-size-fits-all. Certain populations are harder to fit into traditional commercial relationships, such as the elderly, the poor, the undereducated, and the chronically ill. A system that doesn't address those needs will be acceptable to fewer people.
Finally, how will the mass of people afford healthcare if we don't have someone else paying for it? This is a frightening prospect that fuels a huge wall of resistance to healthcare reform.
Answer Key. . . in your dreams
Just to recap, these are the issues we must thread to solve our healthcare problems:- Other people's money
- Interest alignment
- Absence of knowledge
- Cost-efficiency
- Undue risks
- Cost containment
- Me (selfishness)
- Elderly, poor, undereducated, chronically ill
- Resistance to healthcare reform
Chart by Kaiser, solution by ??
Update 4/4/12. A national news story on recommendations by doctors' groups on cutting the number of procedures. A first step in the right direction. Stories: Washington Post Health, WaPo wonkblog, MD newsletter, organization website.
1 comment:
Well, I think you are right. One important quibble to everything you have said, however, is that "Massive resistance to Healthcare Reform" is, in effect,the trump card that can sweep away all other factors. Even if one could address all 8 other factors (and really no proposal does), until the ninth is changed we are engaged in a Sysyphean task.
Most likely it is going to take a rather marked change in public opinion to reach any kind of workable solution to our problems. Too bad, but what can you do?
We are in a very difficult trap. The problems we have are serious and systemic -- which is to say that they won't yield to minor tinkering or piecemeal approaches (and such attempts may very well make them worse). Unfortunately, systemic solutions are frightening, which scares the public, which means problems get worse, which means that systemic solutions become all the more necessary. It's all very sad.
Should the ACA fall (and I think that is very likely, judging by oral arguments) then I guess we will just have to let the public sort it out in their own minds. The SCOTUS is, after all, only siding with the large majority of the public. That is, I think, bad policy, but once again, what can you do?
Other systems, be they Canadian or British or Swiss or Hong Kong or whatever, have managed to achieve stability in large part because they have electorates and policy elites that have jointly bought into them and give them solid majority approval. Do we have anything that does that (or shows promise of doing that)? The present system -- no. The ACA -- no. Libertarian solutions (i.e. use of an individual market perhaps with major Medicare reform and repeal of the care mandates for Emergency Rooms) -- no. Single payer -- no. HSAs -- no. High deductable catastrophic plans -- no. Tort reform and national insurance market -- no.
The electorate simply shows no ability to coalesce around a solution or set of solutions that might actually make a difference. Until that happens, until the ninth factor dissappears, then mostly likely trying to deal with the other eight is only a parlor game.
Very well then. As Ed Koch said, the public has made up its mind (or refuses to make up its mind in this case), and the public must now be punished until it comes to its senses. When enough people decide that they want these problems solved they will be solved. Until then, probably not.
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