February 28, 2013 -- Posing this question to healthcare thought leaders, they often reject the question, as “too negative.” Is this a form of denial or lack of interest in sensitive critical thinking? A setup for extremely narrow definitions of the problem: irresponsible patients (fix that!), profit-making insurance companies (fix that!), a system that is not a system (whatever that means), and shifting the blame? Can we fix a system without having a clear eyed appreciation for what makes it unfixable? With apologies to all committed optimists!
We have been committed to incremental health reform for decades without the burden of a quality definition of the problem or measurable standards of expected results. (If you don’t measure it, you will never know when you get there!) -- the more ideological (left or right) the more the aversion to prospectively stated measurements or proof of concept. Ideology is the default safe harbor for all, euphemistically referred to as “values”.... “My values are more moral and right than yours. “
One of our great historical leaders was Benjamin Franklin, who was known to avoid expressing personal opinions, rather favoring the positioning of contentious discussions around questions -- made him a “friend and nice man to all” as he rarely disagreed openly with anyone. Perhaps health reform should be more focused on the questions that need asking?
What are the questions ? (Add your own)
1. Can an entitlement culture that wants healthcare to be “free” to the user, with limited third party intervention, and a free will relationship between user and supplier, succeed? Effectively a financing system provided by “other people’s money.” Is private enterprise and the profit motive, the solution, or at the core of the problem driving healthcare sustainability?
2. What constitutes an adequate problem definition as it applies to healthcare in the United States? Is incrementalism a solution, method of execution, or the consequence of an inadequate problem definition?
3. Is our government, so hopelessly compromised with its own political and bureaucratic self-interest that it cannot articulate a sustainable solution without meeting its interests first? Must some greater authority be in charge to make the unpleasant decisions? Should the public dollars allocated to healthcare compete with the public dollars of other market segments? (Education, Transportation, Security, etc.)
4. Should personal means allow for access to health services not available to all? What role should choice, self-determination and personal responsibility play in the provision and access to healthcare services? Should high risk, high deductible insurance be disqualified as allowable? Do we want an all powerful state or federal government to displace private insurers?
5. Is the problem so complex that it must be broken down into smaller parts and changed incrementally, in an order satisfying to various advocates....easy and nice first, tough stuff later or never? Is a comprehensively stated plan for reform simply “unrealistic?”
6. Should responsibility and authority run consistently? If providers, insurers, or patients are respectively the most responsible for the system’s performance, should their authority follow those same lines? Who do we want to be held “most responsible” (and therefore have the most authority) for system performance? Does the concentration of power, indeed corrupt?
7. Does the advocated right to healthcare include the right to personal immunity from “money considerations?” Should providers be made to compete on “apples to apples” price? Or is that too abusive to individual rights? Do the incomes of those employed by the healthcare industry need to be regulated? The least effective providers disenfranchised?
8. Do we need a culture that advocates more dependence or independence? More or less reliance on insurance? Should tax and health policy encourage personal savings for future health care expense?
9. Does the pitfall of “moral hazard” (Good intentions worsening the problem) deserve consideration as a caution? Are there any limits to what the “haves” owe the “have not’s” in the context of health as a right?
10. If we are in search of more control and influence over demand for healthcare services, should there be a symmetrical commitment of controls over provider supply? Can we assume that if we reduced demand as a result of weight loss as an example, system costs will decline, as Dr. Oz postulates? Savings from corrective actions are linear and do not precipitate offsetting responses within the system?
11. Are anticipated savings from intuitive solutions speculative enough that experimentation, proof of concept, independent evaluation, morally and ethically required? Or do we just go with well-meaning as adequate justification?
12. If there are two dominant ideologies (left and right) governing healthcare, can a sustainable solution be implemented without those ideologies “making an explicit deal”?
Maybe health reform needs to consider two side by side systems founded in the ideologies of the right and left as contrasting alternatives that just will never come to terms with each other?
Stephen Gregg is a retired hospital administrator and managed care executive and can be reached here.
