Our side needed to win last night's vote on health care financing reform to stave off short-term political disaster. But now that we're past that hurdle, we can and must start on the real task, the long-term, real-world, task at hand, and come up with a plan to reform, not just how we pay for health care in this country, but how that care itself is delivered and managed. We need to do this because that plan we passed last night has no chance whatsoever of working, in any terms, because it does not even begin to address the causes of the health care financing crisis, much less the underlying problems of health care delivery itself.
The Dilemma
My point is not that we should or could have done things differently this past year, and that if we had only had the good sense to listen to that world-renowned expert, gtomkins, and follow his advice, we’d have a reform plan in law today that would actually work, politically and as policy. Even if we had followed my advice on what to support, and then actually managed to pass Single Payer this year, we would still need to be having this discussion the morning after the great victory. Single Payer solves only the insurance end of the financing problem, and we wouldn't have a fix even just for the financing half of the problem until and unless we take the next, politically more difficult step, and break up the cartels and monopolies within the health care delivery industry itself. And even that doesn't get at the even more difficult problem of the loss of rational control and oversight of medical care itself, that has led us in this country alone in the industrialized world, to have systemic and systematic overtreatment and maltreatment, at huge human as well as monetary costs.
It was inevitable that we should have started badly, as we have done. We pay more attention to monetary costs than human costs, this being the United States, the magic land where money talks and everything else walks, so the crisis of an out-of-control medical care non-system could only get our collective attention when the consequences of systematically bad, out-of-control medical care rolled all of the way down the line to out-of-control premium prices for health insurance. But, logically and practically, premium prices are the end of the line, the last consequence of problems far upstream, so, of course, any reform that responds to just this last consequence was going to be misguided at best. We didn't do Single Payer, the obvious political and policy winner, to address the insurance problem, precisely because doing that would solve this last step of the problem so completely that it would have left us clearly and squarely faced with the upstream problems. Single Payer, Medicare for All, would have been quite doable politically, much easier sledding to sell to the public than the opaque mess, that only an interested lobbyist or a deluded policy wonk could love, that we ended up with. But if we had done Single Payer, we would have had to, we would obviously and transparently had to, break up the provider cartels, most prominently Big Pharma and the hospital chains. That would not have been easy sledding.
Worse, had we done Single Payer, and wiped the board clear of the private insurance industry, this new, governmental, Single Payer would have inherited the industry's role, that it assumed in the Great Managed Care Revolution, as the manager, at least partial manager, of medical care itself. Yes, Rethuglican talking points about Death Panels and a "government takeover", of Medicare, no less, are obviously hypocritical demagoguery. But this line of attack has this quite real and honest point behind it, however hypocritically and fantastically exploited, that a Single Payer, however constituted, has to manage care from its commanding height atop the mountain of money that financs the whole enterprise. At the very least, it has to set prices. It could not, as Medicare does now, go with fee-for-service, and pay providers prices for their services based, at some remove at least, on market prices established by the industry, as that industry currently negotiates prices with providers, duns them lower to hold its costs down. The industry would be gone at that point. We could get by for a while on fiat pricing, just having the Single Payer extrapolate the prices it will pay from current market-derived prices. But, as medical care evolves, an evolution we certainly don't want to curtail, fiat prices will get ever more out of line with reality. We eventually would need the Single Payer to do what the industry does now, and negotiate prices, setting priorities for medical care itself, if only in its negotiating strategy with the providers. No, this isn't Death Panels, and insofar as it does involve the government taking over decisions the industry now makes, you could certainly argue that it's better to have public servants making these decisions than people who serve only the shareholder. But, at the end of the day, we are talking about the infamous Third Party, some bureaucrat somewhere, getting between the other two parties, patient and provider, and making decisions for them that they both think should be theirs alone to make. That's really, really, tough sledding to sell to anyone but the health care finance academics.
Of course, the downside of avoiding the actual problems, because they would be too difficult to address up front, is that what is politically doable within that constraint, simply won't work in the real world. Again, this is as true of the public option, however robust, as it is of this exchange concept in the plan passed last night. Neither would have any chance of actually controlling prices, or getting more people insured at reasonable, sustainable, costs. Neither would be able to withstand sabotage by the insurance industry cartel, aided and abetted by its brother cartels in the provider sector. Both reforms could only succeed in accelerating the price spiral, as the industry would simply acquire a new and more accommodating source of revenues, a rich Uncle Sugar to support its cartel pricing habits. Politically, both plans, by leaving most of the voters chained to the oars of industry insurance plans, would create so many hostages vitally interested in not having the government do anything to increase the insurers' costs, that there will never be the political will to actually enforce measures like the prohibition on price discrimination against pre-existing conditions, much less micromanaging the industry's operating expenses.
Think of this diary series as a sort of guide to what's coming down the road, a way to understand the pressure points created by a reform that so fatally compromised with short-term political needs that it will break up on the reefs over the next few months and years. The only way forward is to be ready to salvage what we can from the inevitable crack-ups, against the day when the outlines of the real problems become so clear to so many people, that we will be politically able to do something that will actually work in the real world. That's a touch-tap method of parking sort of empiricism, that probably seems a horribly loose-wrapped way to approach a matter of public policy as weighty as health care reform. But that's the world we live in. It is just that sort of empiricism, trial and error, with your health in the balance, that your physician has no choice but use, because, as poor and genuinely scary as it is to have your health depend on trial-and-error, it's the best method we have, in medicine, in health care policy -- in everything. Well, I should say that empiricism is what your physician relies on if he's a good physician, not too constrained so much by time pressure that he can't be honest and open with his patients about the severe limitations of medicine, and not some quack-by-necessity. These days, in this country with what the Republicans assure us is "the best health care in the world", admittedly you probably have to make do with quackery and not empiricism as the standard. Let's try to do somewhat better at the level of health care policy. Let's not be quacks who pretend to have firm answers where none are possible, who imagine that anything at all from last night's first stab at the problem will survive even five years into the future.
So as not to end this first installment on a pessimistic note, let me give a quick glimpse of the Good News, the light at the end of the long dark tunnels that both health care reform , and this diary series, will have to pass through.
The Good News
Having started with such a resolutely and uncompromisingly grim view of the staggering tasks ahead -- two much more difficult steps ahead, when we couldn't even manage the first step properly -- it's probably best to turn immediately to the good news. The crisis we're in, of low quality and high cost health care, is actually more manageable, more solvable, if you take it from the other end, the problem of low quality care.
No one wants one bit more of medical intervention than he or she absolutely needs. And medicine is such that the interventions it prescribes carry a monetary cost in very close relation to their human costs. Let's call that gtomkins 1st Law of Medical Economics: "Monetary costs of medical interventions vary directly with their human costs." Very few people would want open-heart surgery, there are very few people who will ever meet rational criteria for open-heart surgery, because it is a cure so terrible, with such high human costs, that it takes a really terrible disease to be worse than this cure. And it takes a disease, not only terrible in its severity, but which the intervention happens to actually make less terrible, to make the patient willing to proceed, for if there is not this match of means and ends, the patient is simply left with both the original terrible disease, and now a terrible cure that did nothing for the disease. This combination of severity of disease, and efficacy of some high-cost intervention is quite rare.
So, yes, the good news is that medical interventions ration themselves. When we get to the end of reform, if we do it right, we won't need anyone getting between the patient and whatever medical intervention he or she wants. We can rely on the self-interest of the patient, an interest of the strongest and most immediate variety, to minimize the human costs he or she must pay for medical interventions, and in doing that hold down the monetary costs. Doing too much, overtreatment, treatment even an iota beyond what is strictly indicated, is arguably the worst deficiency in quality possible, because it creates pain and suffering and death beyond what nature has imposed in the form of illness. Clearly it is the the worst quality problem our "best in the world" system suffers from, at least for that majority of us who have insurance.
The trick is getting the patient sufficiently in charge of his or her care, that the patient's strong interest in holding that care to the minimum necessary can be met, rather than have care decisions hijacked to serve the interests of others. That's the trick I'll take up tomorrow, when this series continues.