Tuesday, February 17, 2009

Our National Delusion

The lead editorial in the March 8 Sunday New York Times and the responding letters to the editor comprise a vivid illustration of our state of national delusion about health care reform.

The editorial mildly praises President Obama for his health care reform initiative and for his emphasizing both the cost and access issues. It then gently chides him for not being more specific about solutions for either one.

Of course, The New York Times doesn’t offer any solutions, either.

Then last Sunday the Times published five letters to the editor responding to the March 8 editorial.

The following are quotations from the letters and my comments:

Quotation: “….any plan that retains the private, multipayer insurance system that is the source of our out-of-control costs cannot possibly work.”

Comment: Insurance may be a source of cost, but it is not the source. The continually rising cost of providing services is more important.

Quotation: “The Congressional Budget Office has shown that a mandate to purchase insurance will not lead to universal coverage. It has shown, as well, that neither information technology nor chronic disease management nor comparative effectiveness analysis — all of which the administration is counting on — will significantly curb costs. Only a unified public plan, based on our successful experience with Medicare, can truly address the problems of the health care system.”

Comment: I agree with the first two sentences. I note that the third sentence does not specify how Medicare for all will fix the system.

Quotation: The “hard choices” called for in the editorial will include “….that quality of care and cost control are the prime responsibilities of the doctor, not the insurer or payer; that the doctor should be accountable for the desired indices and rewarded for their achievement.”

Comment: This quote comes from old (in both senses) friend Mitch Rabkin, long-time CEO of Beth Israel Hospital in Boston, now retired. Doctors play a key role, but only institutions – not individual physicians – can be effectively held accountable.

Quotation: “If we want to cut costs, we can eliminate the cumbersome bureaucracy of private insurance by turning to a single-payer system. If we want to help businesses like General Motors, single-payer would eliminate the cost of providing coverage for employees and retirees. And unlike the current system, single-payer would let patients choose their own doctors, instead of forcing them to pay extra for ‘out-of-network providers.’”

Comment: Eliminating the administrative cost of private insurance would be a one-time saving. It would not affect the underlying escalation in the cost of providing services. General Motors would be helped only if the extra taxes required to fund single payer were less than it now pays for insurance. Freedom of choice of physician is an important source of cost escalation. Requiring health insurance to pay whatever doctor the patient picks neutralizes the accountability called for by Rabkin.

Quotation: “If we want to have health care that is both universal and affordable, instead of letting people go without coverage or requiring them to buy insurance they can’t afford, a single-payer system is the only answer.”

Comment: Single payer is obviously a way to provide universal coverage, but it is by no means clear how it relates to the cost issue, other than for the one-time saving mentioned above.

Like everyone else, nobody wants to recognize that providers are the only ones that can get cost under control and that nobody, including The New York Times, has asked them to do so. Instead, they go merrily along spending the added revenue from the windfalls of Massachusetts-style health care reform programs, SCHIP expansion and stimulus appropriations, increasing cost still further as they do so.

Neither does anyone want to accept the truth that until we get the cost of health care under control, we can’t afford universal coverage.

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