Health Care Anew

I have never been a strong fan of the Accountable Care Act (a.k.a. Obamacare), but given all the circumstances I think it just as well that it was upheld. 

I thought that the cost issue was more important than the coverage issue and should have been addressed first but others, including wife Marilyn, failed to find my arguments persuasive.  So if we have to get the coverage issue out of the way before we can address cost, the sooner the better. 

As to mandatory health insurance, I was for it when Romney was for it and Obama was against it.  I continued to be for it after they switched sides.  Believing that we would never get single payer and that everyone would expect care when sick or injured, I have thought it only fair that everyone be required to contribute. 

As to the constitutionality, it was going to be a stretch however it was decided.  The authors of our constitution could scarcely have anticipated the day when health care would be considered a social entitlement like food, clothing, and shelter, when it would represent nearly a fifth of the economy, and when it would be financed largely by public and private insurance.  There is no way to know how they would have dealt with the question of whether those electing to remain uninsured should pay a penalty or a tax.  So eight of the Supremes voted their politics and the motives of the ninth remain obscure.

Anyway, the judicial phase of the challenge is now over and we can go on to the next one.

Healthcare IT 

The Healthcare IT boondoggle continues alive and well. 

On a recent visit to one of my medical specialists, I noted a sign asking me to have my insurance cards ready for reading into a new computer application.

The doctor and I have a friendly relationship so when he came into the examining room I mentioned the new application and, as I like to do in such cases, asked him what problem it was intended to solve. 

His immediate answer was “to satisfy the government.”  The small specialty group practice to which he belongs is now being penalized 1% by Medicare for not being computerized and the penalty rate is expected to go up.

He then, with some apparent emotion, said that the application cost a lot of money (though Medicare is reimbursing $40,000 of it), will make his practice less efficient, and affects patient care negatively in that the new method of communicating with other physicians is less flexible than the one it replaces. 

He mentioned that while one stated intent of computerizing medical records was to allow the sharing of medical information among providers, his new application was able to communicate with almost nobody.  Even other nearby providers using the same system could not communicate if it was a different version or if it had been modified, as many of them had. 

We agreed that the effort to automate medical records was like going from bicycles to space travel without bothering with cars and airplanes.  

And the amount of money being spent is prodigious.

For my alumni book group, I’m reading Thinking Fast and Slow by Nobel Laureate Daniel Kahneman, widely recognized as one of the important founders of what has come to be known as behavioral economics. 

In Kahneman’s Prospect Theory, people weigh losses more heavily than gains, so that they are to a greater extent affected psychologically by the loss of a hundred dollars than by a gain of the same amount.  

Prospect Theory has come to take an important place in the thinking of economists and it occurs to me that it also helps explain why health care reform is so difficult. 

Every reform has winners and losers and, as explained by Prospect Theory, the losers feel the effects more strongly than the winners. 

It is clear to me that the medical profession is the big loser in health care reform.  When my career in health care began in the 1950’s, doctors were the dominant force in everything medical.  Through the AMA and state and county medical societies, they controlled medical schools, medical licensure, state and local health departments, and, for all practical purposes, hospitals.  Until Medicare, it was almost impossible to enact a piece of legislation that organized medicine opposed. 

That level of influence has been diminishing gradually for some time and health care reform has brought it into steep decline.  The role of doctors as arbiters of quality has been taken over outcomes measurement, clinical protocols and other tools of the quality movement.  The growth of technology, the increasing complexity of the payment system, and other factors have strengthened the role of hospitals to the extent that they have largely supplanted the medical profession as the dominant force in the provider side of health care. 

The profession has largely lost its will to fight back, but society continues to hold doctors in high esteem and displays no desire to acknowledge their diminishing role, or even to talk about it.  There are various efforts under way to more effectively integrate the components of medical care and to establish accountability for outcomes, but none of them come right out and say that this means that doctors will be part of a system that they no longer control. 

It is an unusual application of Prospect Theory, but it seems to be no less real.

“Hope springs eternal” would make a good motto for the advocates of single payer (a.k.a. national health insurance).  A few days ago, I got a large, impressive looking envelope in the mail from Public Citizen, a Washington D.C. based advocacy organization.  It contained material inviting me to sign a petition to my U.S. Senators advocating single payer. 

The June 16 issue of The Boston Globe also had a letter or two urging single payer as the solution to our health care issues. 

Single payer may be a good idea and the people who so persistently urge its adoption are undoubtedly intelligent, sincere, and well-meaning, but I have news for them.  It isn’t going to happen. 

The reason is this:  Most of the politically active people in this country have health insurance and are satisfied with their coverage.  Given that we already spend too much for health care (if costs are too high, that means that expenditures are, too.) there is no conceivable program of national health insurance that would leave these people better off.  Some of them would be worse off, and, given the legendary American distrust of government, the rest are likely to fear that they might be, too.  

No politician skillful enough to earn election to national office would be likely to vote for anything having such a result.  An example has been provided by the Affordable Care Act (a.k.a. Obamacare).  It contains reform measures much less drastic than single payer and despite a number of provisions that have been well received, has proved to be less popular than the President might have hoped for.  

For over forty years now I have been predicting that we would not have national health insurance in the U.S.  I’m sticking with it.