The following is a reader take by S. Robert Snodgrass.
I want a better American healthcare system. I scan blogs for plans and wisdom, but I mostly find slogans. Paul Krugman’s columns, the Archimedes Movement and current proposals to repair the healthcare system frustrate me. They have different political philosophies, but each considers healthcare in isolation and repeats the same stale incantations.
Our political system is broken, with state and national legislators catering to special interest groups. They prefer slogans to priorities, because honest talk about money angers people. Consider that military costs consume more than half of our federal budget, crowding out spending for social needs. Why does Congress keep funding massive supplemental off-budget appropriations for Middle Eastern wars? They want us to believe that we can fight a war on the cheap, without the need to follow a budget.
The same applies to healthcare. Turn to Massachusetts, whose underfunded health plan began last July. Over 340,000 people are newly covered; 176,000 receive subsidized insurance – far more than expected. Another 55,000 are newly enrolled in Medicaid. The governor’s 2009 budget ignores these increased costs, looking for better healthcare on the cheap. A proposed tobacco tax increase may cover the deficit, but only if Massachusetts legislators don’t use it for other priorities.
A recent Boston Globe op-ed spoke of the plan as a “second Big Dig”- a well-intentioned, thoughtless financial disaster. The subsidized part of the plan will probably double in size and cost over the next few years. Only cost control and honest budgeting can save the Massachusetts plan. It’s more than blaming the drug companies. The op-ed recommended the old shibboleth of cost control by curbing frivolous lawsuits and railed against marketing bans or restrictions on pharmaceutical companies.
Can the program survive? Of course it can, but only if it is a priority for the voters and legislators. Collapse of the Massachusetts plan will derail national healthcare reform.
The failure of the pundits and politicians like Clinton, Krugman, or Obama to honestly discuss costs is disgraceful. Recently, the New York Times wrote about the need for more Massachusetts primary care doctors. This is true, but it considers the trees and not the forest. It doesn’t address costs.
Primary care should be at the center of the system, but it stumbles in our complex world unless networked to specialists. This means teams of providers with defined group responsibilities, communicating by secure email in an orderly manner, not playing phone tag. Most providers should belong to teams of specialists and primary care physicians. That’s not true today. A better system will cost more, not less. Preventive care reduces hospitalizations but it doesn’t save money.
We want premium healthcare for ourselves while we grudgingly offer generic care for others. To truly control costs, we must accept limits in order to do more for more people.
Without priorities and honest talk about budgets, healthcare reform is an empty slogan.
Like victory in Iraq.
S. Robert Snodgrass is a pediatric neurologist at Harbor-UCLA Medical Center.
Related posts:
- Dr. SSS: The two most expensive words in medicine
- ER visits and health care costs rise in Massachusetts due to lack of primary care access
- Single payer DOA in Connecticut
- Paying to remain uninsured
- My take: Preventive medicine, Rhode Island, C-sections
- Grand Rounds 5:1 – In Your Own Words
- Why not a down payment for primary care, and problems with the medical home?
{ 9 comments }
Yeah, socialist control freaks running healthcare. That’s the ticket. Works great in Zimbabwe and North Korea.
I can see what I want for a healthcare system, but I can’t see how to get there from here. My concepts wouldn’t be popular. Too many people would be out of jobs. And what I want is quite different from what the people I see in the ER want…Generic IS just fine for me.
So the slogans spout.
If we want to spend less money on healthcare, then cut the Medicare budget. Employers can stop offering insurance benefits. Costs will go down. But THAT isn’t REALLY what we want, we whine…And the politician avoids the difficult choice, like the doctor avoids the difficult discussion. About uncertainty, risk, responsibility…
And getting somewhere in political America requires compromise. Just like education of the ignorant requires listening to the student. Neither of which one has to do on ones blog…Here in cyberspace we can avoid responsibility to our colleagues and fellow citizens with ease. It’s those face to face discussions that are tough.
One big mistake – military spending is half of the discretionary portion of the budegt. This is itself less than half of the overall federal budget, meaning that military spending is about 20% of the overall federal budget.
And I would argue it needs to be mentioned that federal spending is a little more than half of overall government spending (if you consider state and local spending), meaning military spending is something like 14% of all government spending.
The idea that government social spending is crowded out by military spending is highly falacious. I would never argue that military spending is not highly wasteful, it is no used for often bad purposes, and it doesn’t subsidize the rest of the world; but it is important to not use misleading numbers.
S. Robert Snodgras:
Yes, yes and yes.
Not too long ago, I interviewed Dr Don Berwick, head of the Institute for HealthCare Improvement, and he expressed his concern that “the American public just isn’t mature enough” for the health reform we need.
And by “mature enough” he didn’t mean “old enough.”
It’s the emphasis on “me” rather than “we” which undermines the social solidarity needed for to create an affordable, sustainable, high quality health care system for everyone.
I think some reform-minded politician understand this. I pretty certain that Krugman does. But many are afraid to talk about costs and sacrifice because they fear that means giving ammunition to the conservatives who don’t want reform.
I don’t agree. I think we should pre-empt the conservatives by saying, yes, this will cost money. Their could be significant savings down the road if we reduce waste, refuse to be gouged, etc., but the savings will come in the medium to long-term, not up front.
And we need to acknowledge that while many Americans get too little healthcare, many are getting too much care int he form of unnecessary tests, operations, hospitalizations, over-priced medications, etc.
My husband just went to a new opthamalagist for a second opinion because we both had been feeling that our current doctor was too rushed, wasn’t paying attention etc.
Our old doctor had my husband scheduled for cataract operations in each eye–the first was supposed to take place a week ago. My husband just didn’t feel comfortable and cancelled.
He went to a new opthamalogist recommended by a doctor who I know, still assuming that he needed a cataract operation.
This second opthamalogist spent a long time examining him, and shocked my husband by saying no, he doesn’t need an operation at this time. . .
The vision in one eye is 20/20! In the other eye, it’s not as good, but still no need for the opeartion . . .
Returning to health reform, I’m not giving up. (And I’m certainly not suggesting that Berwick is either.)
The United States is one of the few if not the only country that allows medical insurance to be sold for profit.
And your point anon 7:29? We live in a capitalistic model do you think these insurance company’s are going to do this for free? If you want NHS then just say it. Otherwise your statement is totally meaningless.
Talking about truly fixing health care invites difficult conversations. It is not a surprise that policiticians steer clear of this. Sen. Clinton essentially admits in her “I have the scars to prove it” stump speech on health care that she pushed too hard the first time around. We want everybody to have everything and not cost too much, and this is simply impossible. Even if we had Medicare for all and incentives for doctors to go into/stay in primary care fields, the system would still be broken. Here are a few difficult conversations we need to have in order to fix health care:
1. Rationing. You can’t pay for everything. As an example, we spend a ridiculous amount of money on the first and last 30 days of life. When grandma goes into the ICU without much hope of any future viability, she is often kept alive for days because the family want to do “everything,” sometimes even if that isn’t what grandma would have wanted. And if you think pulling the plug (or saying insurance won’t pay to keep the plug in) on grandma is a tough one for our country, try the 1 pound, drug addicted, preemie that will stay in the NICU for months, with a high probability of problems down the road. Based on our country’s division on abortion, we are just not ready for this one. Ironically, we already have rationing, it is just irrational rationing.
2. Tiered health care. We would like health care to be a right, but it is currently a business. With retainer medicine growing, tiered medicine will continue without a public debate. Currently our education system is tiered, and though there are issues (lack of resources for inner city schools, falling behind compared to other countries), as a country we don’t seem to have a problem with it. We would need to decide what basic health care rights are guaranteed for all, and if you want more, it’s going to have to be out of pocket. As above, we currently have a tiered system: the insured who are both rich and poor, and those without insurance.
3. Changing our unhealthy ways. Though technology (new drugs, new tests, new procedures) is likely the biggest driver for rising health care costs, our country’s lifestyle and the chronic diseases it leads to (diabetes, emphysema, cardiovascular disease) is also a major player. We literally want to have our cake and eat it too. Solutions need to be both societal and individual. Is our country ready for a junk food tax? Are we ready to say that if you are overweight, you need to pay more towards health care? Are we ready to look at and eventually spend money on infrastructure that allow people to exericse and eat healthier?
Anon 7:29 PM
The United States is one of the few if not the only country that allows medical insurance to be sold for profit.
That’s just plain not true. Health insurance is sold privately, by for profit insurance companies, all over the world.
Fortis is just one example.
Dr. Mintz — your #3 is not true. There’s pretty good data coming out that diabetes, obesity and smoking (for example) costs a lot of money up front but actually saves money overall because people are boxing before they end up with Alzheimer’s in a nursing home. For just one study see http://medicine.plosjournals.org/perlserv/?request=get-document&doi=10.1371%2Fjournal.pmed.0050029&ct=1
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