An advantage of being a foreigner, or a recent immigrant to be precise, is that it allows one to view events with a certain detachment. To analyze without the burden of love, hate or indifference for the Kennedys, the Clintons or the Bushes. To observe with both eyes open, rather than one eye looking at the events and the other looking at a utopian destination.
The most striking thing I’ve observed in the health care debate in the U.S. is the absence of an honest discussion of trade-offs.
I’ve found that the term “trade-off” carries a sinister connotation in American health care parlance. Its mere utterance is a defeatist’s surrender. If optimism is the iron core of the United States, acknowledging trade-offs is her kryptonite.
I was raised in Britain. I learnt to guard optimism with pursed lips. You never knew when it would rain. I also learnt in Britain’s NHS where health care resources really are finite, there is a trade-off between coverage and access.
In the discussions preceding the implementation of the Affordable Care Act (ACA) two disparate truths were conjoined by a single solution. The unsustainable trajectory of health care spending. And the large number of uninsured population. It was scarcely acknowledged that solution of these problems are inherently oppositional.
This has led to the search for utopian payment models. Fee for service incentivizes physicians towards generously reimbursable services of marginal benefits. Capitated systems dissuade physicians from taking sicker patients.
How about we pay for outcome, value and quality? Sounds simple enough.
There are trade-offs. Transaction costs are incurred in defining, ranking and measuring outcome, quality and value. There is rent seeking when stakeholders feel undervalued. Physicians may avoid sick, non-compliant or poor patients, caring for whom might be unfavorable to the metrics. Finally, there is Goodhart’s Law, well known in Britain’s NHS, which states that when a metric becomes a target it ceases to be a good measure.
We must tackle waste, we are told. There are few better example of waste than over utilization of diagnostic imaging. But we also want emergency physicians to never miss life-threatening conditions. Once again we face a trade-off, a dilemma.
If we don’t want to miss an impending heart attack in a young patient presenting with vague symptoms, in whom the chances of a heart attack are minuscule but not zero, many patients will need imaging to pick up that black swan. Because we don’t know who has an impending heart attack and who has heartburn, with certainty, before the event.
If we want zero misses there will be waste. If we want zero waste there will be misses. Choose.
We want to please the patients, the consumers. We want to reward physicians for satisfying patients. But then be prepared for unnecessary antibiotics. Let’s not bemoan antibiotic resistance. Patients often equate good care with intervention, whether antibiotics in a common cold or MRI for back pain.
We don’t want patients to wait too long for medical services. To achieve this we must build services that not only are optimally efficient but have redundancies built in to them. This costs.
We want systems to be efficient, uniform and have low marginal costs. That means consolidation, Cheesecake Factories. But we also want the Marcus Welby type of doctor, available within a canter; who is personable and very knowledgeable of us.
We now face another dilemma: uniformity or nuance.
We want Dr. Welby to have the latest electronic medical record, one that communicates with the Cheesecake Factory, but pay attention to us not the screen.
We want pharmaceutical companies to innovate, to innovate safely and to take it on the chin when they fail to be innovative. Yet when they succeed and place a price tag for both their success and failure (and cost of complying with the FDA) we balk at what we see.
Why would big pharma stay zealous about innovating if their pills are going to be sold at Walmart prices?
We want equality in health care. It hurts our sensibilities that someone might not have access to the latest treatment for hepatitis C just because life’s lottery placed them in a modest income bracket.
We must decide if we want MD Anderson-level care for all. That will cost. Or will we restrict care to ensure equality within a finite budget? That means rationing.
Equality means cost or rationing. Choose.
We want big data to do its magic with information. But we want our privacy to be guaranteed.
We want vendors for health information technology to be imaginative but also collaborative. That’s like asking Colonel Sanders to share his secret recipe with local restaurants and continue developing new recipes.
We want insurers to bargain with providers to bring the charges down. They can achieve that through narrow networks. But we want to retain choice.
We want trainee surgeons to be experienced when they operate on us. But never to be their first surgical candidate. How can they get to their 100th operation bypassing the first?
Halbig v. Burwell is fundamentally a tension of trade-offs. Subsidies do not arise out of magic but through taxes. Taxes reduce the chances that small businesses arise and grow.
Do we want more mandates and coverage and fewer jobs or more jobs and less coverage? Choose.
The biggest trade-off is between a constitutional republic, with all its checks and balances, and a centrally planned health care. The two are fundamentally incompatible. The future will yield many more convulsions. Many more Halbigs.
The optimism surrounding the ACA, summed up by President Obama’s promise, “if you like your doctor, you can keep your doctor,” gave many the impression, myself included, that health care reform can be Pareto optimal: a win-win for all.
Regrettably, trade-offs are a fact of life. Which means there are winners and losers. This is not unusual. But by not acknowledging the trade-offs we have created resentment in the losers, and widened the partisan chasm.
The partisanship, that sadly is all too typical of the health care debate, comprises the two wings of the trade-off. If we desire less polarization in our debates we must start acknowledging trade-offs.
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