Health Care Reform Triangulation

Today on the front page of the NY Times was a feature article about an effort by health insurance companies to offer more restricted plans for less money. As consumers we are silent bystanders to these negotiations, since the insurers deal mostly with employers. Companies large and small are struggling with the cost of providing health insurance for their workers. These newer insurance products present lower costs, or at least lower increases in cost in exchange for offering companies (and workers) fewer choices.

One of the selling points repeated loudly and often by the President was that with the health care reform package no one would lose their insurance; they could keep the coverage they had or opt into something better. The President was right to a degree. The government won't force these decisions, but the health care market is spiraling out of control; this would have been true even if Obama had never uttered the words "health care reform." Our current system is unsustainable. No segment of society, not government, not corporations, not individuals (except the very wealthy) will be able to afford our health care system going forward. This is not even addressing the serious failures of our system in protecting and promoting health. We have a lousy system now, but we can't afford it much longer. Though much maligned by Obama’s opponents, the European systems are wildly popular with their citizens, less costly, and get better results.

As the Times article illustrates, many people may lose their current health insurance plans, not because of health care reform, but because employers can no longer afford plans we've taken for granted in the past. This would be true even if Obama had never come on the scene.

The focal point of what we value can be visualized by a triangle, with cost, access, and choice at the points. Up until now, choice has been in the ascendancy. Americans want to choose their doctors, their drugs, their hospital. Of course most consumers' choices in this regard are not guided by evidence of value. Data to guide these choices has not been available, and so we are persuaded by marketing ploys and superficial indicators. This is beginning to change, but slowly.

The primary driver of this year's health care reform legislation has been to increase access, bringing in the 40 million Americans with no health insurance, and therefore no choice except emergency room medicine. While universal access is a worthy goal, and something demanded by social justice, it will increase cost unless adjustments are made elsewhere in the system. If we want to increase access without increasing cost, we have to limit choice.

Some of the most vocal opponents of the health care reform proposals which passed this year claim that we will have to ration care. What they really mean is "I have good care now, and don't want to sacrifice so that those shut out of the system can be served." Of course we ration now, but those excluded, by and large, have no voice in the political system. In order to hold down cost while maintaining choice, we limit access.

Researchers at Dartmouth Medical School have clearly shown that unlimited access is not really a good thing. Not only does it drive up cost, it also drives up waste. Those researchers (Google Dartmouth Atlas) estimate that somewhere in the neighborhood of $700 billion per year is wasted. This expense might enrich providers, but does nothing for individual or public health. This represents a fourth to a third of the nation's health care expense. Costs come from duplication of services, or providing services which do not benefit patients. In other words, we are victims of inefficiency and gaming the system, charging for things that shouldn't be provided in the first place. This latter practice is so common it is a standard of care in some places. It is theft in plain sight.

It is clear that there is much to be done to reach the potential we have as a nation, finding a better balance between the best of open markets and private enterprise and being sure that health protection and promotion is the goal, not just a business plan.