HC Reform - End Game or Last Hurrah? Dysfunctional Sausage-Making
Well we're definitely playing the end game for Healthcare Reform, after trying every generation or
so since at least the time of Truman, if not Teddy Roosevelt. Ironically the Western World's first comprehensive health reform was conceived and passed by the Iron Chancellor, Furst Otto von Bismarck. Ironic, isn't it? The Last Hurrah by Edwin O'Connor is one of the great political novels and is based on the life and times of one of the last great Boston Irish-American politicians. Whether this is "just" an endgame and we'll try again or it is indeed a last hurrah is TBD but the way to bet is the latter. Either we pass it or we won't see it come again. Unfortunately we no longer have any runway to maneuver with either. By the time another generation has passed insurance will no longer be affordable, most people won't have it and the public finances will be in real shambles. Worse yet almost everything you've heard about problems with it is largely false-to-fact and represents a deliberate political distortion. Largely undertaken for partisan political advantage hiding behind a facade of concern.
So as we move into the endgame that may be more we thought we'd take one more shot at trying to level-set the playing field and explain what's going on here. Starting with the realities of cost, performance and value. This composite of two charts is taken from a study by the McKinsey Global Institute and confirms a lot of what a lot of folks have been saying all along. First off healthcare in the US is more expensive by far than in any other developed country. Secondly, our results are NOT at the forefront on standard measures of effectiveness. That shibbolethic statement that America has the best healthcare is just flat not true when you look at overall results for most of the population, which is IOHO the only valid measurement. It is true that for very advanced treatments at great expense American capabilities are the best in the world and for the 1% who might need them and the .01% who can afford those treatments more power to you. For the rest of us what this tells us is that we should be spending about 1/2 what we spend and getting about 2X better performance.
The Economic Impact: Private Insurance
Of course that's not the only problem either. Kaiser did a study late last year that looked at trends and consequences in Health Insurance costs, as anybody who's facing surging premiums should now be aware. Costs have been racing ahead of inflation by huge margins over the last decade and, as a result, family coverage has ballooned to almost $14K/year. There's nothing slowing any of that down either so it's no surprise that the estimate is that over the next ten years annual costs are estimate to near $30K/year for family coverage.
Does anybody think that's affordable? Better yet does anybody think it's affordable now? Certainly not business which is busy lopping off coverage for retirees and reducing coverage for current employees. The part where we can keep deferring these issues for future debates is over. The great bye and bye where rising HC costs become 50% of GDP and bankrupt the country is still a ways away but the part where everybody's choking to death in the dark because they can't afford coverage is here now.
The Economic Impact: Alternative Misfeasances
Like we, and many others, have said. We can't keep deferring this, if we don't resolve us it's going to kill us shortly and by avoiding coming to gripes with it it's already damaged the economy, the individual and the competitiveness of small and large businesses. In fact it's one of the great ironies of this whole debate that the strongest supporters of reform should be business but instead they're looking at short-term impacts and, strangely for supposedly rational and analytical folks, not doing their homework.
Reviewing some more old and new evidence in this last decade incomes were stagnant because of healthcare costs. Yet (on the bottom) when you look at it we're well on our way to "socialized" medicine - the government already pays 50% of per capita spending and that'll go up as all these other trends play out. But the most important part of this whole chart is the UR corner - take a real good luck. NONE of this had to happen if we hadn't indulged ourselves in political gamesmanship and special interest pandering, absolutely none of it. And the LL corner reinforces the point - too many other countries are spending less for more by taking different approaches (and for the record many of them are as or more "market--oriented" as is the US Switzerland or Germany, or even Japan, for example). Frankly the chart suggests to us that we set a "concerted national goal" of reducing spending to ~10% of GDP AND improving overall performance in the next two decades. Think what that would do for freeing up l.t. debt, funding for Education, Energy, or Infrastructure, investment in new industries, corporate profitability or the ability of small businesses to hire and create new jobs! It continues to amaze us that all of this has gotten shunted aside.
What the Existing Proposals Actually Accomplish
To reach that end state our fundamental requirement is to figure out how to slow, then reduce and perhaps eventually reverse, the growth of health costs. We're truly headed for the edge of a cliff otherwise and we're headed for that cliff because of the dysfunctional dynamics of a system that encourages over-consumption of health resources and a political system that allows special interest groups to protect those dysfunctions to create rents for themselves, instead of value for the rest of us. One of the great myths going around is that the current proposals don't control costs. That has two major flaws. First off it takes all the necessary steps that we need to get started AND that we know how to do. As somebody keeps pointing out this is 17% and growing of the US economy (2X what it should be) and you don't change it on a dime. Especially when we don't actually know exactly what works or how to scale it up across an entire continental economy.
But what we do know how to do is done. All previous debates have largely concentrated on expanding coverage as a matter of social justice. This is the first one where cost control was as much a part of the discussion from the get-go as coverage (NB: and a universal national program was off the table from the beginning). That's actually the first step in controlling costs, not just fairness, because you need the largest possible population to spread total costs across and reduce rates. That's a bedrock part of the proposals. It also feeds forward to a critical important feedback that is created by the combination of exchanges and reimbursement standards.
The biggest problems we've got are that all the incentives are to maximize consumption of healthcare because providers are paid for treatments administered not care realized. And also because the consumers of healthcare don't see the total costs because they're hidden behind tax barriers that create implicit subsidies. Despite all the free-market rhetoric of the Republicans they didn't actually put anything substantive on the table and certainly not something as radical as moving healthcare out in front of the tax shelter. Like John McCain did in the campaign or the Whyden-Bennet proposal does no. That really gets to the heart of the problem - after the summit it's been made chrystal clear that the Rips are more interested in winning than in fixing.
But wait there's more! What we think is nicely setup by the exchange and standards combination are two things. First off it becomes very straight-forward to migrate coverage and make it portable, once we find out how to implement the exchanges. The other thing it makes possible is many....many field experiments. In fact the great strength of a market economy is that no one size fits all and as long as common standards for services are set it'll be possible to try a lot of different approaches. We think the ultimate fix though is to migrate toward a flat fee for service, say a flat monthly charge for basic coverage with riders for special circumstances. This is already being tried in a lot of places and again would fit nicely on the foundations that are laid in these proposals. Especially after we get some experience.
The real key difference that's then set up is an entire structural shift to a different engineering design philosophy of HC management from detailed standards, which required lots of work, inspections, administrative overhead, payment and adjustment methods, etc. etc. to a flat fee structure. On that path lies the ability to more than just bend the curve.On that path lies the ability to get costs headed back downward on an apples-to-apples basis.
But then again, we obviously lead a rich fantasy life. But don't say we haven't warned you about the consequences, the causes, the alternatives or the pragmatics, please!
BtW - the underlying feedbacks aren't something we entirely made up. If you want to see the collection of our previous work that lies out the bad cycle vs. the good cycle as the bad poltiics vs. the worse politics see this whitepaper collection: The Great Healthcare Reform Debates: Understanding the Causes, Complexities, Policy, Politics and Consequences
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where few risky positions were taken, not a lot of truth was told to power (the voters) and substance was somewhat downplayed in favor of labels (supwise, supwise,....heh, heh) Barry has really hit the decks arunnin indeed. Starting with his accepetence speech which you really ought to listen to carefully, with the caveat that his moved so far and fast beyond that it seems like ancient history. Nonetheless here it is and it really is well worth listening to: 

























