The American Health Policy Trap

The American health policy trap: a costly and complicated system that has left a growing minority of Americans without financial protection in sickness but has nonetheless satsfied enough people to make it difficult to change. The key elements of the trap are a system of employer-provided insurance that conceals its true costs from those who benefit from it; targeted government programs that protect groups such as the elderly and veterans, who are well organized and enjoy wide public sympathy and believe that, unlike other claimants, they have earned their benefits; and a financing system that has expanded and enriched the health care industry, creating powerful interests averse to change.

Paul Starr, Remedy and Reaction: The Peculiar American Struggle Over Health Care Reform

Mitt Romney's Health Care Dilemma

Tonight, Mitt Romney promised his Iowa supporters that as president, his first act would be to pursue the repeal of "Obamacare." Romney's dilemma is plain: The Affordable Care Act  is also modeled after the Massachusetts Act Providing Access to Affordable, Quality, Accountable Health Care championed by then Governor Romney. In particular, Romney opposed mandated participation by employers in health insurance, insisting on individual mandates.

Romney's reasoning followed what was then traditional Republican logic: Requiring individuals to take responsibility for their health care eliminated free riding whereby the costs of uncompensated care are absorbed by the insured. Now, to be sure, there is plenty of free riding in American health care, and it goes beyond uncompensated care. For example, large companies use bargaining power to negotiate more favorable rates with insurers, who then pass the loss onto small businesses, the self-insured, and the uninsured. Moreover, since the self-insured do not receive a health insurance tax break, they subsidize the insurance of people with employer-provided insurance.

Senator Charles Grassley (R-IA) introduced employer mandates as an alternative to the Clinton attempt health care reform. According to Paul Starr in his book Remedy and Reaction, many Republican politicians supported individual mandates as recently as 2009. Since then, the party's desire to defeat President Obama and the ascendance of its libertarian wing has trumped a policy that has roots in the Eisenhower administration. As a result, Mitt Romney has been forced to repudiate a policy that he successfully effected in Massachusetts and that he once believed would help him run for president. If he can thread that needle, more power to him.

Are We Patients or Consumers?

"[There is] no difference between men, in intelligence or race, so profound as the difference between the sick and the well." 

F. Scott Fitzgerald, The Great Gatsby

"Everyone who is born holds dual citizenship, in the kingdom of the well and in the kingdom of the sick." 

Susan Sontag, Illmess as Metaphor

Advocates of consumer-driven health care contend that patients are consumers of health care and that choice of insurance plan forms the basis of a successful health care model. In their seminal book Redefining Health Care, Porter and Teisberg argue that CDHC champions err by focusing on consumer choice rather than value-driven care as the primary economic driver of competition in health care.

The question of whether we are patients or consumers need not be considered in such binary fashion, writes George Annas in The Rights of Patients: The Authoritative ACLU Guide to Patient Rights. The word "patient," Annas says, "...is the best term to describe an individual who is sick or injured and in need of medical care." Annas recognized the paternal implications of the term and agrees that it requires refining.

However, he also finds "consumer" wanting, writing that it best applies to healthy people physically and psychologically able to contemplate a choice of plans or elective procedures. An important reason why there has never been a sustained, effective, widespread consumer movement in health care is the when we are sick or injured, our first priority is to become well, and we are willing to cede rights that we might otherwise take for granted in order to regain health.

Moreover, public attention lies elsewhere: Advances in medical technology that delay death and increase the curative power of modern health care, costs, access, patient rights, and matters as basic as adequate time with physicians.

In short, we are consumers when well, and patients when sick.

(Source: The Rights of Patients: The Authoritative ACLU Guide to Patient Rights, 3rd ed.)

State Profile: Court Blocks Indiana Law to Cut Planned Parenthood Funding

Federal judge Tanya Walton Pratt has overturned provisions of an Indiana law that blocks Medicaid funding to Planned Parenthood because some of its clinics perform abortions. In denying funding, Indiana invoked its authority to determine the qualifications of a provider. However, Judge Pratt responded that the services offered by a provider were unrelated to its qualifications and therefore not a legitimate consideration. She also cited a recent federal Medicaid ruling warning states that they could not exclude qualified providers simply because they performed abortions.


Although federal law already bans the use of Medicaid money to pay for abortion services, the Indiana statute goes further by refusing funding to “any entity that performs abortions or maintains or operates a facility where abortions are performed.” It calls for the immediate termination of state contracts with such providers, hospitals excluded.


On January 22, 1973, the Supreme Court issued the Roe v. Wade decision affirming a woman's right to an abortion under the due process clause of the Fourteenth Amendment. Subsequent rulings confirmed that the right exists up until viability. Although Roe v. Wade remains controversial, it has been the law of the land for almost forty years. While conservatives decry the heavy hand of the state as a health care regulator, Republican-controlled state legislatures have shown little compunction in passing laws intending to erode Roe and in effect restrict abortion rights.


Judge Pratt's opinion alludes to the likelihood that suits challenging the Indiana legislation were likely to prevail. Perhaps. But conservative judicial activism is driven more by ideology than legal interpretation. Is the eventual upholding the Indiana statute a foregone conclusion?

IOM: Six Aims of Quality Health Care

The balance of health benefits and harm is the essential core of a definition of quality.

Avedis Donabedian

In 2002, the Institute of Medicine published Crossing the Quality Chasm, an influential book that framed all future discussions of quality health care. Crossing came on the heels of the IOM publication To Err Is Human (2000) and a Journal of the American Medical Association report (1998) that warned of "serious and widespread quality problems...throughout American medicine." The report called attention to three broad categories of quality defects:

• underuse, whereby scientifically practices are not used as often as they should be;
• overuse, especially of imaging procedures and prescription of antibiotics; and
• misuse, when a proper procedure is not administered correctly (such as prescribing the wrong drug)

To Err Is Human estimated that as many as 98,000 people dies each year in hospitals from injuries or illness contracted during care.

In Crossing, the IOM outlined six specific aims (explained by Dr. Donald Berwick in the video above) that a health care system system must fulfill to deliver quality care:

1. Safe: Care should be as safe for patients in health care facilities as in their homes;
2. Effective: The science and evidence behind health care should be applied and serve as the standard in the delivery of care;
3. Efficient: Care and service should be cost effective, and waste should be removed from the system;
4. Timely: Patients should experience no waits or delays in receiving care and service;
5. Patient centered: The system of care should revolve around the patient, respect patient preferences, and put the patient in control;
6. Equitable: Unequal treatment should be a fact of the past; disparities in care should be eradicated.

Recognizing that aims must be accompanied by observable metrics, the IOM defined sets of measurements for each aim. For example:

• Safe: Overall mortality rates or the percentage of patients receiving safe care;
• Effective: How well evidenced-based practices are followed, such as the percentage of time diabetic patients receive all recommended care at each visit;
• Efficient: Analysis of the costs of care by patient, provider, organization, and community;
• Timely: Waits and delays in receiving care, service, or results;
• Patient centered: Patient and family satisfaction;
• Equitable: Differences in quality measures by race, gender, income, and other population-based demographic and socioeconomic factors.

Of course, this is all easier said than done. Hospitals could more easily follow evidence-based practices were there a national outcomes data base that provided population-based information. Effecting efficiency programs can mean a complete redesign of institutional culture, as in Virginia Mason's (Seattle) 20-year commitment to Lean management principles. Equitable care is unlikely without a sea change in national health policy (not that there is one) that extends well beyond the limitations of the Affordable Care Act.

The most encouraging developments in the industry-wide reassessment of quality are the recognition that safety and efficiency need not be mutually exclusive, an increased capacity for the practice of evidence-based medicine, and a new emphasis on patients when it comes to setting goals and measuring results.

Source: The Healthcare Quality Book (2nd edition), edited by Elizabeth R. Ransom, Maulik S. Joshi, David B. Nash, and Scott B. Ransom.

Paul Ryan on Single-Payer

As Sam Husseini reports, there is a fair amount of floundering and disingenuousness in Ryan's remarks. It's not the case, for example, that government-run health care has failed wherever it's been tried. The actual track record of government-run health care is good, including in the United States: The VA health care system is highly regarded. Moreover, Ryan's own plan is "patient-centered" only in the sense that it shifts costs onto patients without doing anything to slow medical inflation or end fee-for-service payments.

Also, anyone who thinks that U.S. health care is not rationed hasn't been paying attention. Ryan would state his case more honestly (and accurately) if he said what he apparently believes: De facto rationing by the free market is acceptable, while policy-based rationing by government to assure equal access is not.

Choice?

David Brooks argues that the future of health care comes down to "centralized technocratic" planning or a a free market solution. Health care, he sagely observes, is "phenomenally complicated," then goes on to inform us that providers have more information than patients and that insurance companies "are rapacious and are not in the business of optimizing care."

Brooks then compares what he calls the Affordable Care Act's concentration of cost-control power into a board of fifteen experts with the Republican laissez-faire model, which opposes top-down decision making (at least from the government). Rep. Paul Ryan's proposal to finance U.S. health care with a "premium support system" would replace fee-for-service medicine (in fact, it would not):

Seniors would select from a menu of insurance plans. Their consumer choices would drive a continual, bottom-up process of innovation. Providers could use local knowledge to meet specific circumstances.

Brooks writes with great confidence that this will happen -- presumably due to the Magic of the Market -- without explaining exactly how or why anyone should buy this argument.

Jonathan Cohn points out that the Republican plan has a track record, and that it's not especially encouraging. He argues that Ryancare would effectively eliminate health insurance for elders and summons the 1959 congressional testimony of retired autoworker John Barclay:

We retired workers are very proud of being citizens of the greatest country in the world, but … we cannot think it is the greatest possible country when about 65 percent of the aged do not have any insurance to deal with their needs for hospitalization and medical care. Without such insurance, the retired person must pretty much exhaust any savings he has before he can get free hospitalization. This is a constant source of worry. Many of my acquaintances will not visit a doctor for minor illness because they have no money to pay for drugs. After they exhaust their savings they go on welfare to get medical aid, but then, in many cases, it is too late.

The real difference between Democrats and Republicans on health care is not, Cohn writes, between an idealized free market and Stalinist central planning. Rather,

The most salient difference is that Democrats would preserve Medicare's fundamental guarantee of health benefits at affordable prices. Republicans would not.

Meanwhile, Ezra Klein contests Brooks' claim that

...if 15 Washington-based experts really can save a system as vast as Medicare through a process of top-down control, then this will be the only realm of human endeavor where that sort of engineering actually works.

It happens all the time, Klein writes: Around the world, government-regulated and -planned health care has a excellent track record for controlling costs without sacrificing outcomes.

At The Economist, M.S. dismisses Brooks as well, and focuses on the distortion brought about by the marketing and advertising of drugs and devices. 

As I've written before, Ryancare substitutes ideology for honesty. Brooks sips from this cup of Kool-Aid regularly, rarely if ever pointing out that Ryancare is all in on controlling costs by shifting them to elders. If that's what the country wants, then it's what we should do. But how about being up front about the choice?