Bubbling Up

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In previous posts, I’ve discussed why the American Health Care Act (AHCA) is the wrong medicine and explored the right medicine – universal, affordable care – needed in the long run for a healthier nation. In this post I look at the deeper pathologies of our system and note short-term risks and opportunities as we seek a pathway toward health care that is sensible, productive, efficient, and fair.

Unfortunately, what needs to be done now is hard work – for all of us. We – and here I mean everyone who benefits from our current health care system – have taken from it without tending to the common good that must sustain it for the long term. Health care has been compared to a “tragedy of the commons,” in which everyone seeking their own greatest benefit eventually undermines the collective common good.

Putting more and more money into health care at the same rate we have for the past several decades is a pathway that will weaken the nation, including the overall economy. As Warren Buffet recently said, “Medical costs are the tapeworm of American economic competitiveness.” All of us who benefit are responsible: insurers, hospitals, doctors, employers, drug companies, suppliers, patients, politicians. The task we face is how to fundamentally change a sprawling, profitable, diabolically complicated sector that will soon constitute a fifth of our economy. How can health care be made affordable and accessible for everyone? One thing we know – spending is too high, and that’s a basic challenge.

In a recent interview, doctor (and novelist) Abraham Verghese captured the challenge vividly: “The reason we can’t scale back anything or have a discussion about rationing care, is because we have all these people feeding at the $3 trillion trough. And anybody planning to take away their share of it, they’re going to lobby Congress and fight it. As long as there’s a profit motive, not to say we shouldn’t all make a good living, but at what point does it become mercenary?”

Mercenary is a provocative word. It is seldom used in connection with health care. Nor is greed. But it may be worth thinking of these terms not just in the monetary sense (although that is certainly an important factor driving behavior), but in the broader sense of self-serving. What is it each of us wants out of health care, and to what extent are we prepared to be modest in the benefits we reap? As patients, what is reasonable to expect? Certainly care, and relief of suffering. As patients, too often we experience what we don’t want and don’t experience what we do want.

Institutional actors have a different calculus. Payment incentives, largely fee-for-service, along with a proliferation of perverse practices to extract ever-greater spoils from health care have caused us to almost lose sight of the purpose of health care, the ethical core. While “mercenary” and “greed” may not apply to the individuals working in these organizations, these terms may apply to the institutional structures and incentives that drive systematic behavior over decades.

Remedying these ills by transforming health care financing and organization is an overlooked area of common agreement on a pathway forward. Leading health organizations like Mayo Clinic are grappling with these basic changes in their work. People from across the political spectrum understand and continue to support the portions of the Affordable Care Act (often referred to as Obamacare) that have prompted necessary restructuring of the system. Such efforts constitute seismic shifts that will take years to bear fruit. The concept of “from volume to value” captures how payments need to change, as one step forward.

Yet while the delivery system evolves, governmental regulatory and administrative steps risk doing harm. As one example, the president’s administrative order (issued in January) led the Internal Revenue Service to change its rules. The IRS now accepts and processes tax returns when an individual excludes information about health insurance. This action weakened the enforcement of the individual mandate and undermined the stability of the insurance markets. Opportunities for doing such harm abound in the routine administration and regulation of the current laws and practices.

The near-term outcome of congressional work on the AHCA is uncertain. Looking at the process broadly, it is disheartening to realize that there is little chance for genuine progress toward an improved health care system emerging from the current situation. In fact, we are teetering on the edge of a very dire outcome: millions of Americans losing their health insurance and millions more remaining uninsured in the years to come.

Perhaps it is time to reflect and be buoyed by remembering recent past successes, such as the Excellence in Mental Health Act, co-sponsored by Senators Roy Blunt (R-Missouri) and Debbie Stabenow (D-Michigan). The progress from the act and follow-up legislation reminds all of us that our politicians can still make good decisions that improve our health system and move it forward toward better care and lower costs. In discouraging times, this example provides much-needed hope that our nation will find a pathway to heal our health care system.