Spend Less, More Care

As always, let's remember that reform of the health care system isn't about abstract ideas, it is about real people in America who are suffering. It's about an insane system, one where I'm now often forced to treat dangerous sexually transmitted diseases with antibiotics without first testing for them, as many patients can no longer afford the testing. It's about a system where I no longer choose medications because they are the best for the patient's problem, but because they are available at Walmart, where they are only $4.

So far, the Obama health care reform plan has few details, except that he would like to find a way to give more Americans access to health insurance, and that somehow, computerization will improve quality and save money (which, by the way, is not a foregone conclusion).

I can't help but feel that the Obama team takes less than a comprehensive view of the American health care system and the problems it faces. This is unfortunate, as failure to address any number of issues will undo his effort to increase the number of insured Americans.

The American health care system faces three main issues:
1. Lack of access to affordable care: 50,000,000 Americans lack health insurance, resulting in 18,000 deaths per year. Many more millions have insurance with a high deductible, effectively limiting their access to care. Compounding the issue are health insurance companies that deny care based on pre-existing conditions, and arbitrary application of incomprehensible rules. Even worse, poor reimbursement rates have systematically created a near crisis shortage of primary care doctors, so that, even if more people become insured, there are no doctors to see them (which currently plagues Massachusetts health care reform efforts).
2. Out of control costs: health care now accounts for 17% of the GDP (it was 8% in the early 1990s when Bill and Hillary took on the system). More than 50% of personal bankruptcies are related to medical expenses. The average cost of a family health insurance policy is $12,000. In addition, the high cost of health care severely affects the bottom line of U.S. businesses.
Why do costs continue to increase far faster than the rate of inflation? Many reasons. Medication costs in America are far higher than in other nations, where the government plays a role in bargaining prices lower. Administrative costs in the American system are outrageously high, accounting for 1/3 of every health care dollar spent in America. Legal threats drive up the costs of care, as doctors order extra tests in an attempt to avoid multi-million dollar law suits, and pay skyrocketing malpractice rates. High-tech, cutting edge care also accounts for part of the problem. And finally, and maybe worst of all, Americans suffer from an epidemic of costly, largely preventable conditions related to lifestyle.
3. Poor quality: despite paying more for care, Americans appear to be getting less. American health care statistics are some of the lowest in the developed world. Again, the causes are complex and many. Efforts to document and study medical errors are stymied by doctors' fears that revelation of any error will result in a lawsuit or other punitive action. American doctors lag in use of electronic medical records because the Bush administration refused to organize and guide the fledgling industry, insisting that it was the job of the markets, which haven't done a good job.

The Obama administration, and most politicians that are vocal about health care reform, focus only on the access to care issue, pushing strategies to increase rates of insurance (and increase costs). Failure to address the costs of care, then, will surely undermine these expensive ventures. Failure to reform medical reimbursement rates to increase the number of primary care clinicians will also undermine the effort. And if we don't address issues of medical quality, which is a complex task that will take a generation to accomplish, than we may be wasting money, and merely giving more people bad care!

Seems daunting, doesn't it? It's not as bad as it seems. The point is that if health care reform is to be successful, it must be comprehensive, and must address how to increase access to care, how to lower the costs of care, and how to improve quality.

BE HEALTHY