Yes, Mr. President, Health Care Is Complicated

 

Toothpaste tubeI nearly fell off the couch when I read the President’s statement that “nobody knew health care could be so complicated.”

Um, Mr. President, everyone knew. In fact, health care is considered the most complex industry out there. That would be why, as you and your colleagues are finding, transforming the system is “incredibly complex.” It is also why it will be nearly impossible to repeal-and-replace the Affordable Care Act (ACA) with something better unless you move to a single-payer system.You can, of course, focus on fixing its weaknesses.

I remember a healthcare economics course I took when I was in my 20s. During the first class, the professor told us: “Take every basic economic concept out there, including resource allocation, supply-and-demand pricing, and rational consumer behavior, and toss it aside. Very few apply to health care.”

The past 30 years as a healthcare writer have reaffirmed that statement hundreds of times over.

The Health Care System as a Tube of Toothpaste

I have my own analogy to describe the US healthcare system. I think of it as a tube of toothpaste with the cap on. You can squeeze it in one spot to get the tube flat but all that does is push the paste to another spot. However, if you open the cap the entire contents explode out, creating a mess that is pretty useless for its intended purpose – brushing your teeth. In other words, you must approach the healthcare system as a whole.

Another analogy: The healthcare system is like a game of Jenga. Pull enough pieces out and the entire thing topples. Consider:

  • You can’t require insurance companies to cover individuals with pre-existing conditions and not charge them more than healthy people (guaranteed issue) unless you also require that everyone have health insurance (the individual mandate). Otherwise, you don’t have enough premiums from healthy people needed to offset the medical claims from the sick. Eventually, the plan runs out of money.
  • You can’t reduce healthcare costs without addressing the epidemic of chronic disease in this country. You can’t address that epidemic if people don’t have access to affordable preventive care. You can’t provide that access if you don’t provide free or subsidized health care to those who can’t afford it and ensure that people with pre-existing conditions get affordable coverage. But, of course, as noted above, you can’t ensure their access without an individual mandate.
  • You can’t reduce waste in the healthcare system without fundamentally changing the underlying system of reimbursement, moving it from fee-based (ie, volume-based) to value-based (ie, based on cost effectiveness and outcomes). You can’t do that without massive changes in how Medicare and Medicaid pay providers, because they are the largest payers. You can’t make those changes without legislation.

The ACA, for all its flaws, addresses these complex issues. There’s a reason it’s more than 900 pages long – it is trying to fit all the toothpaste into one tube without the tube exploding. Taking bits of the toothpaste out and hoping they will eventually coalesce to provide enough to brush your teeth is wishful thinking.

True Health Care Reformers Need Passion to Succeed

You also need passion to reform a healthcare system. A recent article in the The New Yorker aptly quoted David Blumenthal and James Morone’s book, The Heart of Power: Health and Politics in the Oval Office, in which the authors write: “The health care reform story illuminates almost every aspect of the presidency. Because health reform is excruciatingly difficult to win, it tests presidents’ ideas, heart, luck, allies, and their skill at running the most complicated government machinery in the world.”

“Major health care reform is virtually impossible,” they continue, “difficult to understand, swarming with interests, powered by money, and resonating with popular anxiety. The first key to success is a president who cares about it deeply.”

President Johnson, who brought the country Medicare and Medicaid; President Nixon, who opened the door to managed care; President Clinton, who started the conversation about wide scale healthcare reform and brought us the Children’s Health Insurance Program (CHIP); and President Obama, who fought for the ACA, had passion.

However, as The New Yorker article’s author, Ryan Lizza, writes: “Any President who is just learning the basic fact that health care is ‘complicated’ has failed the passion test. And without that, little else matters.”

 

Debra Gordon is a medical and healthcare communications consultant based outside Chicago.

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