Wishful thinking leads many well-meaning reformers to imagine that we can accomplish universal coverage in a single stroke. Writing in the December 31 edition of the New Republic, political scientist Jacob Hacker suggests that by declaring “healthcare for all” we can achieve universal coverage and , simultaneously, kick-start the economy. How do we do it? Easy—just spend as much money as possible as quickly as possible.
“In fact,” Hacker writes, “we have a magic bullet.”
This sentence stopped me. To my mind, the word “fact” just doesn’t belong in the same sentence with the phrase “magic bullet,” certainly not when we are talking about something as complicated as national healthcare.
Nevertheless, Hacker, who is an intelligent, highly-respected healthcare reformer , is dead serious. Just spread the money around, he says, and everyone will be happy—particularly the lobbyists who might otherwise object to any attempts to cut spending and eliminate some of the waste in our bloated system.
“Buy off the opposition,” Hacker advises. “Britain's health minister was once asked how he had gotten doctors on board for the National Health Service. His reply: ‘I stuffed their mouths with gold.’ Money may not change everything, but it does make it easier to win friends, or at least divide and placate them. . . .”
The problem with the Clinton healthcare plan Hacker explains is that “it didn't include enough handouts to appease interest groups.”
Still, I cannot help but wonder: Does “stuffing their mouths with gold” mean “stuffing health care legislation with pork”? Is that really the most prudent way to design an affordable, sustainable, and effective health care system?
But according to Hacker, Americans don’t want to hear about affordable; nor are they interested in eliminating waste. “Most don't believe our nation spends too much on health care; they believe they spend too much.” In other words Americans are distressed that their own bills are so high. The fact that Medicare spending is sky-rocketing, and that eventually we all will have to pay the piper, is, apparently, beyond the grasp of the average citizen. The notion that unnecessary, often unproven and usually over-priced drugs, devices, tests and operations can be hazardous to our health is just too hard to understand.
Granted, the fact that “more care is not better care” is counter-intuitive; certainly it runs against the grain in a culture that adores “More.” Still, there are indications that the public is catching on. These days, many patients are beginning to ask their doctors—“Do I really need this extra pill? I’m already taking four others every day.”
But Hacker implies that they are not catching on fast enough: “The way to get reform [now] is to give Americans what they want,” He argues, “better coverage at lower cost, made possible in the short term by a major infusion of new federal dollars.” In a recent speech, he made it clear that the infusion will depend on deficit spending. He makes no provision for pausing to ask whether that borrowed money will buy us more effective care. That’s the problem with deficit spending; it always seems like play money.
Moreover, Hacker ignores the fact that just throwing cash at the economy will not stimulate constructive growth. For years, the Japanese stayed warm by burning money. This did not solve their problem. You cannot stimulate economic growth unless you invest in something of lasting value. As I have argued in an earlier HealthBeat post, we will not add to the health or the wealth of the nation by pouring money into a broken health care system. Think about it: would we spend millions to repair a bridge that we knew was structurally defective?
Today we know that our healthcare system is clogged with hazardous waste: one out of three of our healthcare dollars are squandered on care that provides no benefit to the patient—and too often, exposes her serious risks. Before we mandate insurance for all, we must make the structural reforms needed that ensure that we are building a safe, effective healthcare system. Otherwise, we are delivering captive customers to for-profit insurers, drug-makers, device-makers, and hospitals—funding the very industries that will fight meaningful structural reforms
Nevertheless, Hacker argues, full speed ahead: “The faster everyone is in the system, the faster money flows into people's pockets, and the sooner reformers start reaping the political rewards.”
Good for the reformers. But what about the patients? Sometimes reformers seem so caught up in the politics of “winning” that they momentarily forget the purpose of the game. In this case, it is not economic stimulus, or placating the opposition; it is not creating customers for insurers or political rewards for reformers. The goal is better health for all Americans.
To his credit, Hacker makes it clear that he believes that the political capital that reformers accumulate by pleasing everyone ultimately will allow them to take a hard look at the “the difficult but essential task of controlling long-term health spending.”
In other words, after lining the pockets of the lobbyists, and assuring the American people that they can have all the health care they want—for less than they are spending now—then you break it to them that, in fact, we cannot afford runaway health care spending.
The Congressional Budget Office Report—A Different Approach
The alternative is to tell the public the truth upfront. For eight years our government has lied to us. Truth-telling would be a refreshing change, and I believe that the American public is up to the challenge.
The Congressional Budget Office (CBO) recently released two reports that are eye-opening in their honesty. Universal coverage, CBO advises us, will involve “tradeoffs.” Americans will have to share more of the costs of their healthcare and/or accept “tighter management” of what is covered.
CBO knows that given the amount of waste in our system, we can cut spending without lowering the quality of care. But CBO also realizes that this won’t be easy. Over at Health Care Policy and Marketplace Review, Bob Laszewski offers an excellent summary of the CBO report:
"1. There are no one, two, or even ten silver bullets. There are literally dozens of steps that will likely have to be taken in order to achieve the savings necessary to make our system more cost and quality effective.
"2. The politically easy stuff won't get it done. Democrats and Republicans have said that things like prevention, wellness, and wider use of health information technology can free-up the savings we need to make our system affordable even while we dramatically expand the number of citizens covered. But the CBO confirms that these less politically problematic “cost containment lite” proposals won’t be enough: '…approaches—such as the wider adoption of health information technology or greater use of preventive medical care—could improve people’s health but would probably generate either modest reductions in the overall costs of health care or increases in such spending within a 10-year budgetary window.'
"3. Really controlling costs will be very hard and will require some courageous and politically problematic actions: 'Those problems cannot be solved without making major changes in the financing or provision of health insurance and health care. In considering such changes, policymakers face difficult trade-offs between the objectives of expanding insurance coverage and controlling both federal spending and total costs for health care.'
“When you read through the reports,” Laszewski observes, “it becomes clear that there are things we can do that will help but really be a drop in the huge health care bucket.
“For example,” he notes, the Baucus Health Plan makes a big deal about saving money from ‘waste, fraud, and abuse.’ But such efforts are estimated by the CBO to save a relatively inconsequential $500 million over ten years.”
By contrast, if Medicare updated its assumptions about how often diagnostic imaging equipment is used, from 50 percent of the time to 75 percent of the time—and reduced fees paid to physicians accordingly—federal outlays would be cut by $1.9 billion over the same ten years.
For even greater savings, CBO estimates that if Medicare required that drug-makers pay a minimum rebate on drugs covered under Medicare Part D (using the Medicaid rebate policy as a model) the government would save $110 billion by 2019. If Medicare raised the age of eligibility to 67, it could save $85.6 billion.
All in all, CBO outlines 115 discrete options to either alter federal program or affect the private health insurance market in ways that would contain spending while lifting the quality of care.
Note: these are options, not recommendations. Some are politically more palatable than others. While some reforms yield only small savings, together they could make an enormous difference.
If you read the entire report, what becomes clear is that healthcare reform that we can believe in cannot be achieved with a single stroke of the pen. It will, as Laszlewski suggests, take more than one piece of legislation. National health reform will become a process—a political process—that will require time, thought and courage
Some suggest that, when it comes to healthcare reform, the Obama administration has only a narrow window of opportunity. Today, the economic meltdown has left Americans feeling insecure, ready for government to take charge, ready for charge. If the administration hesitates, the national mood may shift. Those who call for universal coverage Now say that the Clinton administration moved too slowly, and while they dragged their feet, the window closed.
The truth is that the white collar/ blue collar recession which created such anxiety at the beginning of the 1990s eased before the end of Clinton’s first year in office. By the time he presented his plan to Congress, in November of 1993, “the American people found that they weren't feeling so scared anymore,” observes the American Prospect’s Ezra Klein: “Thus their status quo bias once again overtook their feelings of insecurity. The initial calculus of the Clinton plan was that Americans would be more afraid of their health coverage being changed by recession than reform. As the recession eased and unexpected economic changes looked less likely, reform grew scarier, and thus the ‘fierce urgency of now’ that animated the 1991 discussion over health reform dissolved before a bill had even been presented”
Unfortunately, President-elect Obama need not worry that the recession of 2008 will end too quickly. The Bush administration dug a very deep hole; it will take years to repair the damage. Economists say that unemployment may hit 8 percent by the end of 2009; some say that eventually 10 percent of Americans could find themselves without jobs.
In the meantime ask yourself: “Who would benefit most if we race to pass sweeping national health care legislation next year?” The answer is anyone who wants Congress to pour money into our healthcare system—without regulating that system. The lobbyists representing the nation’s for-profit insurers, drug-makers, device-makers and even of our highest-paid health care providers are salivating at the prospect of 45 million new customers, many arriving on the scene with government subsidies in hand.
If we take too much time thinking about how to spend our health care dollars wisely and selectively, we might put too much emphasis on safety, quality, and cost-containment. Those who profit from what we euphemistically call a health care “system” prefer the current laissez faire chaos which allows them to sell whatever they like, at whatever price they like, without being constrained by too many rules.
But as recent experience on Wall Street has demonstrated, games need rules—particularly when billions are at stake. The smell of money attracts vultures.
It’s interesting that when many Americans speak of “reforming” our healthcare system they generally mean better access to care, not so much cost control. When pressed about where we are to find the money to pay for all the care that universal access would bring, folks fall back on the old “waste, fraud, and abuse” meme — in other words, nothing painful. (They also generally toss in tort reform, even though malpractice/defensive medicine issues are minor in the big picture.)
Hacker’s suggestion sounds to me like those who have said meaningful cost control can only come when we have a bigger crisis than we’ve got already. Therefore we should hurry into that crisis; we should go ahead with universal coverage, thereby sending costs straight through the roof, and use the resulting mega-crisis to get the cost control we need.
I’m not that cynical. I think people (and legislators) can be convinced that needless, pointless, and ineffectual care is the principal offender, and thus some kind of impartial mechanism to winnow out what we will pay for and what we won’t is key. This would be easiest to do in a single payer system, but even if we did it just with Medicare it would make a huge difference. Plus, most insurers follow Medicare’s lead.
Hacker is smart and right. Like Reagan, he acknowledges that there may be no easy answers, but there is a simple answer. If the problem is that we want care for all, the simplest solution is to just write a check for coverage. We can afford it, ask Wall Street and the auto companies. Then we could amend reimbursement as we did for medicare once the providers were totally reliant on it. There’s no evidence public has any interest in greater efficiency or total cost.
Jim & Chris–
Thanks for your comments.
It’s amazing–and interesting –how well you two have defined the two sides of this argument.
Jim (a regular reader whom I respect) argues for the pragmatic point of view: write a big check now, then fix the program later when the check proves too expensive.
He argues that there is no evidence that the public wants intelligent reform.
Chris (another regular reader whom I respect)
is realistic about the public. He reocgnizes that most Americans want health care reform without pain. They want their own health care bills to be lower–and they would like to see everyone have coverage-as long as it doesn’t cost any of us anything.
Chris also recognizes that Hacker’s commentary is not nearly as optimistic as it sounds:
Chris writs: “Hacker’s suggestion sounds to me like those who have said meaningful cost control can only come when we have a bigger crisis than we’ve got already. Therefore we should hurry into that crisis; we should go ahead with universal coverage, thereby sending costs straight through the roof, and use the resulting mega-crisis to get the cost control we need.”
Chris adds: “I’m not that cynical”
I’m not that cynical either.
I thought about using the word “cyncial” in the post, but did not want to accuse Hacker of being a cynic–with all that implies.
I think Hacker has simply been persuaded, by the poltical strategists, that we should be sternly pragmatic–which may mean driving our health care system over a cliff in order to save it.
I once heard Hacker describe his proposal, somewhat glumly, as “a second-best plan,” but, he added softly, “we live in a econd-best world.”
I’m not willing to accept that proposition. I know that this will sound sappy to many, but I think we always must aim for somehing much better than a second-best world, if only for the aake of the children who live on the bottom tier of our seocnd-best moral universe.
And I also think that at this time in U.S. history, with the president that we will have in the White House, we don’t have to settle.
Obama should take to the bully-pulpit. This is a presdient who could use the word “sacrifice”–and convince Americans that we must begin to think collectively.
On the other hand, I should acknowledge that Jim has far more real-world political experience than I have, so perhaps he is more realistic than I am.
But I persist in thinking that, in these changing times, we should try to change the rules of the policical game. We don’t have to accept the rules of the past 28 years.
Maggie Mahar correctly states above “The lobbyists representing the nation’s for-profit insurers, drug-makers, device-makers and even of our highest-paid health care providers are salivating at the prospect of 45 million new customers, many arriving on the scene with government subsidies in hand.”
But as a practicing physician I see two admittedly anecdotal trends among my patients that they very well may be accepting “the more is not always better in medicine” message.
The first is that many of my patients, who by the way are working class, want to reduce or come off of too many meds.
Secondly, many of my patients have living wills which stipulate that they do wish to have their “lives”(deaths)prolonged by extraordinary medical technology.
I view these two as a sign that American health consumers may be more ready for change that Prof Hacker posits
Dr. Rick Lippin
Southampton,Pa
Dr. Lippin,
I’m curious. Do you and/or your colleagues do anything proactively to try to encourage your patients to execute living wills? If so, what’s the typical response and is it a change in practice pattern as compared to, say, 10 years ago in attempting to get on the record what patients want and don’t want related to end of life care?
Barry,
Firstly I made a typo in my original comment. They do “NOT” want to prolong their lives (death)
As far as physicians’ role in discussing living wills I would ask some of the leading Palliative Medicine leaders if this is a trend? My favorite national leader in Palliative Medicine is Ira Byock from Dartmouth.He is remarkable! (google him)
Personally if I were designing medical school curriculae I would insist that all future Docs be trained to raise this issue with all patients.
But the previous(hopefully dying) prevailing model in Medicine was to teach Docs that “death is the enemy to be vanquished”.Thus demonstrating arrogance, hubris and general lack of wisdom about life.
Barry- Wish I had some studies for you. It is a cental question for the future of medicine as physicians and as patients.
Rick Lippin
“Granted, the fact that ‘more care is not better care’ is counter-intuitive; certainly it runs against the grain in a culture that adores ‘More’.”
Ah! That’s a conflation of terms which is quite misleading and which is also the norm for reportage.
It’s not that more care is not necessarily better. It’s that more treatment is not better.
More care is exactly what is needed, but just not what is typical in the high tech/high cost/rapid episodic patient encounters with treating physicians.
Treatment includes doing things and prescribing things and services to patients. Care includes assessing, educating, counseling, supporting, intervening, interacting and partnering to facilitate the patient’s ability to make fully informed health and healthcare choices. These are precisely the parts of healthcare which provide the greatest satisfiers for physicians, nurses and patients and which are not reimbursed, and so have been pushed aside.
It’s the very lack of care which leads to preventable medical errors, preventable harm, preventable suffering and preventable deaths of patients who are able to access any care at all. It is at the root of recidivism. It is at the root of patient noncompliance. It is at the root of high costs.
Make no mistake: care is not the exclusive purview of physicians. Professional nursing is built upon care. Indeed, there is a nursing theory of care, by Jean Watson out of the University of Colorado, which is greatly influential in how nursing is proscribed and enacted.
When physicians say that they are going to take good care of you, that’s for the most part a misnomer. They are going to diagnose and treat you.
It’s registered nurses who take care, provide care, coordinate care and assure care.
And their costs don’t even register in most models of US healthcare spending.
Any model of healthcare reform which doesn’t specifically address professional nursing isn’t reform at all. It’s simply repackaging and customizing details.
Annie, you say: “When physicians say that they are going to take good care of you, that’s for the most part a misnomer. They are going to diagnose and treat you.”
I enjoy your insightful posts, but I object strongly to that generalization. Even though you include the qualifying “for the most part,” your statement does not describe me or the physicians I work with.
I do agree with your basic point, however, that care ≠ doing things.
Barry–
I think lawyers are more apt to ask a client if he wants a living will–when he comes to a lawyer to make a will.
This is what happened in my case, and it seemed a logical question.
I guess I would be a little surprised if my PCP asked if I wanted a living will. Unless I were very sick and we were discussing end of life care, it would seem an odd, out-of-the-blue question, and I’m not opposed to talking about death.
I suspect some people would find the question
totally inappropriate.
There might be another way to do this–A doctor might have information about living wills in his waiting room . . .But I think springing the question on the patient is probably not a good idea unless the doctor knows the patient very well.
Re: living wills discussions
Most of the time, it’s a nurse case manager or social worker who initiates that. As I recall, (without looking it up, so take with a liberal dose of salt) the Joint Commission requires that all hospitalized patients be asked about whether they have a living will, durable power of attorney for healthcare, healthcare proxy, etc.
During my tenure as a nursing administrator and a critical care nurse, the facilities I worked in all included at least one specific question on the initial nursing assessment about whether the patient had a living will and whether the documentation had been added to the medical record. It used to be common practice to include a copy of it and proxies in the front of the record next to the patient demographics admission sheet.
@ Chris Johnson re treatment versus care:
I think the two terms are not interchangeable, and that professional care includes assessing, educating, counseling, coaching, advising, comforting, reassuring, supporting (both physically and psychologically) and guiding patients to facilitate their return to self-care and to facilitate informed and appropriate health and healthcare choices. I can’t recall in my own experience of a physician providing physical care to patients as routine, while they do indeed provide medical, surgical, diagnostic, and psychiatric treatment where advising and educating is provided to further the aims of the physician relative to treatment and patient compliance.
Care is used so broadly, but it has so much more specific meaning in professional nursing, that I think that more discussion and analysis is due that term. Do you object to the term, treatment, as I used it?
Are you familiar with the way the term, care, is used in nursing’s code of ethics and standards of care and practice?
No offense intended, of course.
Maggie-
On the question of doctors talking to patients of all ages (exluding pediatrics of course) about death and dying including having a living will- we disagree.
This mind-set change could literally revolutionize US Medicine
I’ll find the exact quote next week but it went something like this – “The prevailing model of health in any given culture is driven by its views on death” And the immature model of US Health Care is definitelty “thanatophobic”to a degree where it has the arrogance and hubris to actually believe it can “cure” aging and death. Thus our highly irrational and expensive addiction to bio-technology.
(Also I now remember on the DoD psycho-social history form I actually am required to use for all patients it has a question on it “Do you have a living will?”)
Maybe other Docs could weigh in?
Dr. Rick Lippin
Southampton,Pa
Maggie,
While I don’t have precise data, I think a significant percentage of the population has not had a lawyer draw up a will and have no intention to because they either don’t have much in assets, own all of their property jointly with their spouse and intend for their spouse to inherit it upon their death or are willing to let their state’s administrative procedure that applies to those who die without a will divide their property.
When I’ve filled out paperwork as a new patient, there is always a request for the name and phone number of an emergency contact person. Whether or not one has executed a living will would seem like a reasonable question to me. It could also be brought up as part of the follow-up discussion after a routine physical and certainly more easily after the doctor and patient have gotten to know each other.
As “wisewon” ( a doctor who comments frequently and very knowledgeably about medical issues on Ezra Klein’s blog) points out on The Healthcare Blog, there has to be a lot more to reducing healthcare costs than squeezing the profits of drug and device manufacturers and insurers. Getting more people to execute living wills is a meaningful part of the solution, I think, as is reducing or eliminating payment for cost-ineffective drugs, devices and procedures and reforming the tort system to protect doctors and hospitals from lawsuits based on a failure to diagnose a problem as long as national evidence based practice were followed. While there are no healthcare reform silver bullets, as you say, there are many silver pebbles. I have alluded to several that could drive more cost-effective practice patterns by providers.
Barry, Annie Rick–
Interesting commments on the living will.
Barry, you are no doubt right, most people don’t have wills.
Certainly including the question on a form that new patients fill out would be a much gentler approach–rather than just popping the question.
Annie–and it certainly makes sense that someone find out if a patient has a living will when he is hospitalized, though I do think it has to be done in a tactful, “of course nothing is going to happen to you” way–especially if the patient is already fearful.
Dr. Rick– You know I agree with you about the American view of death and dying, I was just responding to the idea of PCPs poppoing the question with patients who are unaccustomed to talking about death and dying. . .
It’s also my sense that we may put too much emphasis on how much money is “wasted” on dying patients. As Diane Meier, the pioneering palliative care specialist points out, often we don’t know which ones are going to die. Some people do make it out of the ICU. And since these are the sickest people in the hospital, you do want to give them maximum care while they still have a chance of leaving the hospital and enjoyiing a high quality life. . .
A great many people have been told a relative isn’t going to make it–and 4 years later he’s still around and in relatively good shape.
My husband’s great-uncle Joe is 94. A number of years ago, he wasn’t supposed to survive. These days, his biggest problem is that a couple of weeks ago, he fell off his exercise bicycle. Mind perfectly sharp. Ramrod posture. Enjoys life.
On the other hand, in many cases we simply prolong the process of dying.
This is why I wish all hospitals had palliative care teams. Doctors and nurses who are trained to deal with death and dying are not as likely to over-estimate the chances that the patient will be saved–and not as likely to give up–in disgust–with a patient they seem to be losing. (Some surgeons do this.)
And Barry– all of the research does suggest that the last two years to six months of many people’s lives are medically very expensive, even if the care they receive is appropriate. That’s just the way it is when people are very sick and outcomes are uncertain.
I’m all for living wills, but they don’t solve the essential ambiguity of medicine.
I always asked my patients at some point if they had discussed their “End of Life” wishes with anyone. And gave time for the discussion if they wanted….Maybe that’s why my “caring” earned me $45/hour as a Family Doc…
And Maggie, it is part of Medicare regulations that the “Living Will” box be checked on any hospital admission, usually done by the all night receptionist. So bureacracy has us covered there.
I believe continuity has value. And what you are talking about in the first part of “throwing Money at it” has to do with waste vs value. I practiced in a small town, 20 bed hospital. 15 years ago I asked the records department to review how people died in our hospital. First, 25% of patients in our county died at home. (30k population). 50% died in nursing homes, only 25% died in hospital. Average length of stay with death was 3.5 days. Only 5 died in ICU. some 75% were on “palliative”, what we called comfort care, at time of death…And almost all were cared for by their primary care doc that knew them and their family….
It’s hard to make this provable in any way, but I believe the comfort of continuity can eases the pain of transitions.
Happy New Year.
Ddx:dx–
I agree that continuity eases transitions. But in the world we live in today, a primary care provider is likely to be at the patient’s hospital bedside only in some parts of the country–mainly smaller towns with smaller hospitals.
In many places, PCPs feel that they just don’t have the time to visit their patients in the hospital–and if they do, all they can really do is drop in to say hello.
In today’s hectic hospitals, it’s very hard for a PCP to walk in and make things happen. Co-ordinating care becomes the job of the hospitalist.
But a think a good hospitalist does make the patient feel that he/she is “his doctor”–
Happy New Year– mm