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THE NEXT HEALTH CARE SCHISM.
This is a very important point by Drew Altman, CEO of the Kaiser Family Foundation:
We could be headed for a new schism in the debate about health reform...For one group, I will call them the "Delivery System Reformers," true health reform lies in making the actual delivery of care more cost effective over the long term. Delivery System Reformers champion health IT, comparative effectiveness research, practice guidelines, and payment incentives to encourage more cost-effective care such as pay for performance. They believe that only if we can weed out unnecessary care, promote more cost effective and scientifically proven therapies, and distinguish between new technologies that produce new benefits and not just new profits will we be able to get a handle on health care costs and produce value for the health care dollar. The recent op-ed in the New York Times by baseball executive Billy Beane, Newt Gingrich, and John Kerry exemplified the delivery system reform movement, and notably did not mention the uninsured once. Indeed some delivery reformers believe it would be a mistake to put more money into the current system through expanded coverage until more fundamental changes in the system are made.As Altman goes on to argue, the two agendas fit neatly in a comprehensive reform package. Coverage expansion isn't sustainable unless cost growth is slowed. Cost growth can't be slowed without delivery system reform. Ergo, coverage expansion, in the long-run, requires delivery system reform. But if the zone of opportunity narrows and a comprehensive reform is jettisoned for an incrementalist package, you could see a real battle between those who want to spend political capital on deliver system reform (which means overcoming opposition from entrenched medical industry interests) and those who want coverage expansion (which means overcoming opposition from Republicans and budget hawks). That would be a Bad Thing.The other group, I will call them the "Financing Reformers," is focused on an entirely different set of problems. Its major concern is the problem of the 46 million Americans without health insurance coverage and the serious problems all Americans are having today paying for health care and health insurance. For these reformers the health care crisis is fundamentally a problem of economic security and ensuring that everyone has access to affordable health care. Financing Reformers may differ on solutions -- tax credits, expanding public programs, building on the existing employment based system, single payer -- but their primary objective is to fix what they see as a growing crisis in the health insurance system that harms people's economic well-being and access to care.
Obviously many in our field advance both agendas simultaneously, but there are also two very distinct camps. They think about different problems and often attend different conferences. The health reform field is like a Venn diagram with circles that intersect (though not by a lot).
Incidentally, for a good introduction to delivery system issues, you could do worse than downloading CAP's recent book, Reforming the Health Care Delivery System, which features chapters on most all the major issues, and also happens to be free.
COMMENTS (5)
Of course, the whole point of establishing universality is that you will then have an across the political spectrum consensus for improving healthcare delivery.
If we go the S-CHIP route instead, we'll get neither meaningful expansion of coverage nor improved deliver.
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The window for Dems to get this done is this particular Congress. If not, it won't get done for a decade, and when it does get done, it'll get done by the GOP, with the attendant political and policy fallout.
Posted by: Petey | November 17, 2008 12:02 PM
I suppose my biggest concern is finance reform, but that has been informed by the information that national health systems in other countries deliver health care more cheaply than we do. Now, why is that? Is there a way in these countries that the system is cheaper, or would we, for some reason, just have the most expensive national health care in the world.
I've been for single payer because it seemed to me the administrative cost in the insurance system were the easiest target in reducing costs. Are there really other such targets?
Posted by: David in NY | November 17, 2008 3:16 PM
Comprehensive finance reform followed by delivery system reform strikes me as the only sensible way to approach things.
1) Once you've included everybody in the system, you've created a whole lot more constituencies for maintaining what will then be the existing system.
2) Once you've covered everybody, the fiscal pressures to control costs will absolutely mandate delivery system reform. Short of kicking people out of the system (see #1) there will be no other way to afford things.
Posted by: flory | November 17, 2008 5:02 PM
Of course, the whole point of establishing universality is that you will then have an across the political spectrum consensus for improving healthcare delivery.
That's only true if everyone gets their health care from the government. If everyone is forced to buy private insurance, the focus will be on keeping the cost of the mandate down (because many people can't afford to give as much as $1 to an insurance company) even if it comes at the expense of care.
Posted by: Dilan Esper | November 17, 2008 6:22 PM
But if the zone of opportunity narrows and a comprehensive reform is jettisoned for an incrementalist package, you could see a real battle between those who want to spend political capital on deliver system reform (which means overcoming opposition from entrenched medical industry interests) and those who want coverage expansion (which means overcoming opposition from Republicans and budget hawks). That would be a Bad Thing.
As I've argued since the primaries began, I believe the "delivery system reform" on the table is already less robust because of the desire to do both it (a little) and access reform at the same time. Recognizing the political capital that will be needed for mandates, government funding with poverty limits, public option, community rating, and the like-- our reform proposals during the Democratic primaries were unquestionably timid on the concept of "delivery system reform." High-level platitudes around pay-for-performance, discussion on variation in care without any real proposals behind it, "Comparative Effectivenss" without any insight as to what that means and what is being targeted. No mention of the billions wasted on procedures with no demonstrable clinical benefit, etc. There is a lot to system reform that wasn't even on the table-- and still isn't. So to the degree there is a battle between the two groups, its clear to me which has already won.
Posted by: wisewon | November 17, 2008 6:37 PM