Nobody knew health care could be so complicated.
– President Donald Trump
Actually, lots of people did. In the president’s defense, I am sure he never had much reason to delve deeply into this topic before now. I suspect he is getting a crash course, and before long he will know that every so-called solution creates new problems.
In simplistic terms, we have 2 fundamental problems. Problem No. 1: Health care in the United States is too expensive. Problem No. 2: Too many of our citizens are under- or uninsured. Most attempts at addressing US health care woes have focused on problem No. 2. In fact, the Affordable Care Act (a misnomer if ever there was one) did virtually nothing to tackle problem No. 1. It did tackle problem No. 2 head-on, resulting in coverage for about 20 million US citizens who did not have it previously. It should come as no great surprise that costs have increased because someone must pay for the additional 20 million insured persons. I chuckle at how many seem to think the Affordable Care Act is the entire reason for the high cost of health care, however. Health care costs have been a major issue for 25-plus years.
If health care were more affordable, fixing problem No. 2 would be substantially easier. So why doesn’t anyone go after problem No. 1? There has been substantial talk in Congress over the past 2 weeks about “restoring the marketplace,” on the basis of the theory that the Affordable Care Act is stifling it. The snag is that the free market has never worked well in health care. Who shops around for the cheapest deal on an appendectomy? And do you really want the cheapest surgeon? Buying health care is simply not analogous to buying a TV. I suppose one could make it more like auto insurance. We do shop around for that. To do so would require de-linking health care from employment, which is an appealing notion.
Suppose your employer, rather than provide you with a couple of plans from which to choose, gave you the money it would have spent on premiums to purchase your own health insurance. That would create more options for the individual consumer and would stimulate the marketplace. Insurance companies would need to compete with one another for business and might negotiate more effectively regarding the cost of a box of Kleenex dispensed during your hospital stay. De-linking also would have the benefit of making people with chronic medical conditions less of an employment liability. It never ceases to amaze me when one of the first questions I receive after giving a patient a diagnosis of diffuse large B-cell lymphoma is, “Can I still work?” People are terrified of losing their jobs because job loss is the pathway to losing health insurance.
Of course, the simplest solution is a single-payer system. Put everyone in the same risk pool. The young and healthy essentially pay for the care of the old and sick, and the cycle continues as the previously young and healthy get old and sick. A single-payer system would have incredible leverage to force down cost simply by what it’s willing to reimburse. Some of that is appealing. I would love to see a situation in which pharmaceutical companies must open their books, and after they have recouped their development costs and made a healthy profit on a novel anticancer agent, they can no longer charge $13,000 per month. The potential danger here is that the single payer would hold all the cards in negotiating reimbursement with hospitals, health care systems, doctors, and pharmaceutical companies, and it might abuse that position.
We do have a single payer for our older citizens—Medicare. I hear Congress bash Medicare all the time with pronouncements like “it’s broke.” Of course it’s broke, you knuckleheads (I am talking to Congress now). It’s the system that takes care of the older and sicker citizens—whom no private insurance company will touch—and you are unwilling to tackle the cost issue. In fact, you exacerbated the problem by expressly prohibiting Medicare from negotiating drug prices or having a formulary when you passed the Medicare Part D provision in 2003. Pardon my French, but WTF?
So guess what. Health care is complicated. There is no simple fix. We do need to decide on some guiding principles and make decisions based upon them. For example, let’s agree that the most important stakeholder is the patient. We are all patients at some point. All decisions should flow from that premise. I suspect there is plenty of money in the health care system. By system, I am talking about the whole thing—hospitals, clinics, physician groups, pharmacies, drug companies, device companies, insurance companies, etc. We just need to spread it around and take care of one another.
Until next month,
Brad S. Kahl, MD