How to Have a Rational Debate About Health Care Reform

Is there anyone left willing to talk about health care reform calmly?  At this point, the dialogue has become so partisan and stained that it seems that the only decision anyone needs to make is which team they’re on; then it becomes just a matter of saying anything you have to in order to win. Instead of a discussion of how we can make things better, or reduce the cost of health care to our economy, we’ve been spending time arguing about whether illegal aliens will be able to buy insurance, whether the government will force the elderly to decide when to die, or whether an optional public insurance plan is the equivalent of the Final Solution.

While I have my opinions on health care reform, I try every day to remove them from my work.  I’m a health services researcher, so it’s my job to study how we can improve the health care system.  And the one thing I can tell you for sure about the way we are talking about reform is that it’s backwards.  We’re looking for solutions, when we haven’t yet declared what the biggest problem is.

Here are some facts. There are three factors that are critical to every health care system: Quality, Cost, and Access. On all of them, the United States performs poorly.

It is a fact is that The United States spends about two to three times per person what most other countries spend. In 2007, we spent more than $7000 per person on health care. The UK spent less than $3000 per person. And we can quibble about the other differences between those two systems, but they’ve made a conscious decision to have an extra $4000 per person to spend on other things. Imagine if we had another $1.2 trillion dollars to play with.

It is a fact that our quality is middling at best and sometimes shockingly bad. And we can argue which is the best metric to pick to judge a health care system’s quality, but the truth is that it doesn’t matter. Life expectancy, infant mortality, maternal mortality, immunizations for children, immunizations for the elderly, the number of CAT scanners, the number of practicing physicians, continuity of care, and – most importantly – the number of preventable years of life lost - on all of them, every single one, the United States is sometimes in the middle and often at the bottom when compared to similar countries.

And, as one of the few countries that does not have universal coverage of its citizens, it is a fact that our access isn’t good. The latest census data showed that there are 46 million Americans who were without health insurance for all of last year. Almost half of those people have full-time jobs and are working. Many more have part-time jobs, or are retired, disabled, or stay-at-home parents. More than 15% of them are children. The uninsured aren’t shiftless, they aren’t lazy, and they didn’t choose this.

Further bad news is that (short of scrapping the system and starting over) any movement we make to improve any one of these three things is likely to negatively impact one of the other two.  Anyone who tells you that they can manipulate our current system to achieve universal coverage, improve quality, and reduce cost is lying - or a politician.  If we want to have an honest debate, we have to be honest about the repercussions of reform.

Want to do this right?  First, we need to decide which of the three – access, quality, and cost – are most important.  Then we need to decide what we are willing to sacrifice in order to achieve that goal.

Do you want to improve access? Then you need to admit to the American people that it’s going to cost money, and you have to discuss how we are going to raise that money. You may also want to address how this will affect the quality of everyone’s care, because it might.

Do you want to bring costs down?  Tell us how.  It’s going to have to come in the form of either covering less people or spending less on health care.  That can negatively impact quality as well.

You know what you can’t do?  Scream about the cost and the deficit and then lose your mind whenever someone discusses limiting coverage (rationing) or removing the profit incentive from insurance (public option).  Both of those things have been shown, empirically and theoretically, to reduce cost.

You know what else you can’t do? Demand universal coverage and then lose your mind whenever someone remarks that costs may skyrocket and that quality may suffer. Pointing those things out does not make you evil or mean you don’t care.

It’s easy to demonize those who disagree. We have to stop - right now. People who disagree with me or with you don’t hate America. Nor do they hate the poor. They don’t hate insurance companies, they don’t hate sick people, and they don’t hate capitalism. It’s a myth that only one solution is available or that we can’t disagree about what to do. We should debate this; we should argue with each other passionately. That’s what Americans do.

But let’s argue about the right things. There have to be trade-offs. What do we want out of a health care system? What exactly do we want to improve first? What are we willing to sacrifice to achieve that? Then, let’s figure out how we get there.

P.S.  Or we could scrap the whole system and start over, doing better in all three domains.  Pretty much every comparable country in the world does so.  Seems pretty rational, so it’s ironic that not doing that is the one thing everyone in this fight seems to agree on.

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