Who Knows Best: The Quest for Equitable Health Reform

Government may think it knoweth,
What is best for most of us,
But the market often bestoweth,
What is good for the rest of us.

From Foreword, The Health Reform Maze (2011)

February 13, 2013 – Who knows what’s best for Americans’ health care? And what is the most equitable way of going about providing  that care?

·         Government politicians and experts?   Certainly that is the intent of the Affordable Care Act. At least that is what the ACA’s proponents would have you believe.  That has been the case since Alexander Hamilton (1755-1804), one of our founders, said a government of elites could best decide what is best for the rest of us.  President Thomas Jefferson (1743-1826),  another founder, disagreed with Hamilton.   Jefferson maintained the will of the people and free markets  should prevail.  There is no doubt the government has the political platform – and  the money to fund the  administrative, technological, and information resources -  to do the job.  But government control comes at a price – personal freedoms and suppression of normal market forces. 

·         People themselves?   Perhaps.   But ordinary people  may lack the requisite  information to decide what is best. They  may be  gullible. Hucksters and those who profit from providing care may mislead them.   Still, there is another school of thought  among those who back a concept known as defined contributions or vouchers.   These folks say: give a fixed,   tax-exempt discrete amount of money,  to every citizen,  to spend as they see fit.  People are smart, and given the right information, they  will decide what is best for themselves and their families.   This school is led by those who advocate  Health Savings Accounts for everyone and their families  to spend as the occasion arises from birth until death. 

·         Health professionals?  These include doctors, hospitals, and a host of other trained caregivers who provide care.    But, ah, say critics.   These various professionals are paid on the basis of fee-for-service. That is an open invitation to overuse services.  Fee-for-service payment cannot be trusted.  Only government oversight and regulations can curtail  inherent greed in a FFS system.   Only not-for-profit organizations should be allowed to exist in a national health system.   Physicians should be paid on salaries.  Private options, and private contracts, outside of government should be verboten.  Market forces, in other words, cannot be trusted to provide equitable “fair” care for all citizens, regardless of economic status.  The cliché, “Doctor knows best,” is outdated, even as the drug companies keep advising, “Ask your doctor before taking this medication.

• Integrated care organizations?   Then there are those who insist the answer lies in organizations providing “integrated,” “coordinated,” “patient-centered, “ evidence-based care, “ “team” care.  The “evidence” in most cases is data accumulated from mandated electronic medical records and government-sponsored comparative outcome studies.    Ideally,  these organizations should consist of regulated health plans,   hospitals, and salaried physicians under one corporate roof.  Kaiser Permanente, headquartered in Oakland, California, is the  prototype of this type of organization. Its CEO, George Halvorson says to make these organizations work:

        “We must make online information instantly available at the doctor’s offices, at the bedside, at    policy levels, and to health consumers; we must invest heavily in electronic health records, as Kaiser has done by investing $4 billion in its electronic information system; we must innovate;  we must form ready-response teams to respond to the crisis of hospital-acquired infections; and we  must educate patients with diabetes and heart disease and hypertension how to prevent and minimize complications, from these and other chronic conditions."

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