Sunday, September 30, 2007

Effect of culture -Health Reform and American Culture

Health Reform and American Culture:
Good Intentions, Unknown Consequences

“Almost daily, we're bombarded with apocalyptic warnings about the 47 million Americans who have no health insurance. Sen. Hillary Clinton wants to require everyone to have it, big companies to pay for it, and government to buy it for the poor.”

John Stossel, “Our Crazy Health-Insurance System,” September 26, 2007

James Carville, sparkplug of President Bill Clinton’s 1992 winning presidential campaign, proclaimed, “It’s the economy, stupid!” The slogan worked, and 12 years of Republican presidential reign ended. If Carville were to come up with a similar slogan for Hillary Clinton in her universal health reform campaign, it might be, “It’s the culture, stupid!”

She may be following that advice. Her new health care initiative promises no new federal bureaucracy, open choice of doctors and hospitals, leaving alone those happy with existing plans, punishing HMOs by forcing them to accept high risk patients, and, for starters, spending $100 billion to $125 billion more each year of government money to help cover the uninsured and fix the system..

The big problem is that she and other presidential candidates offer few convincing suggestions on how to significantly lower costs – the major U.S. health care issue. The candidates have put forth the usual cost-lowering list – EMRs to end errors and increase efficiency, preventive care, wellness programs, better coordination of care, and government negotiating Medicare drug contracts – none of which are likely to seriously dent inflation, which could cause Medicare to run out of money by 2017 if current projections hold.

The candidates are smart enough to avoid those cost cutting measures the American culture might reject -- limiting use of expensive new technologies, cutting reimbursements to badly needed doctors and hospitals, which employ 10% of Americans, or forcing people to use HMOs.

American Culture

Just what is American culture? One would have to be either a skilled anthropologist or an American historian to answer. But basically our culture dates back to attitudes of our founding fathers, who sought to avoid European aristocracy models and a centralized American government. So they created a Constitution with system of checks and balances. Add to that our culture is our belief in unlimited horizons of opportunity, fostered in part by the opening of the West, the natural resource riches, and our belief in American exceptionalism, and you have a picture of our culture.

Our health system is a creature of our culture. When asked what Americans believe, Garry Orren, a professor of political science at Brandeis, who polls for the New York Times and Washington Post, said, “A good place to start is to remember we are pro-democracy and anti-government. It comes down to ideas that are essentially any-authority and tend towards self-regulation. If there were an American creed, I think it might begin: one, government is best that governs least; two, majority rule, and three, equality of opportunity.”

Shattering the Creed?

Unremitting health inflation and vast numbers of uninsured may shatter this creed. But the creed explains why, up until now, at least, Americans prefer local or regional health solutions and choice, quick access to high tech procedures without waiting lines, why they have rejected federally mandated universal coverage since 1912, why they feel capable of making their own health decisions, why they allow market-based and public-based institutions to co-exist and compete, and why they have been reluctant to significantly raise taxes to pay for the have-nots.

What could happen now to overcome this culture of individualism and choice is the perception that the problems are so big – read 47 million uninsured and health inflation three times overall inflation - only government can handle it.

Monster Questions

But under any health reform proposal, whether market and government based, these monstrous problems will rear their enormous heads. not necessarily in this order.

• Where will the money come from to finance health care services – an open-ended demand fed by an aging U.S population, swollen by 78 million boomers set to qualify for Medicare in 2011.? It certainly won’t come solely from taxing the rich,” who already shoulder 70% of the overall tax load. Nor will it emanate from tax increases, when it’s been shown government revenues, now at an all-time high, increase with tax reductions, not tax increases. Individual mandates forcing everyone to buy insurance may be partial answer but not for the poor, who must be subsidized.

• Where will new physicians, or their replacements, come from? Already projections are we’ll be 50,000 doctors short by 2010 and 200,000 by 2020? Maybe physician assistants and nurse practitioners and international graduates will fill the gap, but its likely new federally-financed medical schools will be necessary to meet the needs of our immigrant-fed swollen population, likely to reach 350 million by 2020.

• How will reform prevent for-profit HMOs, with investor stakeholders, from charging higher premiums, after being forced to accept high risk patient’s raises costs and cuts profits? Whether we like it or not, 85% of HMOs are for-profit, and these HMOs are responsible for administering care for most private planes and many Medicare and Medicaid plans. As far as I know, profit still drives U.S. capitalism. The same profitability argument might apply to drug companies, whose financial stability may be threatened by low-balling government negotiated drug prices. Will government allow reasonable profitability for the drug industry – one of the bulwarks of our economy?

• Who will pay physicians, already in short supply and overloaded with patients, to spend time counseling patients about wellness and prevention? So far government and the private sector haven’t shown any inclination to come up with the money. Maybe employer-based wellness and prevention programs will help.

• If wellness and prevention strategies work, who will care for and pay for elderly patients who survive to die a “natural death? At home and in nursing homes? As everybody knows, our Medicaid system is already stretched to its budgetary limits paying for nursing home care.

• Who will protect doctors against predatory lawyers, who may thrive should demanding boomers not get what they demand from doctors? So far, the presidential candidates have chosen to avoid the $30 billion to $50 billion problem of “defensive medicine” and frivolous malpractice suites, the threat of which is driving many doctors to early retirement or denial of risky drugs, tests, or procedures.

• How are patients and their doctors to deal with and master the vast array of new technologies promising better health and greater longevity? It’s fine to claim predictive modeling, clinical protocols, and policing of those who don’t practice evidence-based medicine will streamline and improve the system - but who will enforce the rules and who will pay for the systems required?

• How can one judge and punish doctors for poor outcomes, when these outcomes are often due to patient non-compliance outside the physicians’ office? For example, 30% of patients never fill their initial prescriptions, and as many as 50% don’t opt for refills. Who will educate these patients, and how will we identify and punish the non-compliers who refuse change their bad habits or comply with doctors’ orders? Do we make smokers, drinkers, over-eaters, and non-exercisers ineligible for work – or do we make them social pariahs? In a democracy, we do neither.

• Who will pay for all of those EMRs, which cost roughly $15,000 to 30,000 per physician per year to implement? And how we reward doctors and their staffs for the time, effort, and upkeep of these systems and for the expense of entering the data to meet all those quality indicators to make them eligible for pay for performance rewards?

• How will the federal government round up and punish citizens who don’t pay for mandatory insurance? The IRS, despite its vast regulatory apparatus, only collects 85% of taxes it levies. And perhaps 20% of drivers never pay auto insurance, though it’s mandatory in most states.

In The End

In the end, I suspect some patch-work system, comprised of both federal and private elements, and covering more citizens, will evolve. It’s likely the reformed system will permit stratification of care, meaning if you have the means, you’re likely to be able to gain access to the care you want. And it may even shrink the number of uninsured through some combination of higher taxes, near universal coverage, individual mandates, and employer-based fines and taxes. Trickle-down regulation may partially circumvent or pacify most those who expect much and enjoy the freedoms of the American culture, but don’t count on it.


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