Friday, April 8, 2011

Fixing Health Care: Care + Cost

Yes we have to fix financing. Yes we have to fix the delivery system. It's not a choice. Whichever we do first will not "work" (that is, control costs, and improve health) til we do both. It's understandable that we are having this debate: the Administration has tried to sell the delivery system reforms in the ACA as sufficient cost controls; many mainstream health economists are dubious about this, as are we. But it is also not the case, as Dr. McCanne asserts, that "the single payer model is structured as an altruistic, aspirational system that, quite automatically, actually does, in itself, improve quality and control costs." That's why every single payer bill before Congress also includes delivery sustem reforms, and always did. We need to be ready to fight for these reforms and for equity and accountability, as well as cost control, or we'll be surprised when the elected officials we put in charge of the single payer system cave in to the medical industrial complex. (Read up on Taiwan pre-single payer to get an idea of the relative simplicity and low cost of their system pre-reform. Different universe from the U.S.) Or try to cut funding for family planning.

As a single payer advocate I value the delivery system reforms in the ACA. They will not control costs unless and until we impose a budget on the healthcare system. We need a 900 pound government negotiator saying "no" to the drug, medical supply, institutional care, and provider industries. We can "save" all the money these reforms can achieve and the industry will find another pocket to put it into. (And by the way the ACA does put a cap on the Medicare budget as of 2019; we cd debate about the value of this and the likelihood of it occurring; but can also recognize the value of using the levers we have, including this one.)
But when we get to that point we'll be in better shape to make it work if we understand (as you both do) what we need to do to fix it so that people get care, and what safeguards and incentives we need to have to keep the system accountable. (It helps that Sebelius at HHS and CA's Insurance Commissioner Dave Jones, for example, are modeling what we want our regulators to do.)
Some people will not die in Massachusetts this year who otherwise would have because they have coverage. If they get sick next year, as the system becomes less "affordable" (meaning the state raises co-pays, instead of raising corporate taxes to pay for health care) they may be at greater risk.
We continue to murder people in hospitals through preventable errors in medications and other organizational dysfunctions, to say nothing of antibiotic resistance. This hasn't changed much since "To Err Is Human" came out in the 1990s. Electronic medical records will help address some of these problems. Better nurse staffing ratios will also help (something that nurses continue to fight for while fighting for single payer, because it improves quality and because it gives them more power as workers and professionals; it's a fight we can and must support at the same time as we fight to get rid of the parasitic insurance industry.)
Some teachers in CA took over a Wells Fargo bank in Oakland on Monday and closed it down for 2 hours.
If people all over the country were taking militant action on a regular basis, things might look a lot different today. Didn't happen. in 2009-10; might happen now.
So. do we go back now and accept that delivery system reforms in themselves, including those in the ACA, will control costs? Nope.
When we talk - and think - about what a single payer system is going to do and how we're going to make it work, why on earth would we abandon talking about delivery system reforms?

The point is not just to make health care cheaper; we could put the whole military budget into CMS and it wd be a vast improvement in our health. The point is to make the health care system equitable, high quality, universal, accountable and affordable. And to rebalance power relationships so that we have more of it (a major determinant of health).

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