The ACP Advocate Blog

by Bob Doherty

Wednesday, May 9, 2012

A health reform wish list

Remember as a kid tossing a coin into a fountain, closing your eyes, and silently mouthing your deepest wish (a puppy, a bike, a BB gun?). Didn't work, of course, unless your parents or Santa (coincidentally?) had the same wish for you.

Nowadays, I wish there was a magical Wishing Well that would deliver on my wish for a more civil, more informed, less ideological, more evidence-based, more compassionate, and less polarizing debate over health care reform and the Affordable Care Act. More specifically, I wish:

--That fiscal conservatives who say we can't afford the ACA because it doesn't do enough to control costs would not in the next breath label as "rationing" the programs it creates to reduce costs and even improve patient outcomes. Advance care planning, Accountable Care Organizations, evidence-based benefit packages, medical homes, Comparative Effectiveness Research, regulation of insurance companies' underwriting and administrative expenses, preventive care, and even the beleaguered Independent Payment Advisory Board may save money, or maybe they won't, and maybe there is a better way (let's hear it!), but they won't ration care, period. And while we are at it, how about acknowledging that no society can spend unlimited resources on health care alone, so decisions have to be made on what we can afford, and what we can't? It is just a question of how, and by whom.

--That liberals would not automatically dismiss the concerns of conservatives about the ACA's cost. The law will cost a ton of money—a trillion dollars over the next decade, according to the CBO. Both sides should admit that even though the CBO says that the law (barely) pays for itself, long-term cost estimating is an imprecise business and it could cost more, it might cost less. One can still argue that the ACA is worth it—my view, and ACP's view—for the good it can do in expanding health insurance and eliminating other barriers to care, while still acknowledging that it is legitimate to worry about the cost of a big new entitlement program.

--Speaking of CBO, I wish that all sides (and yes, I have done this myself, mea culpa!) would stop selectively citing the CBO or the Medicare actuary when it helps their case and then dismiss the same when it doesn't. The CBO and actuaries do the best they can, but as far as know they are not soothsayers and can't see the future. And let's face it, their methodologies are rather opaque. So yes, their forecasts should be considered in context, but we should all be a bit more humble about citing them to "prove'' our own biases.

--That conservatives would stop calling the law socialism. Only in America would subsidizing the purchase of private, often for-profit, health insurance be labeled socialism! (We do have socialized medicine in the U.S—it is called the VA and the health care system for men and women in uniform administered by the Department of Defense—but even Tea Party types aren't calling for their repeal!).

--That liberals would acknowledge that the government isn't the source of all good and business and markets the source of all evil. The government does some important and good things, like regulating the safety of food and drugs, funding medical research and providing programs to help people who are falling behind—like the uninsured who will be helped by the ACA. But the government also often does things inefficiently, bureaucratically, indifferently, and expensively, and at its worst, it can stifle innovation and distort markets. And corporations—yes, even drug companies and health insurers, for heaven's sake—can simultaneously contribute to the public good and generate profits for their shareholders, like producing a new cure (drug companies) and helping millions of people afford health care (insurers).

--That conservatives would acknowledge that the government isn't the source of all evil and business and markets the source of all good. An elected government "of the people, by the people, for the people" (as Lincoln called our American democracy in his Gettysburg address) is the way that Americans make decisions together on how to "promote the public welfare" (per the constitution). Government regulation and funding can help keep us safe, find cures to diseases, and provide economic help to people (see above list) when companies and markets are unable or unwilling to. The ACA was created precisely because business and markets alone have not been able to provide tens of millions of Americans with access to affordable health insurance.

--That liberals would listen to the concerns of conservatives about government getting too involved in their health care, the most personal of personal concerns. It is not irrational or unreasonable for people to worry that if the government can define what services will be covered, how and what their physicians would be paid, what insurance companies can cover, and even require people to buy health insurance, the government will over-reach and limit personal choices and freedom.

--That conservatives would acknowledge that lack of health insurance is a matter of life and death, and that liberals would admit that having health insurance doesn't guarantee access to care. It used to be that Republicans and Democrats alike agreed that the government has a role in ensuring that all Americans have access to health insurance, but disagreed on the means, but now many on the right argue that health insurance really isn't all that important, that the uninsured get care anyway. But an Urban Institute update of a groundbreaking Institute of Medicine report from several years back found that tens of thousands of Americans die each year because of lack of health insurance. But the left needs to understand that many of the uninsured get compassionate care from selfless physicians, and that health insurance won't guarantee access if, say, there aren't enough doctors to take care of them.

In other words, my wish is that all sides of the health reform debate would be more humble, more willing to consider the other sides' views, more informed about what the law actually does and doesn't do, less inclined to use polarizing and absolutist words to make their points, that is, to be more willing to listen to each other and try to find the right balance on how much the government should be involved in health care. But getting that wish fulfilled is about as likely as the BB gun I wanted as a child and that my (rightly) protective parents would never give me.

Today's question: What do you think of my wish list? Do you have your own?


Blogger Steve Lucas said...

Good list.

I would add a trick taught to me by an older flight instructor. Before doing anything with the plane he would stop, open his hands, and take a deep breath. While this only took seconds it allows you to break any tension and collect your thoughts about the task at hand.

A great trick I use everyday and one that has saved me countless mistakes, usually ones where I speak before I know what I am going to say. Take a second and think before speaking.

Steve Lucas

May 10, 2012 at 8:04 AM  
Blogger Jeffrey Jaeger said...

Bob, that's a great list. I think you owe it to the nation to turn this into an oped for the NYT or even the WSJ.

May 16, 2012 at 1:02 PM  

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Bob Doherty is Senior Vice President, American College of Physicians Government Affairs and Public Policy; Author of the ACP Advocate Blog

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