Waiting for the Health Care Tsunami

One of the questions I get all the time is, okay, you study the health care system, what should it look like? How can we get out of the so-called state of crisis we’ve been screaming about for the past 30 years and create a system that is truly fair, effective and affordable?

Now, a pitfall of studying something closely for a long period of time is that there’s a tendency to become mesmerized by the minutiae of its parts and always invent reasons why the whole can’t change: too complex, too political, too many entrenched interests, too wrapped up in dysfunctional cultural expectations, too many economic obstacles, etc.

So, it’s hard to change something like the health care system by so-called intelligent design and rational planning. We plod along with occasional lurches to the left or right until something truly cataclysmic comes along – a health care tsunami, so to speak – that forces us to do things differently. We won’t change because we want to. We’ll change because we have to.

While we wait for the tsunami, here is my short version of what our health care system should look like. It’s what makes sense to me now, but I’m open to alternatives. The best thing about having a mind is that you can always change it.

1. Health care at some level is a basic right and a public good. What that level is, I don’t know, but that is the discussion we should be having, not whether everyone should have access to affordable, high quality services.
2. All Americans should be required to enroll in a national health insurance plan that would guarantee, but not necessarily deliver itself, a basic package of health care services, with an emphasis on preventive and primary care services and catastrophic coverage. This would be funded by broad-based taxes. All services would require co-pays scaled to income.
3. Everyone would enroll in one national risk pool. Services would be delivered privately through individual and/or group products. Insurance plans, brokers and the usual hordes of middlemen would make their money by arranging for the best care based on the best information based on efficient networks targeting carefully selected segments of users, and not on risk avoidance and cherry picking. Health plans would market and sell information and networks; some will design plans for people willing to trade up from the basic national plan to a dazzling variety of private plans. This will engender considerable controversy about fairness and social justice, which in turn will continually redefine the concept of ‘basic benefits.’
4. Medicare and Medicaid would fold into this one national system. Employer-based insurance – an anachronism in a global economy and transitory work environment – would not necessarily disappear, but employer health insurance tax deductibility would. Employers could choose to subsidize their employees’ health care or not, depending on the design of taxable benefit packages necessary to attract workers.
5. There would (eventually) be one national health information exchange based on one standard code for developing electronic medical records (EMR). The federal government would establish the code; various EMR and related products would be developed privately – and in infinite variety – based on common operational standards of transparency and portability.
6. Ideally, consumers would interact more directly with physicians and other providers through just-in-time electronic health and provider networks, increasingly managed by providers themselves (in the future, the smart docs will get business degrees, too). But maybe not. America is a nation of brokers. Otherwise, three-fourths of us would be out of work.
7. Information on quality and cost will naturally bubble up under this new system, which over time will tend to drive efficiency through the system. The result: general physician supply and salaries will decline; the profession will turn increasingly technical and fragmented; those that remain in practice will be highly rewarded. New providers and products will move upstream; services will be driven by software and complex technology/systems.
8. The health care system will go through this process of “industrialization” on the front end and eventually emerge on the other end as a transformed system based on shared values of fairness, openness, compassion and effectiveness. Human connection will trump ruthless economic efficiency; attraction will replace promotion as a growth strategy, and health care will be as much about adaptability and acceptance as it is about conquering disease and infirmities.

One could imagine other scenarios, of course. That’s the fun of it. While we wait for the tsunami, we make a life and pursue our dreams. Who knows? When the tidal wave finally hits, we may even be prepared. Wouldn’t that be a novel thought.

Feedback? Send it my way: Roger.Hughes@slhi.org.
*The Drift reflects the views of the author, and does not represent the official view of SLHI’s Board of Trustees and staff.