02/2003 Scandlen at Large: It’s Up to Us

Published February 1, 2003

Health care reform is going to be the biggest domestic issue in 2003. The private sector keeps developing new financing options, while financially strapped state governments are in a crisis over the rising costs of Medicaid and state employee benefits.

At the same time, the scientific community keeps developing new drugs and treatments that are full of promise, hospitals struggle to keep up with changing workforce demands, physicians are reeling from additional cuts in Medicare payments, and insurers are profoundly affected by seemingly unrelated issues such as lawsuit abuse, the drying up of reinsurance post 9/11, and depletion of their reserves by the weak stock market.

Patients, consumers, and workers may not know the details of the issues, but they are developing a growing insecurity about the whole system. It isn’t just financing. They also feel confusion about what the experts tell them about medical practice. Is hormone replacement therapy good or bad? Just when we get comfortable tracking our LDL cholesterol, they tell us C-reactive protein is more important. Do childhood vaccines really cause autism? Or is it just those that contain mercury? Or is the whole idea just paranoid bunk?

The Great Choice

Some people are attracted to the imagined simplicity and security of just letting the government take care of it. They have enough to worry about. Managed care has made them comfortable with ceding health care decisions to someone else … does it really matter if that “someone else” is a private insurer or the government?

Others recoil at the thought of concentrating more authority in government hands. They look at how the government runs other programs and see how interest groups and political patronage influence government’s decisions. They see how politically difficult it is just to add a prescription drug benefit to Medicare, and how all the generous benefits of Medicaid aren’t worth much if you can’t find a doctor who participates in the program. They don’t want Tom Delay and Nancy Pelosi defining their insurance benefits package.

Faced with confusion and complexity, which path will most Americans choose? Will we say, “This is just too much for me, somebody please take it off my hands?” Or will we decide that given all this chaos, we need to be the masters of our own fate? Will we impose our own order for the good of our own families?

The decisions we make next year and the year after will set us on a course that will have a profound effect on each one of us, our children, and our grandchildren yet to be born. There is no more important public policy issue than the future of our health care system. There is no service more personal and more intimate.

Let Health Care Compete

There is also no service more expensive. But who can say if it is too expensive? Who knows what the “right” amount is to spend on health care–or shoes, or peanut butter, or lawyers, or entertainment, for that matter? There is no right answer.

And there is no limit to how much money we could potentially spend on health care services. Our consumption is limited only by our priorities. Few of us would choose to spend every dollar we earn on health care services. We have other needs as well–food, shelter, clothing, education, even our desire to leave our children with an inheritance.

The way to determine the “right” amount of spending for health care is to have it compete with all the other needs and desires we have. Then we can make the judgments based on our own system of values and priorities. This requires removing the veil of subsidies, entitlements, mandates, and hidden taxes that currently hides the true cost of health care.

We who pay the taxes and insurance premiums, and we who earn our benefits as surely as we earn our wages, should be deciding how that money is spent–not some distant bureaucracy that doesn’t have a clue about who we are or what is important to us. Once we regain control of the dollars, the entire health care system will rearrange itself to suit us. That is the real meaning of “patient power.”

It’s Up to Us

But just as the health care system affects all of us, so are we all responsible for fixing it. This is not an issue that can be left in the hands of politicians … or employers, or doctors, or insurance companies. Reform is not a federal responsibility, nor a state, nor a private-sector one. It is our responsibility.

The reforms need to be all-inclusive. The private sector can do only so much before running into the restrictions of 50 years of ever-increasing regulations. Similarly, while the states have a lot of control over insurance regulation and the practice of medicine, they are also constrained by ERISA, HIPAA, Stark One and Stark Two, COBRA, and a whole bowl of alphabet soup. Even the feds can’t do it by themselves. In 1996 they enacted a limited medical savings account program, only to discover many states imposed requirements that prevented MSAs from being offered.

Meanwhile, employers and physicians are in pitched battle over the Patient Bill of Rights, insurers and pharmaceutical companies are at war over direct-to-consumer advertising, nurses and hospitals fight each other over wages, working conditions, and staffing requirements. The consumer gets lost in all these parochial battles, and reform becomes a tug-of-war over which special interest will prevail.

Ultimately, we health care consumers will have to assert ourselves. The big dogs and the fat cats have dropped the ball. They cannot be trusted to do the job. We need to start calling the shots, and the best way for us to do that is to retake control over our own money.

Greg Scandlen is director of the Galen Institute’s Center for Consumer Driven Health Care and assistant editor of Health Care News.