Reframe the health care debate

President Obama is scheduled to talk to us about health care this evening. Anyone notice how much of the health care debate isn’t about health care? I hope some of the follow on conversations are more substantive than much of the discourse over the summer. The results of a democratic process depend on the quality of the conversation. But we are spending a lot of time and money talking about other stuff.  Aside from some of the more obvious quality issues with the health care debate (e.g. bringing guns and trying to talk about gun control at a health care debate, focusing on the fabrication of “death panels,” ideological extremists decrying communism,  and the fact that many of the most vocal opponents of any health care reform already use a single payer government system [usually medicare]), we don’t talk much about the salient health care reform issues.

Here are the topics I want to hear analyzed from all sides of the health care reform debate:

• Economics of health care. This one is complex.  What are the trends of health care cost in terms of percentage of income and GDP?  How does this compare to 10 years ago? How will it look in 10 years? How much do we spend on health care vs. prevention vs. administration?  Who is paying whom for what?
• Health insurance.  Closely related to the topic above, insurance is a statistical and information problem.  An insurance company lives and dies on population statistics and predictive mathematics.  When insurance companies have enough information, they will choose only healthy customers;  when consumers have enough information, they will only buy insurance when they are about to incur expenses.  In the world of improving information gathering, access and analysis, there will be minimal shared risk. If we believe some baseline of health care is valuable to socienty, we need to build it into the system explicitly.
• Rationing.  (Again, broadly and economics problem.) Health care is rationed now.  People without insurance don’t get non-acute care. Insurance companies tell you what is covered and when. Insurance companies ration based on profit. Doctors make decisions to give and withhold care based on the personal ethics, pressures of time, cost, and legal considerations.  Health care will be rationed in the future. The question isn’t if, it is how and who and whether the process is transparent.
• Medicine as art and science.  Doctors, understandably, want autonomy.  Insurance companies, understandably, want less expensive treatments and minimal responsibilities, and patients, when scared, want everything possible.  We need to improve our ability to synthesize treatment form the experience and intuition of doctors (art) and both statistical and causal understanding of how the body works (the science of outcomes we can cause).  And we need to take some care around the “innocent frauds” of expensive drugs and treatments that don’t improve health or quality of life.
• Learning from other countries.  We seem to be pretty smug about our health care system.  Yet the rest of our economic and political peers in the World spend significantly less (20% – 50% less in the case of our favorite punching bags of Canada, Great Britain and France) and get similar outcomes (statistically) to ours from their health care systems.  We continue arrogantly dismissing these successes as if we have nothing to learn.  They have tried things that work and some that don’t. Ignoring this experience is foolish.
• Agency.  The current system is expensive and inefficient not primarily because of “conspiracies” but due to the system structure. Each party is making rational decisions given the compensation and risks each party has to deal with.  This problem isn’t going to fixed by encouraging people to “be better.” They are already being socially responsible, rational agents in most cases.  We need to redesign the system so that decisions that are good for the country are also good for the individual agents in most of their daily work.
• Inevitable change. The current trajectory of health care costs points to an unsustainable future.  Major reforms of parts of the system will happen–one way or another, now or 10 years from now. These problems can’t be solved by ideological soundbites yelled louder than the next guy’s.

We can improve on a design through better conversations.