Healthcare Challenges

Last week’s attempt to repeal Obamacare and replace it with what by pretty much all accounts was a rather pathetic package of half-measures, brings the challenges of healthcare back into clear focus.  Unfortunately, the solutions to these challenges are not nearly as clear as the challenges themselves.

Healthcare is a multi-layered problem, which makes it particularly resistant to easy fixes.  Cost and efficacy are interwoven in a complex web.  There are numerous basic contradictions or paradoxes at the heart of the issue.  Here are some of them:

Should healthcare be considered a right for every citizen, regardless of income level or status?  I find it difficult to understand how one can argue against this proposition in a modern, developed nation.  One can debate how much healthcare is guaranteed, but basic healthcare should be provided for everyone.  Someday soon we will be shocked that we once allowed people to go bankrupt with healthcare expenses or denied life-saving measures to people who could not afford them, just as we are now amazed that we once condoned slavery.

Should everyone in society participate in healthcare insurance?  This also seems irrefutably logical to me.  If we are willing to require participation in a social security system and medicare system for later years, then it only makes sense to extend this to the entire lifetime of healthcare provision.  How else can we conceivably fund the care of the sick if we do not have full participation?  This is simply an extension of the basic concept of shared risk and communal responsibility.

Do patients have certain obligations as recipients of societal healthcare?  Of course they do!  They should use this scarce and finite resource wisely, being careful not to waste it on frivolous practices.  They should attempt to lead healthy lives so as to minimize their own necessary usage of healthcare.  They should diligently follow the instructions of their healthcare providers. 

Is there any way to motivate or even force people to act responsibly in this regard?  That is a more difficult question.  There must be certain safeguards put in place to monitor and control usage.  Co-pays, deductibles and various other financial mechanisms should be carefully crafted to ensure that healthcare usage is not frivolously engaged, but also is available and encouraged when truly needed.  Moreover, there should be a strong public service ‘indoctrination’ for every citizen about how to lead healthy lives and how to use healthcare services effectively and economically.

There is a fine line between encouraging citizens to use healthcare services energetically to minimize disease and using it too much as a self-indulgence. 

What kind of responsibilities do healthcare providers have?  They must have both ethical and economic incentives to provide the best possible healthcare with as much frugality as possible.  These are often contradictory goals and fine tuning them will be a constant and intricate process.  ‘Playing it safe’ for a healthcare provider will often mean ordering excessive tests.  But with the threat of malpractice lawsuits ever-present, it is difficult to curb this tendency.  Malpractice reform seems to be necessary if we are to control the arms race of lawyers and doctors/hospitals.  Doctors must have the freedom to manage their patients and their practices, but they must also be held to reasonable standards of both patient care and healthcare expense.

End of life expense control must become a priority, or we will be spending a large percentage of our medical dollars on a period of life that quite candidly provides very little return on investment.  The predisposition of elderly people to over-utilize medical services is well known, whether out of boredom, loneliness or understandable frustration with a rapidly deteriorating body.  Hard decisions have to be met regarding how much healthcare can be provided for an ever-increasing number of senior citizens.

The concept of free market components of healthcare has been trumpeted as the way to control costs, avoid bureaucracy and increase efficiency.  In general, competition does indeed create more efficient delivery of goods and services.  However, here again there are paradoxical elements that make a free market approach somewhat problematic.

Insurance companies will naturally attempt to increase profits by limiting what procedures or care they pay for and limiting their clientele to the healthy rather than the sick.  If we are to create free market conditions, then the rules must be constructed such that any profits are derived from efficiencies in healthcare delivery and management, not from limiting care or rejecting people with less fortunate health profiles.  This, of course, is not easily tracked or accomplished.  There are certain aspects of society that do not easily lend themselves to free market implementations.  For example, we would never allow our military defense to become a free market commodity.  We have seen that private prisons are also not necessarily a panacea. The question is whether healthcare falls into this category as well.  The fact that we spend more dollars per person in the U.S. for healthcare than other developed nations with single payer systems certainly begs this question.

If our leaders would evaluate the healthcare challenge as a policy issue and avoid the polemics and demagoguery, then it might be possible to craft a plan that can meet the needs of society without the expense spiraling out of control.  There are numerous reasonably successful models in Europe and Canada to analyze.  The U.S. may be different than those nations, but it can certainly learn from them if we can for once humbly acknowledge that we are not always the most perfect nation on earth!