I started my career as a certified public accountant with one of the then “Big 8” public accounting firms. As each new presidential administration came in, we’d watch the latest and greatest tax reform proposal wind its convoluted way through the legislative maze like an afternoon soap—often with more drama and certainly better acting.
One of our favorite games was and is to track and predict the change in priorities through the legislative process. The initial set of priorities by the vocal tax reformers of either party usually started about like this:
- Tax simplification
- Deficit reduction or tax reduction (depending on the party)
- Income re-distribution (for one constituency or another)
- Policy manipulation (thru incentives and penalties)
- Earmarks (the cost of doing business)
During the public debate, the discourse was full of high morality sound bites—supply side economics, trickle down, deficit reduction, the balance of trade—you know the ones, but by the end, the change in priorities reflected the real deal making. In the end, regardless of who won, the priorities usually were:
- Earmarks (extortion)
- Policy manipulation
- Income re-distribution (based on who gained and who lost)
- Some mishmash of deficit/tax adjustment
As anyone who’s filed a tax return recently knows, the original top priority, tax simplification, was a consistent casualty of the legislative process. Clearly, its proponents didn’t have the power to prevail.
I’ve been thinking about that history as we prepare for President Obama’s big healthcare reform speech tomorrow evening. While I’m not convinced, there is at least the appearance that we are at the point in the protracted haggle where a deal may in fact be within reach. A middle ground may be taking shape.
So it’s time to reflect a bit on the evolving priorities in the healthcare reform debate and play our old game of priority prognostication.
Realizing that everything is fodder for hyperbole at this contentious moment, here’s a ridiculously high level view of what the original priorities were—although not necessarily in a consensus order:
- Reduce the cost of healthcare (for the government and employers)
- Increase access (for the 48 million people who do not have health insurance)
- Increase the quality of healthcare (at least partly by improving information exchange among providers)
- Improve the quality of life (implying a shift to prevention and consumer-centric wellness as well as improvements in living with chronic medical conditions)
The first thing worth noting is what’s not on the priority list. Despite the absurd claims of some, “socialized medicine” is not on anyone’s priority list.
Nor do I believe that “a public option” per se is a priority at all, although it may be a means to achieve priorities. We lose sight of this distinction when we look for the inclusion or exclusion of a public option as measure of the administration’s overall success or failure. If the final legislation makes significant progress towards the priorities, then it is a success regardless of the means.
But what is most amazing about the present discourse is the near absence of improving quality of life and the reduction of cost other than through the manipulation of insurance programs.
This is personal. As the child of two well educated, barely-employable disabled parents, our only access to healthcare came as a result of government insurance programs. It is unconscionable that today one in six people in our country do not have access to healthcare because they do not have insurance. Improving the quality of life is absolutely impossible if you don’t have access to adequate and timely healthcare because you do not have insurance.
It is not about free market versus socialism. If the free market is what is now operating (and that is open to discussion) it has not provided insurance for 48 million people. That is a fundamental failure. It is as simple as that.
As for cost reduction versus quality, it is not an exclusionary choice. There is no doubt that expanding coverage will increase total cost, which makes the focus on cost reduction even more important, but not an exclusionary alternative.
Therefore, as we look to President Obama’s important speech, here are a few items I’ll be listening for, at least between the lines if not addressed directly:
- Reduce cost and improve quality of life by reducing avoidable hospitalizations. Evidence suggests that we could cut cost by $10 billion per year net by improving our management of patient care post discharge. While $10 billion isn’t much in the context of a $2 trillion industry, it is still a big step. Furthermore, reducing avoidable hospitalizations will have consequential benefits such as lower sick time for employees and improved productivity for employers, not to mention improved satisfaction. It is also just the start of other improvements in delivery that can be achieved. (I’ve written about this before, so won’t repeat it all here.)
- Reduce unnecessary testing and improve diagnosis and treatment by improving information exchange among providers. (Fortunately, it appears that the present funding for health information technology is not itself being challenged, although incentives for implementation and support are far from assured.)
- Engage unofficial care givers through technology and process to promote healthy living and improve our ability to maintain active lives living with chronic medical conditions. With our amazing advances in treatment, we see both an aging society and a higher percentage living with or close to someone living with a chronic medical condition. This needs to be a clear and recognized priority.
- Rethink and expand our investment in Emergency Medical Services. A too easy casualty of the political process, EMS is critical to our healthcare system. On the one hand, we see constant and increasing funding pressures on EMS—in my opinion, at least partly because their lobbying power is not as strong as others. On the other, we see a huge increase in the use of EMS as a means of gaining access to healthcare for those who do not have access to insurance and who know they will be turned away if they enter through any other door. The consequence is a waste of precious resources and an increasing percentage of the population that does not seek care until a costly crisis is at hand. Whatever the result of the healthcare reform debate, we cannot allow the further deterioration of our excellent EMS system.
Last month, the Brookings Institute, with support from the Robert Wood Johnson Foundation, published a wonderful report called “Bending the Curve: Effective Steps to Address Long-Term Health Care Spending Growth.” The report suggests steps in five areas which can guide policy makers to substantially achieve the above priorities:
Build the necessary foundation for cost containment and value-based care;
- Reform provider payment systems to create accountability for lower-cost, high-quality care;
- Improve health insurance markets;
- Support better individual choices.
This excellent report stands as the scale against which we can measure the success or failure of our leaders. As we watch this important speech and then pay close attention to how our leaders react to it, I’ll be paying close attention to make sure that the original four worthy priorities are not thrown out with the wash, and I’ll be looking for an environment that allows us to make big progress on some of the specific areas that are outlined in this report.
And I hope we’ll do a better job of fulfilling our promise and meeting our priorities with healthcare reform than we have been able to do with our efforts at tax reform.