Fixing U.S. Healthcare blog reached its one-year anniversary last month. That’s a good time to take stock. And it’s a good time to summarize this blog’s message – that U.S. healthcare spending far outpaces spending in other comparable OECD (Organization for Economic Cooperation & Development) countries, as shown in the masthead graphic, above, and needs to be brought in line with the rest of the economy.
In these first 15 months, there have been 51 posts. These posts have been viewed by 187 visitors (actually by fewer, since some were repeat viewers) from 17 different countries.
I thank Word Press web publisher for providing the platform, occasional technical support, and design elements.
The Original Message and the New Revised Message
The original message was: The U.S. healthcare system has outgrown itself, and is now out of control. It delivers ever more treatments that have diminishing “marginal benefit” at costs far beyond their true value to either individuals or to society. In 1994, the Oregon Health Plan took control of healthcare and managed its costs for 8 years by starting with cost-benefit analysis and proceeding with well-cultivated public engagement. U.S. should scale up the Oregon Health Plan to reform the nation’s healthcare system.
The new revised message is still the same regards uncontrolled growth, unsustainable costs, and non-costworthiness. But the message now includes recognition that, while instructive, the Oregon Health Plan approach would not be sufficient. Twenty-five years since Oregon, U.S. healthcare has morphed into an economic sector that comprises almost 20% of the gross domestic product and is rigged to enrich powerful stakeholders. I conclude that only the full political, social, legal, economic and ethical weight of the federal government can encircle these entrenched interests and rein them in. There are several models for a federal healthcare reform plan that could fall squarely within American tradition and pragmatism.
Call to Action
This blog urges its readers and all citizens to Take Action. This means to think, talk, decide and ultimately engage our elected representatives to tackle healthcare reform. Interested? Then, look at details summarized below.
Some Specifics – Overviews
- 10-Part Video Series: This original YouTube series presents a panoramic look at how U.S. healthcare grew from a cottage industry in Colonial times into the miraculous but monstrous complex of today. It exposes how healthcare subverted its original purpose of health with unrestrained spending growth, and it looks at the consequences socially, politically, economically and philosophically.
- The Problem of Diminishing Marginal Benefit: This is one of the most popular video presentations. It shows that for each additional dollar spent, we get progressively less value.
- The Big Fix: This video presentation is a brief history of the Oregon Health Plan, another popular clip. It lays out lessons from Oregon that still apply today.
More Specifics – Key Claims
- Proposals of all stripes for fixing U.S. healthcare come from many quarters. But this blog concludes that only a comprehensive approach imposed from outside the system itself can effectively fix it and reverse its cost over-runs. For a critical look at other proposals as well as the case for a comprehensive fix see Will These Ideas Fix U.S. Healthcare?
- In particular, this blog disagrees with the claim that “private sector competition” alone will fix U.S. healthcare. Systems cannot set limits on themselves from the inside; the healthcare marketplace needs ground rules created from the outside the system for it to operate properly. Systems analysts, progressive politicians, economic theorists like Hayek, and physician thought leaders all agree in principle. See also Private Sector, Not Public Policy, Holds the Key to Healthcare Reform – Really? for a rebuttal of the “private sector competition” claim both conceptually and with actual empirical data.
- Cost-benefit analysis was a key principle underpinning Oregon’s success in 1994. See How Would Cost-Benefit Analysis Be Used to Restrain Healthcare Costs? for a detailed look at applying the technical concepts of “willingness to pay” and “cost per quality-life-year” to the case of an expensive new cholesterol drug.
- Up to 1/3 of current healthcare spending is harmful, unnecessary, inefficient or otherwise non-costworthy. See How Many Healthcare Dollars Are Wasted? for discussion of a 2012 analysis by RAND researcher and former Medicare chief Donald Berwick MD.
- Despite a divided political climate, Americans can all draw on shared values to reach agreement on healthcare reform, but only if we stop demonizing each other and instead start dialoging civilly. See How Could Oregon-Style Healthcare Reform Satisfy Liberals, Conservatives, Libertarians? for a discussion of social psychologist Jonathan Haidt’s model to support this hopeful claim.
- A landmark report in March 2018 zeroed in on prices as the main culprit responsible for spending in the U.S. that is double that in every other advanced country, not social determinants, over-utilization or unhealthy behaviors. See New Data from AMA Journal Rekindles Calls for Healthcare Reform for discussion of the Papanicolas report from Harvard and the London School of Economics.
- The JAMA data suggests that other advanced countries, no less than U.S., also waste much of their spending (although their wasted services cost less than ours). A careful look also shows that U.S. spending trajectory far outpaces other countries’ (See masthead graphic). This is evidence that the U.S. healthcare is “rigged” by non-market forces (and thus cannot be fixed by market mechanisms alone) – intervention from outside is needed. See more on the JAMA study.
- Who rigged the system? Brilliant elites who were originally well-meaning but eventually became misguided or coopted by greedy forces. See Taming the Healthcare Tapeworm for more discussion, including how we can un-rig the system.
- Where to Start: Four fresh ideas, and another based on Medicare-for-all.
- Socialism: Two posts and posts on why the “socialism” outcry is unhelpful, inflammatory, and bogus.
Conclusions and Warnings
- The politics of healthcare reform is currently mired in the same polarization as the rest of American politics. Politicians curry more votes by stoking outrage than by crafting solutions. Voters derive more gratification from righteous indignation than from civil compromise.
- This blog invokes the need for a new spirit of Yankee ingenuity, American idealism, and shared destiny. With a rekindled civic spirit, political and technical solutions for healthcare would still be daunting but would follow.
- On the other hand, without a rebirth of civic spirit, this blog contemplates two possible crisis scenarios:
- First, a perpetually simmering crisis of cost over-runs and ever-diminishing value. The medical-industrial establishment might be powerful and canny enough to perpetuate this status indefinitely, especially if healthcare polices itself to keep national health spending just shy of societal revolt, or if it buys off ethical health professionals, or if it sufficiently tamps down resistance with persuasive propagandist messaging.
- Or second, an explosive crisis, provoked either by erosion of trust that medicine still puts patient interests ahead of its own profits, or by a national financial tipping point (like Medicare bankruptcy), or by intolerable societal disparities (mushrooming numbers without access to quality care), or a combination. These breakdowns could sap national wealth, social cohesion and economic resilience, and weaken our world standing.
With Lincoln at Gettysburg, we can “resolve that this nation, under God, shall have a new birth of freedom – and that government of the people, by the people, for the people, shall not perish from the earth.” Could coming together on healthcare reform to free ourselves from the grips of the unsustainable healthcare “tapeworm” become a springboard for a new American spirit throughout our nation?
Now, Take Action
Country Comparison: Total health expenditure as percent of GDP, 1970 – 2017 by Peterson-Kaiser Health System Tracker, https://www.healthsystemtracker.org/indicator/spending/health-expenditure-gdp/
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Changes made: Blog author added to the graphic the labels “U.S.” and “OECD Average.”