BOOK REVIEW – CRITICAL: WHAT WE CAN DO ABOUT THE HEALTH-CARE CRISIS. Sen. Tom Daschle with Scott S. Greenberger and Jeanne M. Lambrew. Thomas Dunn Books, St. Martin’s Press (2008).

 This small, readable book should be essential reading for all interested in the Health Care reform debate. It is probably more important for its influence than its content, because it was written by President Obama’s first choice as Secretary of HHS and lead player in the President’s efforts to accomplish health care reform until derailed by his failures in tax planning and by the current Deputy White House Health Care Reform guru, Jeanne M. Lambrew.

 

The book provides a useful overview of the history of Health Care reform efforts since the Truman administration. It details the failure of Clinton’s moribund Health Security Act stewarded by Hillary Clinton and Ira Magaziner.  The designers there organized 630 disparate people into 34 working groups in secrecy while ignoring the public and the Congress in the process.  This was a major lesson to the Obama administration who might have taken it too seriously by deferring to Congress to create the plan without much apparent guidance from the administration.  Then as now each stakeholder in the health care reform game concentrated upon his or her own narrow interests.

 Following the Clinton debacle the reform effort channeled into incremental reform with the adoption of the Health Insurance Portability and Accessibility Act of 1996 (“HIPAA”) and the State Children’s Health Insurance Program (“SCHIPS”). Not much has happened since. In the meantime health care inflation in the U.S. has continued to rise to the point that it now represents close to 17% of the U.S. Gross National Product and growing. It is the most expensive health care system in the world and yet it fails to provide universal coverage with about 23% of the population or 46 Million Americans without coverage for a variety of reasons.  What we receive in exchange is the 37th best health care system in the world (out of 191) according to the World Health Organization in 2000. (France was first with its cost at 11% of GNP).

 Daschle offers a number of solutions. One of his main recommendations is the establishment of a Federal Health Board, a panel of experts modeled after the Federal Reserve that would oversee the health care system in the U.S. and review new technologies and medicine for cost/benefit analysis and the establishment of evidence based treatment protocols to be recommended to physicians. This sends shivers up and down the collective spines of physician’s and the health care delivery system.  It conjures up images of rationing and otherwise limiting care and reduction of technological innovation and government intervention in the free market of medicine- “socialized medicine.”

 Unfortunately, the government is already much involved in the delivery of health care in the U.S. as the biggest provider and payment source and with the cost of health care chewing up an ever greater percent of the federal budget.  Like the automobile industry or the banking industry, when you get federal payments you get federal regulation.  While the idea of federal bureaucrats interfering in the relationship between a doctor and a patient is not appealing, the idea that a physician can ignore the predominant evidence based protocols concerning the administration of care and call on a blank check from the government to pay for it has its drawbacks as well. No one wants to stifle access to important new cures and technology in hopes that we or our loved ones might benefit from medical advances, but at what cost such a hope?  Ultimately even the government does respond to public demands for access and improvement.

Daschle recommends a “stealth” approach to reform legislations with broad general outlines left to federal agencies to fill in. He suggests expanding the Federal Employee’s Health Benefit Program to provide a lower administrative cost program to compete with health insurance providers and the use of the federal government’s financial clout in negotiating the purchase of services from hospitals, physicians, drug companies, etc.

Insurance companies want to have a level playing field by requiring all providers to give them the same deal they give the government. The insurance companies are saying that the federal reform effort is designed to take them out of business. The reformers like Daschle say that it is only fair competition.  In a sense they are both right. Insurance companies are encumbered by extremely high administrative costs and necessary profit margins that the public plan would not have to shoulder. The government has much more purchasing clout because of the size of its purchases.  That is unfair, but who benefits from the failure of the government to take advantage of its clout. Certainly not the public.

 On the other hand, what is value added that the public receives from having the insurance companies serve as intermediaries whose principal focus has been to avoid coverage whenever possible and to insure only the healthy, like Ambrose Bierce’s description of a banker as someone wanting to sell you an umbrella on a sunny day?  What are their deliverables that justify their existence in this market?  Shouldn’t that be a question that should be answered in the market place if a cogent answer exists? What responsibility do we and/or the government have for the 18, 000 annual deaths identified by the Institute of Medicine due to the lack of insurance?  Will “not my problem” continue to be the underpinning of U.S. health care?  These are all questions of trade-offs and should be the subject of reasoned debate.

The recent mob frenzy whipped up by demagogues and special interests seem intentionally designed to promote heat over light and to inflame the two antidotes to any meaningful reform – fear and distrust.  If you care about this issue and want to learn more – this little book is good place to start.