[Mb-civic] The Fix-It Myth - Robert J. Samuelson - Washington Post
Op-Ed
William Swiggard
swiggard at comcast.net
Thu Jan 26 03:08:31 PST 2006
The Fix-It Myth
By Robert J. Samuelson
Thursday, January 26, 2006; A25
Almost everyone agrees that we ought to "fix the health care system" --
a completely meaningless phrase despite its popularity with politicians,
pundits and "experts." Indeed, it is popular precisely because it is
meaningless. The people who proclaim it rarely tell you the
discomforting choices it might involve. Instead, they focus on a few
specific shortcomings of our $1.9 trillion health-industrial complex and
imply that, if we correct these often serious flaws, we'll have "fixed"
the system or at least made a good start. This is rarely true, and so
most forays into "health reform" end with disillusion.
We are about to start the cycle again. By most accounts, President Bush
plans to highlight health care in his forthcoming State of the Union
address. His proposals may or may not have merit, but they surely won't
fix the health system in any fundamental way. The reason is that most
Americans don't want to fix the system in that sense. Most are satisfied
with their care. Most don't see (or directly pay) the vast majority of
their costs. Because politicians -- of both parties -- reflect public
opinion, they won't do more than tinker.
Unfortunately, tinkering isn't enough. As everyone knows, health care
spending has risen steadily. In 2004, it totaled 16 percent of national
income, up from 7.2 percent in 1970. Spending will continue to rise, if
for no other reasons than that the population is aging and the average
annual health costs for someone 65 and older ($7,910 in 2003) are --
surprise -- more than twice those for someone 35 to 54 ($2,966). As
health insurance becomes more costly, the number of uninsured, now about
46 million, may grow. Worse, health costs may depress wage gains, raise
taxes and squeeze other government programs.
Here's the paradox: A health care system that satisfies most of us as
individuals may hurt us as a society. Let me offer myself as an example.
All my doctors are in small practices. I like it that way. It seems to
make for closer personal connections. But I'm always stunned by how many
people they employ for nonmedical chores -- appointments, recordkeeping,
insurance collections. A bigger practice, though more impersonal, might
be more efficient. Because insurance covers most of my medical bills,
though, I don't have any stake in switching.
On a grander scale, that's our predicament. Americans generally want
their health care system to do three things: (1) provide needed care to
all people, regardless of income; (2) maintain our freedom to pick
doctors and their freedom to recommend the best care for us; and (3)
control costs. The trouble is that these laudable goals aren't
compatible. We can have any two of them, but not all three. Everyone can
get care with complete choice -- but costs will explode, because
patients and doctors have no reason to control them. We can control
costs but only by denying care or limiting choices.
Disliking the inconsistencies, we hide them -- to individuals. We
subsidize employer-paid health insurance by excluding it from income
taxes (the 2006 cost to government: an estimated $126 billion). Most
workers don't see the full costs of their health care; a reported Bush
proposal to add new tax subsidies would magnify the effect. A similar
blindness applies to Medicare recipients, whose costs are paid mainly by
other people's payroll taxes. Despite complaints about rising
co-payments and deductibles, out-of-pocket costs are still falling as a
share of all health spending. In 2004, they were 12.5 percent; in 1993,
they were 15.8 percent.
We're living in a fantasy world. Given our inconsistent expectations, no
health care system -- not one completely run by government or one
following "market" principles -- can satisfy public opinion. Politicians
and pundits can score cheap points by emphasizing one goal or another
(insure the uninsured, cover drugs for Medicare recipients, expand
"choice") without facing the harder job: finding a better balance among
competing goals.
Every attempt to do so has failed. Consider the "managed care"
experiment of the 1990s. The idea was simple: Herd patients into health
maintenance organizations or large physician networks; impose "best
practices" on doctors and patients to encourage preventive medicine and
eliminate wasteful spending; and cut costs through administrative
economies. For a while, it seemed to work. From 1993 to 1997, private
insurance premiums rose only 2.6 percent annually. But managed care
upset doctors and patients. It restricted personal choice. Some coverage
denials seemed inhumane or inept. After a political backlash,
managed-care organizations relaxed cost controls.
Now, some say that because the "market" has failed, greater government
control is the answer. Private insurance has high overhead costs and
generates too much paperwork. True. Still, there's not much evidence
that over long periods government controls health spending any better.
From 1970 to 2003, Medicare spending rose an average of 9 percent
annually, reports the Kaiser Family Foundation. In the same years,
private insurance costs rose 10.1 percent annually. Part of the gap
reflected private insurance's greater generosity. It covered drugs while
Medicare didn't.
Americans want more health care for less money, and when they don't get
it, they indict drug companies, insurers, trial lawyers and bureaucrats.
Although these familiar scapegoats may not be blameless, the real
problem is us. We demand the impossible. The changes we truly need are
political. We need to reconnect people with the public consequences of
their private acts. We should curb the subsidization of private
insurance. Medicare recipients, especially wealthier ones, should pay
more of their bills. But these changes won't happen because people don't
want to see the costs. We don't have the health care system we need, but
we do have the one we deserve.
http://www.washingtonpost.com/wp-dyn/content/article/2006/01/25/AR2006012501782.html
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