Why Can’t Americans Get Health Care Right?

Change is desperately needed, agreed readers of Professor Jim Heskett's online forum. But how to make that change remains in doubt. What can Americans learn from solutions implemented by other countries? (Forum now closed; next forum begins September 4.)
by Jim Heskett

Summing Up

Does U.S. health care need more pull or push? There are clear symptoms that something is wrong with U.S. health care. In Edward Hare's words, "It's making us uncompetitive and turning us against each other." In this month's discussion, several of you (for example, Lisa Manners) provided excellent comparative data of the kind that we have seen all too little in the public debate on the matter. And nearly everyone admirably avoided the political rhetoric that has clouded rational thought about a truly complex problem.

The possible causes related to the symptoms suggested above are numerous in a channel that includes, in your comments, food and tobacco producers of unhealthy products (Christy Hitchens, Tom Dolembo); lifestyle equipment and service providers; developers and manufacturers of high-cost pharmaceuticals and medical equipment (James Shanahan, Karen); health care providers such as doctors and hospitals placing profits before client needs (David Stahl, John Van Slyke, Roger Chen, Jan Fersing, Hugh Quick, among others); the agency problem separating payers such as individuals, businesses, and the Government from users (Adam Hartung, Tom Witt, William Freyd); profit-oriented risk managers and payment processors such as insurers (R. MacKenzey, Emre Erkut, and others); specialized service providers (including malpractice lawyers) at various points in the channel (C. J. Cullinane, Michael Otten, and others); providers of currently insufficient and uncoordinated information and education (Mark Beaty, Carlos V., Scott Beaumont, among others); and finally citizens, patients, and their loved ones who do or don't take part in managing their own wellness and care (Mary Parker).

All of this is transpiring in an economy in which more and more people work as contractors in need of portable self-insurance and a consumer-based rather than an employer-based insurance system (Greg Bownik, Al Rossow, Katherine Daley).

No wonder it's hard to define the problem and take action or that several of you concluded that the response requires more time to gather and digest information, test ideas, define the purpose, and align it to a strategy (Akram Boutros, Jack Slagle, Nikos Mourkogiannis, among others). This all will require more leadership (Paul Karras, Phil Clark).

There was general agreement that change is needed. The means by which change should be achieved is in question. Where, for example, should fiat or regulation ("push"), incentives or subsidies ("pull"), or the provision of new information, education, or even competitive alternatives be employed? Given the current proclivity toward "pull" (or as we discussed in an earlier column, "nudge") to what extent and how should we employ incentives? For example, Curtis Craig suggested, "Let's incentivize quality of health care and deincentivize unhealthy or inefficient practices." Just how could that be done? By whom? What do you think?

Original Article

It is said that health care is the biggest threat to the long-term health of the U.S. economy and therefore, to some extent, the global economy. Americans pay much more for what they get (at least measured in terms of share of GNP spent, results obtained, and the percentage of the population covered) than any other country. And things don't seem to be getting any better.

There are a large number of examples of various approaches to the problem extant in the world, nearly all of which include greater government involvement than in the United States. The current debate in the U.S. centers, to some extent, on whether there should be a publicly administered alternative to the private health care system, as opposed to other countries in which private care is supplementary to the public system.

Harvard economist Greg Mankiw, for example, argues that a public option, to the extent that it will require Government subsidy while providing price leadership under a nonprofit cover, will over time drive most if not all health care to the public option (as happened with home mortgage giants Fannie Mae and Freddie Mac), creating the equivalent of a single-payer option. As he argues, "consumer choice and honest competition … are usually achieved without a public provider. We don't need government-run grocery stores or government-run gas stations to ensure that Americans can buy food and fuel at reasonable prices." The problem, of course, is that we are not talking about food and fuel; we're talking about health care, about which consumers and providers may be less rational.

For example, behavioral economists would tell us, among other things, that in the world of health care: (1) consumers have personal fears and lack of information that don't exist with food and fuel, (2) they equate cost with quality, turning the idea of rational markets upside down, (3) individuals' decisions regarding wellness affect the rest of us, (4) rationing is necessary but difficult to achieve, (5) there is an agency problem when neither payers nor providers (including pharma) are penalized by higher costs, (6) there is a "fee for services" vs. a "fee for results" payment system, (7) the U.S. has too many high-cost specialists performing work that could be performed more effectively by general practitioners and registered nurses, (8) high levels of liability encourage the practice of "overly-safe" and expensive medicine, (9) providers have fragmented and often incomplete information, and (10) consumers either have too little information with which to make rational decisions or don't make good use of the information they have.

Why, in a country that provides more medical research to the world than any other, can't Americans get health care right? Is it a problem of too much money chasing the problem? The wrong kinds of capacity? The wrong incentives? Too little or too much regulation? Too much pride in a dysfunctional system? What, if anything, can we learn from solutions implemented by other countries? For example, should Americans have a public option? What else? What do you think?

To read more:

N. Gregory Mankiw, "The Pitfalls of the Public Option," The New York Times, June 28, 2009, p. 5.

    • CJ Cullinane
    If you would like to see a government health care facility in action, go to a VA Hospital. Not perfect but they do get the job done, but how many Americans would want a system like this? The big problem with our system is many of its components (middle men?) are making a lot of money. Consider the lawsuits and insurance cost increases because of them. This is just one example, as you know there are many more.

    I do not know the answer but it is a huge problem.

    • Zack
    I am for a single-payer medicare for all option.
    • Will
    I am interested in solving problem (6) in the list - fee for service versus fee for results. Fee for service is also directly responsible for (7) - too many specialists. To me it is the root of the whole issue. So how to solve fee for service? Do we remove insurance and claims processes from the mix? In the UK, there is no claim. Do we allow benficiaries to choose providers and then provide a fixed subsidy to the provider?
    • David G Stahl
    • Software Developer
    I would prefer a single payer system [my spouse is a physician, a highly paid specialist].

    There is no effective way to comparison shop for health care. It is emergent. There is no effective way to shop for health insurance, as an individual I play a small role in my fortune 500 company's insurance purchase.

    In my wife's field - pathology makes great returns - so each sample sent to the lab is money in the bank. Time to talk with the patient - doesn't pay well. We need to get beyond paying for a particular diagnosis - and pay for Dr's time.

    My wife can also make a diagnosis just by looking at someone in the blink of an eye. It is hard to figure out what a value that is - does she get paid a percentage of the time, money, and effort she saved by her accurate knowledge of her field?

    At the end of the day I hope we end up with the system that educates people on how to be better consumers of health care, a single system for payments/re-imbursement, a rational system for identifying effective treatments, and appropriate penalties on people that scam, over use, and abuse the system.

    Looking at CEO pay in the Financial World - my sense is we are a long way from knowing how to do that; and waiting for the invisible hand of the market will not save us either.

    • Adam Hartung
    • Managing Partner, Spark Partners
    100 years ago there was no "health care industry." The vast majority of doctors had never been to medical school. Pharmacists administered cocaine and opium over the counter. Snake oil salesmen sold cure-alls to anyone with a nickel, dime or quarter. Many weren't covered, many died unnecessarily, care was spotty and quality was hard to evaluate. But the customer made the buying decision, and the provider got paid by the customer.

    For uniquely American reasons the "health care system" developed as an employer-based program. This separated the customer from paying by two steps - the employer and the insurance company. People rarely knew the price for any specific health care, and even more rarely cared. But the standard for unlimited care at any price was created by having these intermediaries - that offered little, if any, value. Instead, the created confusion and mistrust.

    Unfortunately, the impact (runaway cost) has fallen hardest on employers. Those most incented to change are not the customer, but the middle-man. And that person doesn't talk to the service provider, but yet another middle man called the insurer. It's not that health care doesn't work - we have the best health care in the world - it's just that the cost is out of control with too many people between the service provider and the customer. People don't complain about health care - they complain when their employer won't pay for it.

    If we want to keep American workers viable we must alter the system to place the purchase, and price negotiation, in the hands of the customer. Single-market pricing becomes key, rather than the disturbing differential price ranges which now exist. And cost must be tied back to the users so they have some incentive to conserve. No longer simply spending "other people's money."

    Otherwise, we will be forced to have single payer in America, where everyone is covered and rationing exists.

    The system with middlemen provides no price control, or purchase control, and unfortunately increasingly makes businesses of all types less competitive. For whatever good the insurance industry felt it did in health care, we can now see they simply make the delivery process more cumbersome, expensive and opaque to users. At the expense of employers. Employers need to rid themselves of this burden, which is a dramatic distraction to their role, by putting health care cost control in the hands of customers or the government.
    • Al
    Most of the concerns listed could equally apply to our legal system or our tax system. The basic concept of insurance is risk sharing, in which people who consume less resources pay for those who consume more, with the insurer setting up the cost to participate and the services covered. In health care, that has also allowed the insurer to dictate who and where delivers the services (distinctly different from auto insurance, where the premium is based on the performance of the driver).

    The complexity of medicine is not well-recognized, even though we know so much more than 100 years ago. We have better diagnostic tools, better medications, and better procedures, all of which come at a cost. The resulting complexity leads to specialization in the profession in order to provide expertise (just like the legal or financial professions). As a society, we both expect miracles and demand perfection.

    Two significant costs in health care are "extreme care" and "entitled care." Extreme care is extensive and intensive care with little likelihood of success for end-stage care. Liver, lung, and heart transplants come to mind. Entitled care is the provision of medical services in emergency settings to people who, because they are indigent, have the right to emergent care under the Hill-Burton act without the responsibility to pay for it. The expenses for these services are the risks that everyone else pays for.

    I am in favor of simple first steps:
    1. Have the government define "basic health care for everyone" and then require every insurance company to offer such a policy. Do not provide "catastrophic care coverage" as part of this. State governments do this for auto insurance.
    2. Have a graduated premium scale for the policy above based simply on the deductible chosen by the insured.
    3. Make health insurance premiums tax exempt and "government supported" by making them tax credits. In essence, the government pays for the insurance by making first tax dollars go to health insurance for basic care.
    4. Eliminate employer-purchased health insurance, putting the choice of insurance in the hands of the consumer and not the employer. This would also make the insurance a purchasor-tied product rather than an employment/employer-tied product.
    • Akram Boutros, MD, FACHE
    • Founder and President, i3 Business Performance Solutions
    The Healthcare Debate - Important, Heated, Misguided, and Costly.

    The ways of delivering health care in the United States has evolved over the years. It is a complex hodgepodge of rules and regulations aimed at the paradoxical notions of CONTROL and CHOICE.

    There is no structure to promote the overall effectiveness of health care. Our society values the amount of services we get more than the quality of services we get. We also treat healthcare as separate areas, there's no continuum of care. So you go to a doctor who refers you to another doctor who then has you provided with testing elsewhere. Then you come to a hospital for a procedure and then you go to post acute care. All that information is never shared; only very small bits of the information are shared, creating inefficacies in healthcare. Finally, we value treatment much more than we value prevention.

    The current system is a product of lots of unaligned incentives. Individuals have no incentive to go to the doctor until they are sick, I as a physician have incentive to see you as often as possible and keep you happy, and the hospitals are rewarded for performing procedures, so there's very little investment in prevention. The alignment of the system is very poor.

    Genuine civil debate is always helpful. What is harmful is the notion that there is a quick fix to this. We didn't get here overnight and we can't get back on track overnight.

    If I were given the opportunity to fix the health care system, I would put together a commission that would have leaders from consumer groups, medicine, healthcare, technology, economics and sociology and give them three to five years to study the issue and come back with long-term recommendations.

    One of the key emerging solutions is Employer Managed Healthcare. I agree with Clay Christiansen in "The Innovator's Prescription" that it is the most efficient, and effective way to align all parties' incentives.

    I'm so committed to that concept that I created a company, EmployeeFIRST, aimed at helping municipalities, unions, and large employers deliver convenient, accessible, efficient, effective, measurable, wellness-focused healthcare.

    Companies like QuadGraphics have demonstrated near perfect health outcomes for its employees, incredible job satisfaction, and almost 40% lower costs when they used this model. Everyone involved is happy with the results. The employees receive convenient care for themselves and their families; they have no out of pocket expenses; they are healthier. The employer enjoys high employee satisfaction, low absenteeism, low employee turnover, lower healthcare costs. The physicians are delighted to practice medicine geared at improving health and maintaining wellness rather the current production based models.
    • Anonymous
    Why can't I call a Health Insurance agent and get $1 million in catastrophic coverage, and if I was a 20 year old and not very sick, get $500 in Office visits, maybe $1000 in pharmaceutical coverage and have a $300 deductible? When I get married, I call to increase my life insurance and add additional coverage to my Office and pharmaceutical coverage.

    Then when we want to start a family, I add child wellness coverage for GYN and pregnancy issues increase my pharmaceutical and doctor office visit coverage. When my kids are in school, I could cancel my child wellness and add pediatric coverage.

    After my children are out of college and on their own, I can change my coverage again. Then when my wife and I are in our golden years, add hospice or assisted coverage and maybe drop some of the catastrophic coverage and increase the pharmaceutical coverage. The whole point is having health insurance coverage based on my needs at the time.

    If I had to move from one job to another, my coverage would transfer just as my car insurance or homeowners insurance. The amount of coverage is adjusted on my needs and my deductibles. My agent gives me the annual costs based on actuarial data, just like my car, life & homeowners coverage.

    This way my employer is not contributing to my health plan; they do not contribute to my other insurance plans. The Government could disband Medicare/Medicaid and I would venture to say I could pay my health insurance bill based on the money I saved from that deduction. The money employers saved could be used to create TSPs, 401Ks or other retirement options, or maybe a training budget for each employee to improve business skills and employee retention.

    We just need to average the cost of every procedure, pill, process, operation, etc. across the board (all insurance companies). Standardize that part, and most of the duplication of efforts on billing is eliminated, the average then becomes the actual reimbursement rate for all insurers.
    • Bill
    I would like to see more data. How much of this problem is basic health care? How much is critical care? How much is prescription related? Where are the costs?
    Saying "Health Care needs to be fixed" is a broad statement.
    I like Al's idea of a graduated premium which should in some way reward healthy individuals or those blessed with good genes. His thoughts around eliminating employer purchased health insurance and make it an individual choice with fixed costs could have merit.
    • Nikos Mourkogiannis
    Dear Jim,

    You did it again, asking the right question at the most appropriate time! My answer is: We could not have possibly gotten Health Care right because we were too fragmented on what was its purpose. Circumstances have now made us converge on a common purpose. What is left is to align to it to strategy, organizational design, people, and systems. I just published an article on this topic titled: "Purpose, Alignment and Health Care."

    I am submitting it for consideration by those who are participating in this excellent discussion.

    All the Best,
    • Anonymous
    The narrative of the health care debate comes down to one primary issue: the emergence of health care as a right and not as a privilege. Now that the majority of Americans see this as something we need to guarantee to all citizens, we are looking for the best way to do it. The current system of private health insurance was designed around an assumption of health care as privilege, and is not equipped to handle the new paradigm. Inevitably, modernization has pushed universal health care and only the federal government is positioned to handle such a responsibility. Much like inspection of food, national defense, or environmental regulation, industry is incapable of self-regulation, and we need federal organization and management. You can prefer to not like this situation, but you cannot argue with the reality that federal action is required to provide universal health care.
    • John Van Slyke
    • President, Alta Research
    Philosophical and economic arguments are interesting, but ultimately, changes will encounter one of the most complex systems man has devised. Let's take physician charge for example.

    Over the past 25 years, I have had a number of physician practice management companies (PPMC). I can speak with authority that physicians are economic creatures. The drive for maximum income, particularly current income. Liquidity from the equity value of PPMCs is a major challenge, as it is in law firms, consulting firms, and other closely held professional service firms.

    There is an elaborate system of coding for classification and treatment. The coding systems are known as ICD9 and DRGs. Virtually every treatment must ultimately be fitted into a combination of codes. These coded claims go to the insurance companies, Medicare and Medicaid.

    In California and some other states, laws and regulations impose "capitation" restrictions. These restrictions limits how much physicians can charge for services.

    The holy grail is a "procedure." Procedures are compensated on a known scale. For example, and ACl scope pays so much. Consequently, a physician has an economic interest not in effectiveness of treatment, but in specialization and driving down practice costs in order to maximize net income. This is no surprise. That is exactly what good business people do.

    Next, once performed billing and collection is a nightmare and requires financial resources. Physicians bill and balance bill, sometimes again and again, in order to collect fees for services performed. In other words, a physician bills the insurance company or Medicare. Depending on the procedure, the physician may or may not be paid the full amount charged. In these cases, unpaid amounts are re-billed to the next party in line. It is not unusual for the tail on some accounts receivable to stretch out to 9 months. Meanwhile, unpaid AR must be financed, and substantial investments must be made or costs incurred for specialized billing systems. Larger PPMCs set up separate business entities for billing and collection or else farm out AR to other companies whose focus is entirely on billing and collection.

    Then, we have the issue of services provided to patients who have no insurance or otherwise end up not being able to pay. This problem is particularly acute in ERs where, by law, all comers must be served.

    Next we have the issue of management of cases. Right now, physicians, particularly sole practitioners, do work that could and can easily be done by nurses or PAs. This makes no sense, of course. Physicians should be case managers and leave the lower level work to lower level employees.

    In theory, so-called primary care physicians are supposed to screen and handle the delivery of services to their patients. Since time is money, there is little incentive to do anything other than pass off patients to specialists who, again, seek the holy grail of procedures. There is no incentive to save costs in this system. Revenue maximization is what matters.

    And, then we have the whole issue of the channels of distribution of physician services. These range from direct distribution via private offices to indirect distribution delivering services through doc-in-a-box walk in clinics, to working as staff at hospitals.

    I could go on, but my drift should be clear.

    Finally, I have few problems with physicians trying to maximize income. In fact, it is very difficult for physicians in certain specialties like family practice, pediatrics, etc., to earn a living and pay off huge debt balances from undergraduate, medical school, and residency.

    In conclusion, the current system of delivering health care from physicians is extremely complex and it is entrenched because of the massive scale of the system. The system also rewards specialist physicians who become renowned in their fields or extremely efficient and proficient in a certain group of procedures. Orthopedics is one of these categories.

    And, finally, we come to the business people and Wall Street predators who feed on the current system. As in investment banking, I have found these people to be utterly amoral. As we know, Wall Street can capitalize and sell any source of profits and cash flow. Like hookers, turning the next trick is their business. Once done, the devil, investors, and lenders take the hindmost. In this sorry area, roll ups, leveraged buyouts, M&A, and some public offerings are sources of big bucks. Again, the transaction makes no difference. As in investment banking in general, it is fee income that counts. The more and the sooner the better. Again, these people are amoral predators.

    And, now we come to the executives and shareholders of insurance companies and firms that operate hospitals and large public PPMCs. Once again, it has been my experience that we are looking at a group of amoral predators who feed off the large, inefficient, and ever-expanding and costly health-care system in the US. Executives in health care insurance and hospital management companies, like HCA, are among the most richly compensated executives in US business. It has been my experience that few, if any, of the leaders, investors, and Wall Street firms who service them has any sense of public good or public service. Greed is good. And it should be troubling that certain of these companies have made headlines in the past decade or so for engaging in practices that push the envelope in accounting, questionable transactions, and outright fraud.

    In conclusion, when it comes to the delivery of physician services, insurance, and reimbursement, follow the dollars. It is going to take some kind of tectonic force of change to alter the way the current system works. And, I have only talked about physician services. The delivery system is so much larger and includes hospital management and, of course, drug companies.

    Pretty much business as usual.

    Cool, eh.

    In the interests of full disclosure, when it comes to politics and public policy, I am a member of what I would call the Radical Center. I am a champion of the people and a pragmatic person who abhors extremism of both the right and the left. I also an not an ingrate or one who does not know which side of the bread is buttered. I am now old enough to have Medicare. I sincerely appreciate all of the tax dollars you HBS people are spending on my own health care.

    John Van Slyke Jr., MBA '70,
    Former Senior Lecturer at HBS
    • Ren
    Its good to see a thoughtful, logical discussion of this complex issue here (vs. all the positional defenses available in other media). While I agree with many points Hartung makes, I question two things:
    100 years ago there was a health industry and market for products & services, but not a "health care system". And, in his second paragraph, Mr. Hartung describes an insurance system, not a system of health care.

    A true health care SYSTEM serves a purpose that encompasses more than economic profits. For that reason, I like Heskett's 10 points. They begin to look at the variety of drivers that affect meaningful change.

    Given the complexity of leveraging systems, Al's approach of starting with government leaders and representatives setting a few clear criteria for an effective health care system, then working the related legislation, and systems of incentives and quality control via regulation/stimulus/tax policy makes more sense than this circus we are witnessing.
    • Anonymous
    I agree with Al's 4 points in his posting (well stated). I have been in the auto insurance industry for nearly 20 years and it makes sense to set a base minimum coverage and give the consumer options.

    I like the elimination of employer purchased healthcare but would like to make sure that people with pre-existing conditions can qualify for the same coverages that they are given today once the employer purchase policy is eliminated.

    I think we can learn a lot from what TN and MA have experienced with their healthcare initiatives. I am concerned on the rushed decisions the federal government is trying to make on healthcare and not first test a couple of alternatives in various states. Just like any large company, you would never roll out something that would have such an enormous impact on your company results (in this case our economy) without research (including understanding and minimizing potential problems), testing it first and then adjusting where necessary. I don't get the sense this has been properly done.
    • Anonymous
    America spends more money on health care than any other country. Its position in the world is mid 7ties as far what that buys. The reason is not to be found in the health care system but in the legal ferocity in the USA. It would be interesting to find out what percentage of health care money is used to buy cover against indemnities from being sued by the clients of the medical profession. Start by reforming that if you can!
    • Rene
    • self-employed
    Issue a healthcard for all citizens where services rendered are charged by the hospital to the government via an automized system. Probably only two sorts of demand will increase due to incentive: aesthetic surgeries and hypochondriacs unlimited visits to doctors. In the first case, the nation's moral will be better off because there will be nicer people walking in the streets; and in the second case, minor diagnosis sends back home all hypochondriacs, whom probably are not more than 1% of the population. Tradeoffs: close up all health insurance services, medicare and medicaid. Being the service free for all citizens, in this case, would not create an artificial increase in demand, since people don't get sick on purpose, regardless of the cost of healthcare. Whether the service is free or charged, sickness incidence remains about the same. In order to prevent service price overcharge, annual random audits at hospital sites and moni
    toring of prices in the healthcare supply chain should verify service price increase. Once the system is ran by a automized system, data mining will not require much effort, hence, controlling much easier and cost-efficient. Thank you for ignoring this.
    • Anonymous
    Your premise, that Americans pay more for healthcare and obtain lesser results, is incorrect. In Canada, they spend less and deny care to the elderly. They make the calculus as to whether you live or die.

    In the U.K. it's the caste sytem of healthcare. If you can afford it, you pay for private insurance and get American-style care. If you cannot, you get Canadian-style care.

    The best thing the U.S. government can do is stay out of the most intimate part of our lives. Fight wars, build roads, potable water and wastewater infrastructure. Regulate insurance companies so that coverage is not denied. Provide much quicker FDA approval for drugs and procedures and extend the patent protection for drugs to 40 years. That will spur competition and better drugs at lower cost.
    • kwp
    My take on healthcare stems from several assumptions. First is that costs are increasing too rapidly and MUST be contained and reversed for a while. The rising # of uninsured is the sympton that it is too expensive.

    Healthcare has to be a right. Your health is affected by others around you. If you get into an auto accident, you may get a settlement, but have lingering problems. There is second hand smoke, and I'm sure many examples.

    There is a lot of money being mis-used. This is what I have no insight into, but the speed of increases to the consume/insured is a symptom that someone is either taking too much profit, too big a salary (not necessarily the providers), and too much overhead.

    The effectiveness of healthcare is poor. There is no emphasis on cure. Better to be a DR. Hospital, drug co, and create an annuity stream of chronic illness rather than finding a cure. So much r&d is being spent on containment solutions rather than a cure.

    Right now, Dr's are so busy that they can afford to delayy seeing until your situation is at a money making level, otherwise you get neglected or even not seen. This makes perfect business sense, but is just not right.

    Eating/Exercise/Rest are a part of health. When you are working these are impinged by demands of the job to work extra hours, and long extra hours on a regular basis--adding to stress, and reducing time for exercise and relation. Less stress eating leads to better diets.

    There are two opposing forces trying to resolve this. First is the idea of markets. Ideologically, this is naturally appealing, but seem to have created the inflationary, overpriced, bureaucratic illness maintenance that we experience. The other is that go'vt must be in control of the solution. Even a compromised settlement here is not acceptable.

    With these in mind, it is clear that a solution must be overseen by someone--likely the government or a government entity.
    The rules must be put in place and enforced even against strong lobbying. Most individuals and most businesses lose if the special interests of the AMA, pharma, bio-tech, health insurers are allowed to continue unchecked.

    The governemet must allow competition in the medical field, the pharma industry, the bio-tech industry. Right now we have medicine and surgery as the answers to health. I think we had the same solution in the civil war.

    This suggests that the government has to be a player in the healthcare game. There is a cost to poor health and spread of disease. The gov't while likely not be the most administrator, it will take up the slack and be able to transfer the costs of basic care to the insurers. Those seeking additional coverages will be able to get them from insurers, with prices, once set will have to reamain intact for 10 years, and not to exceed the lesser of CPI or inflaction thereafter (only modified by congress).

    There would be gov't rewards for finding cures instead of medicines. The freezing of prices ( I hope for a better solution to the inflation problem) would be to allow providers to maintain their current incomes through this period, and to indirectly guide the industry to a better business model in delivering quality care, finding cures, improving care, and reducing or reversing the inflation in this area.

    This should create an impetus to deliver at least the same level of care less expensively, reward cure over treatment, turn attention from disease care to real health care.
    • Paul Karres
    • Owner, Nevada Leadership Institute, Las Vegas, Nevada
    The health care business faces two major problems which no one, not one person, has clearly identified: First, the industry is critically short of high quality tactical leadership in all areas, both in physican's offices and hospitals. That deficit will prevent any significant changes to be implemented, regardless of Congressional action.
    Second, the industry faces the same problem that banking, real estate and automobiles are still facing: Huge egos at the senior management level. As President Kennedy put it so well, there is always some guy who never gets the word.
    • Mark Beaty
    After giving the idea of health insurance much thought I still believe that a single payer system will eventually return to a regulated, rationed care system that will drive down re-imbursement rates and coverage, not premiums or taxes.
    Additionally, by removing group coverage (under an employer) individuals will pay a significantly higher premium than they do today; as evidenced by those that have to purchase their own insurance because their employer does not offer that benefit.

    Also the taxing of a benefit to then give the "credit" to the employee does not support the ability of the individual to purchase insurance. Only by being employed do you get the tax credit, this defeats the goal of portability; because it is again ties insurance to employment and by extension ties level of credit to level coverage your employer provides.

    Finally, in the against file; I would say that insurance is product, not a right. While we as a nation strive to provide medical assistance to all the realities of life is that all cannot afford the best care available.

    But we can help get better coverage to all through reforms in legislation that does not cost $1.5 Trillion.

    Tort reforms to cap the amount of awards for medical malpractice, lower pass through costs of malpractice insurance to patients.

    National Medical Boards to license and review/revoke doctor's credentials, removing quacks from the industry and lowering insurance costs to hospitals and practitioners.
    Remove barriers to entry for insurance companies to sell nationwide, to drive competition, provide greater range of coverage and drive down cost.

    National Billing System for coding and billing of procedures, equipment and medicines to reduce fraud and cost with a streamlined electronic system that all medical and insurance companies must use.

    And for those that have pre-existing conditions a high risk pool of insurers, similar to the auto insurance requirements - while this will not be cheap it will provide coverage and possibly keep a family from losing everything should a catastrophic illness afflict a family member.
    • Phil
    • Clark & associates
    The health systems of America are an inglorious mess. Easy solutions...no. I fear we will converse about the issue until it collapses...and it will if things don't change. The biggest issue is that we as a nation really do not know what we want. Our health is a personal and social issue. We are trying to fix it with impersonal business models. One of which today is focused on profit. If a majority of the people in health care actually brought value directly to the patient the money would be better spent.

    Unfortunately we have created a business with more CEOs and vice-presidents than any other business segment. None of these multitudes of senior executives provide any direct service to the patient. Today health care companies are spending billions on pandering influence while patients they service labor under thousands of dollars of debt and financial ruin from denied service or huge residual copayments. Something is not right. Healthcare leadership needs a moral compass not a $$$$ sign to follow.

    Sadly, who would have ever thought 100 years ago we would be having this battle in a christian nation. Profit over people is a philosophy that should not be playing from any pulpit.
    • Curtis Craig
    There are two fundamentals that are unique to the US that we tend to forget when we think about healthcare costs: (1) Our society will pay any price to stay alive (but not necessarily healthy) - when you run out of money from your healthcare costs, the government will keep you alive through Medicaid or Medicare as long as possible, and (2) the result is that the US is the source of nearly all globally commercialized innovation in healthcare. We in the US are paying for the world's innovations.

    Granted that our system is full of inefficiencies which contribute to increased costs - our philosophy relfected in 1 above is always going to keep our costs higher in the US, with the benefit of 2.

    We will have to decide as a society how much of our GDP we're willing to spend to keep us alive as long as possible - this decision will come as caps in Medicare and Medicaid spending and will be based on age, severity of illness, or through rationing. It's inevitable and unpleasant, but this type of decisonmaking is occurring in most other countries.

    Inefficiencies and unhealthy practices heavily cost our society - to the extent that we can reduce or eliminate them will not improve our costs of healthcare, but will improve our quality.

    We should continue to incentivize innovation by letting individuals pay for their healthcare if they choose. But more importantly, we should work to eliminate the inefficiencies in our system. Electronic healthcare records, tort reform, insurance deregulation, taxes on practices known to cause chronic disease are all avenues that would be more fruitful to pursue.

    Let's incentivize quality of healthcare, and decentivize unhealthy or inefficient practices.
    • Nina
    Rule#1 in analyzing any business: Follow
    the money. In other words, the unhealthy
    incentives have landed us in this mess. Other western
    civilized nations have understood the incentive must
    be health care, not profits. It's rather simple.
    Rule #2: Some things are simply done better in the
    collective be it defense. education, transportation, or....healthcare.
    • Anonymous
    To those who consider the single-payer system as the panacea for the U.S. health care system consider the following - According to the Congressional Research Service, the U.S. spends $6,102 per person on health care. That's over $1,000 more than the next highest country (Luxembourg). The report goes on to say that $465 of the $6,102 is for health administration and insurance. In other words, if you eliminated the health insurers and all administrative expenses, the U.S. would still have the highest health care costs in the world.

    So then how do you reduce health care costs in the U.S.? In my view, an expert quoted on a recent "Frontline" episode on health care in the U.S. put it best - if you want to reduce health care costs in the U.S. and slow future increases, you need to:

    1. Show me a doctor who thinks they are overpaid
    2. Show me a hospital that thinks it can get by with less
    3. Show me a patient who thinks they are getting too much health care

    That describes the elephant in the room that is currently being ignored while the White House tries to paint insurance companies as the root cause of our high health care costs.

    Truly reducing health care costs will not be painless. Reducing costs on one side of the equation means reducing someone's income and that won't happen easily. Certainly no one in Washington has the political will to do so. Unless, that is, the "public option" ends up being a Trojan horse. For now, the public option is being described as a way of "keeping the private insurers honest". But, once the private insurers get crowded out, who but the government will decide what providers get paid or services are covered? That could lead to reductions in health care costs and bending of the trend line. Unfortunately, advocates of the public solution won't say that's their end game and opponents are getting hung up on phony distractions like the so-called "death panels".

    The President promised change and change we shall receive. The question is whether the devil we'll get through that change is any better than the devil we know. Based on the proposals currently under consideration, and how they ignore the real issues, this is change we can do without.
    • Anonymous
    The demand for healthcare is infinite. People will spend all of their own money and all of someone else's to stay alive. The earth's resources are finite (human capital, materials, etc.). We will never solve the issue of escalating healthcare costs until we place a limit on the dollar amount of healthcare someone can receive from resources outside of their own. It's that simple.
    • Anonymous
    The key hindering block to a number of problems, such as health-care, pollution energy and Middle East, is the our lop-sided lobbying system. Our lobbying system is the result of our distorted and self-serving definition of "freedom." The purpose of lobbying is to buy favors from law-makers. The special interest lobbyists pay enormous amount of money to governmental officials, politicians and political party. In return the lobbying organization gets favors returned usually by cash, gifts and/or votes on their Bills. In other words, it is bribery. Bribery is a criminal act. When our justice system really want to, it can interpret a favor as bribe or special favor. All so-called favors by the special interest groups should be treated as bribery.

    If the above suggestion is implemented, we would not have insurance companies lobbying for health-care issues which are profitable to them. If we have a serious intentions of solving some of the major problems we should overall our lobbying system first. And, make sure lobbyists are kept away from the lobbying reform.
    • Anonymous
    I agree with various points about perverse incentives.

    I'd like to draw attention to another issue. Much of the debate is framed as changing "the healthcare system" as though it were a monolith. Of course, it's composed of a variety of subsytems. I believe we need to separate what aspects of delivering and paying for healthcare should be addressed by government and which should not.

    I'd suggest that governmental action should focus on those areas of healthcare where change has a. the greatest potential to improve healthcare outcomes, b. the greatest potential to remove cost from the system, and c. the lowest incentives for private players.

    It seems to me that area is the provision of preventive and routine care. Better preventive care will certainly improve outcomes and reduce cost on a national scale. A system that provides routine care for all would move underinsured people from the ER to lower cost channels. A public system could also drive cost down by moving much of routine care to more appropriately priced providers like nurses.

    Such a public baseline system would still allow tremendous opportunity for market-based solutions in specialty care and insurance.
    • R. MacKenzie
    A fundamental underlying and unspoken assumption in much of the debate about US health care is that health care is a commodity and market like auto insurance etc. Rather, if we understand basic health care to be a right of citizenship and not a market to be bought and sold like other commodities then we can start to move to a system that provides the best overall value to the citizens. If decision makers don't acknowledge this, they will make little headway.

    The entrenched players who benefit from the existing system are putting up quite a fight to preserve their lucrative piece of the current huge inefficient system. Chief among these is the hearth insurance industry which extracts over 30% of the total cost while delivering less than 5% of the total value. While they are not the only culprit (others include pharmaceutical companies, overpaid fee-for-service professionals, lawyers), they are the biggest and the ones fighting hardest to preserve their place at the trough.

    Other posters have made important points consistent with this view, including Stahl post 4, Rene, post 16 who essentially describes the Canadian and other systems, Nina post 23, and post 26.

    Post 17 (anonymous) is wrong on all points and represents the same sort of uninformed opinion that is all too prevalent and gets in the way of good decisions for US citizens.
    • Anonymous
    Two key items that don't seem to garner the attention they deserve in this discussion of healthcare reform:

    1) Americans need to be more accountable for their own state of health. No matter how the infrastructure is set up, if the citizens are not interested in maintaining/improving their health, costs will continue to rise under any system. Look at the incidence rates of obesity, diabetes, heart disease, etc. People wonder why the U.S. costs more than other countries? Compare incidence rates in the U.S. with those in other countries and you'll see one major reason why.

    2) "Middle men" such as brokers and consultants serve an essential role in keeping clients' healthcare costs affordable by negotiating savings with insurance carriers. The amount of savings negotiated out of the cost structure more than outweighs the intermediary costs.
    • oh21
    Alas, the question is "Pay me now or pay me later?"
    Does government represent the private interest of the people?

    Previous (Dem/Rep) attempts to control cost resulted in more cost with less care. I am 57yo, so I know from personal history and a few healthcare systems globally, that more cost with less care indicates that the public interest (as politicians and senior civil service) has not properly governed private/personal interest.

    Perhaps past failures are personal interest caused, but frequently (my perspective) due to honest ethical sloth, hubris, ineptness, and proxy nepotism (I hire your son and you promote my daughter...). This is not exclusive to USA.

    Can a dollar/coin (gold) cease to exist? NO!
    Can you gamble and lose a dollar/coin (gold)? YES!
    Can debt/credit drive/build a capitalist economy? NO!
    Can insured investments drive/build a capitalist economy? NO!
    Can capital consolidation drive/build a capitalist economy? NO!
    Can capital responsibly applied drive/build a capitalist economy? YES!

    It is that simple. Do we want a capitalist or entitlement economy? Healthcare paid by US the few or US the many is the fact. Healthcare paid or more cost with less care continues for USAll is a fact. The present "separate but equal" healthcare policy/laws entitles the few, at the expense of the many, and harms "Open and Equal" capitalist markets competition.

    The USA does not have the longest life expectancy, not even for the wealthy citizens. The USA does not have the best healthcare in the world.... The USA can do much better with a best solution selection from all the possible functional models globally (that can be web-reviewed) that provide better and more affordable healthcare.

    An illiterate vocal minority of USA citizens (and a majority of politicians) love listening to fear mongering dogma, and apparently hates reading, learning, and thinking for themselves.
    • James P Shanahan
    • Investor
    The focus needs to be on the cost reduction side first because this will allow the system to fund the 46 million non-insured without tax increases and may keep Medicare from going bankrupted. My recommendations are as follows:

    1. Eliminate advertising of Pharmaceuticals except directly to physicians. Pass the huge savings on to the consumers.
    2. Allow monitored nutritional/vitamin /supplement providers to market generic pharmaceutical grade drugs. For example finasteride (Proscar) can be providedfor 10% of what is currently being charged for this non patented generic drug by pharmacies.
    3. Eliminate Class Action lawsuits. Pass the Insurance savings on to the consumers.
    4. Since we would then purchase our Health Care on a "Buyer Beware" concept mandate that all medical practioners post their surgery results
    5. Establish "Life Style" Clinics to educate people in proper nutrition; how changing life style can seriously reduce the need for Doctor visits, surgery, prescriptions and and improve the quality of life.
    6. Teach Life Style choices to High School and College students.
    7. Have a totally independent body analyze the cost/benefit of new drugs and publish their findings in Medical Journals without being influenced by the Pharmaceutical Industry.
    8. Eliminate all vending machines and unhealthy meal choices in public schools.
    9. Increase the use of Physician Assistants to reduce the amount of time a Doctor is required with a patient while improving the quality of the visit.
    10. Provide financial incentives to students who will become Primary Physicans during their education and after they graduate.
    11. Provide every patient with a DVD of all tests that have been done in the past.
    12. Use some of the savings by eliminating advertising of pharmaceuticals to educate thru the media that cheating in the system is paid for by your friends, family and other honest americans.
    13. Advertise that smoking causes poor health and premature death. Provide the advertising funds by taxing the cigarette manufacturer.
    14. Advertise that excessive fat in your diet health and other unhealthy eating habits causes poor health and premature death. Provide the funds for this by taxing the snack food (high fat content) manufacturer.
    15. Allow Medicare to negoitate pricing on a competitive basis the same as the VA currently does.

    These are only a few of the many methods that can be used to significantly reduce our health care costs and improve our mortality and more importantly our qualtity of life.
    • James
    As an individual who has lived in both Canada and the U.S. and now lives in Toronto, Canada, and with two married daughers in the US, I have a particular perspective on health care issues in both Canada and the U.S. I am also on the Board of one of Toronto's largest regional hospitals so have some first hand experience with our health care system and I rank it highly.

    My first comment is that the most efficient dollars appear spent in the U.S. care system on lobbying and propoganda. The level of misinformation on the Canadian health care system propogated in the U.S. is staggering. If Canada's system is all that bad, why was Tommy Douglas voted the "Greatest Canadian" of all time in a nationally televised contest by the Canadian Broadcasting Corporation (CBC) in 2004. Tommy Douglas was a left-leaning politician who took on the provincial medical establishment and introduced "medicare" to Saskatchewan in 1958. In 1962, Prime Minister Diefenbaker, leader of the Conservative Party, appointed Justice Emmett Hall--also of Saskatchewan, a noted jurist and Supreme Court Justice--to Chair a Royal Commission on the national health system - the Royal Commission on Health Services. In 1964, Justice Hall recommended the nationwide adoption of Saskatchewan's model of public health insurance. In 1966, the Liberal minority government of Lester B. Pearson created such a program, with the federal government paying 50% of the costs and the provinces the other half.

    One might claim that those Canadians who did vote were not well informed, but I think otherwise. The vote reflects the importance the medical care system for Canadians and perhaps is a proxy vote for the level of satisfaction with the system, warts and all. Of course it is not perfect. I leave you with a response to a comment above that highlights the level of misinformation that surrounds the debate in the U.S., the comment being that in Canada we "deny care to the elderly." The average age of patients to our ER is 75 and none are denied care. In fact, no Canadian is denied care by virtue of age or financial means, nor are doctors denied payment for their bills as private practioners. This is what Tommy Douglas envisioned. If only you could use some of that lobby money to find a Tommy Douglas among your own politicians; indeed he was a "Great Canadian".
    • Ken Levene
    There is a very simple reason why Americans can't get healthcare right: The power and influence of private insurance companies, the AMA, and other private providers over any public attempts to institute a government sponsored system.

    There is a very strong private enterprise mindset in the U.S., enabling the presence of private corporations to run the health system. I cannot foresee any public run system ever allowed to threaten the status quo.

    As a Canadian, let me be clear: I do not advocate our present exclusively government run system either. Problems entailed include long waiting lists, lack of choice of specialists, to name just two. What I do advocate is a two tier system such as exists in the UK and Europe, combining both public and private systems. In effect, many Canadians adopt their own two tier system by seeking medical help at their own expense in the US and elsewhere. But just as private enterprise makes any change in your country impossible, politically, so ironically, the public system here is so entrenched that it is political suicide to even try to introduce minor private elements into the system, regardless of their logical merits.

    Thus, from time to time , both countries flirt with the idea of changing their respective systems, ultimately to no avail, and I don't see any reason why the outcome will be any different in the future.
    • Anonymous
    1. Responding the the intro above...re. statement "(2) they equate cost with quality, turning the idea of rational markets upside down," I disagree. The author doesn't define "they"...and I certainly don't think high cost buys quality any more than it "should" buy a good mechanic...but doesn't always.

    2. To many doctors are saddled with high costs of space, insurance and their own toys, so have to charge unreasonably for simple checks on a patient. This may as some have noted perhaps, be part of the system of specialists like those in unions. Doctors are not allowed to do certain things...that requires the receptionist or the intern...for what reasons, I have no idea.

    3. As long as there is a government trough to share the wealth, doctors and insurance companies are going to require higher charges than they know they will get paid...so the government in the Medicare field brings some of the high cost on themselves.

    4. There are those who say, one should be able to make as much money as the client wants to pay, like for a new car. But with health care and liability lawsuits, doctors and hospitals do a lot of unnecessary work because they or their hospitals or pharmacies need to pay for themselves, or to cover the liability insurance costs...and for their golf green fees.

    5. I suspect that just as with the economy whereby people stopped buying all but essential things they feel they can afford. Most will stop going to the doctor as I have when they see the fees are not reasonable for the work done...no matter what degrees they have or the experience they may have. At that point perhaps the lawyers and the patients along with everyone in the health care profession will start thinking and doing what is reasonable...not what some of us think is the use of a bomb to remove a splinter.

    6. Fixing the health care system is like anything else, people have to put their money where value is...not to value everything just because that's the way we've always done it. And those HMOs, insurance companies, and hospitals have to start changing their promiscuous idea of making profit as the mission of their business.
    • Milan Radulovich
    • Citizen
    It comes as no surprise for me why American's can't get health care right. Our health care approach is indicative of other key areas of social need (i.e. infrastructure, education, legal system, etc.) that are also showing the wear and tear of systems that have either run their course or are in need of major overhaul. It's called social neglect.

    The perspective that I'm offering in this discussion is from someone that grew up and was educated in these United States, served in the military as an officer stationed in Germany and then spent over 20 years living in Europe as a private citizen. Most importantly and relevant to this subject is that I gained first hand experience with other health care systems.

    I returned to the USA in 2002 and was amazed by: (1) inefficiency and lack of electronic patient systems; (2) high costs -bills, bills, bills; (3) lack of a coordinated health care system. Basically, there is no system but rather something that has grown up historically without a strategic or visionary direction. A patchwork which is pulled in different directions due to diverging interests (insurance providers, doctors, pharmaceuticals, government, etc.). It's a broken system.

    Here's a short list of why I'm concerned about any major improvements:

    1. Fear of Change - the average American is no longer comfortable with major change - fear and anxiety have replaced the free and the brave spirit of earlier times;

    2. US Centric View - "if it's not invented in the USA it can't be good" - this is a key barrier keeping us from gaining a tailored system based on data from other health care systems that can be considered effective and efficient (Canada and UK are not the best examples);

    3. Missing Leadership - not enough political and social vision in our current leadership to portray a clear picture for the average American citizen. Basically, most politicians cannot themselves envision a new system. Since they are a product of the current one, they struggle to help the average American "see" a new way.

    There are answers available now (don't need more analysis) and there is a better way than the current one (systems that work - here and abroad), but unfortunately, I am not convinced that the path or level of debate will produce a very good new health care system.

    Another point I didn't mention earlier, Americans have lost the skill of social debate which is issue oriented and allows freedom of speech. Most things I've seen recently in the news, i.e. townhall meetings indicate that shouting, bullying, and name calling have replaced civil discourse, which is a sign of an educated public; one worthy of democratic systems.

    There is an old saying that "you get what you tolerate" and thus, if we tolerate this level of discussion, then we will not get any real health care reform in this country.
    • Mohit
    All systems in the USA are based on the "checks and balances" philosophy. There is an assumption that all interested parties have representation and hence "checks and balances" enforced by them result in a system that works for all. Unfortunately, there are several areas where one or more interested parties does not have a voice. Healthcare is one such a system.

    Health care providers consisting of hospitals, pharma companies, doctors(AMA) and insurance companies have lobbies but health care seekers don't have any representation. President Obama promised to change this and represent the interests of health care seekers.

    I don't know what the best system will be, but it is obvious that instead of re-inventing the wheel we can copy the Canadian or British system and we would be much better off than we are now. Obama's plan, although not ideal, aims to do that without requiring a complete overhaul of the existing system (although I argue that a complete overhaul is required despite the short term pain the transition will cause) and if enforced will make things better than they are now. The only obstacle to that is the health care provider lobbies that have become too strong to negotiate with even for the US president :-(
    • Denise L.
    My brother is alive today because of government health care. As retired Army, he is receiving top notch care for a rare form of leukemia. If it were one of his siblings, with limited private insurance, we'd be forced to either forfeit our life's savings for the treatment or die.

    And for those who think that government-run health care would involve rationing, wake up. Your insurance company is a heck of a lot more efficient at rationing than the government, except it's called "pre-existing condition," "not a covered benefit," "lifetime cap," "medically unnecessary," and "out of network."
    • Stephen Hyde, MBA '71
    • President, Hyde Rx Services Corp.
    Jim, all the issues your cite are fixable, but first we have to recognize and correct a fundamental medical market failure first identified by economist Kenneth Arrow in 1963 and more fully explained by me in my recent book "Cured! The Insider's Guide to Health Care Reform." Then a functioning, lightly-regulated market can indeed deliver affordable health insurance and medical care to everyone, as similar markets now do for groceries and gas.
    • Anonymous
    I suggest it's long overdue for American healthcare leadership to take a long, hard and objective view of systems elsewhere in the OECD and in this way develop a "best practice" model that can be rolled out in the USA.

    However, given the suspicion that the world stops at America's borders, I'm not hopeful that this potentially useful research exercise will make it to the starting blocks.
    • Carlos V.
    • RN, AXA Assistance USA
    I have been very fortunate to know the ins and outs of the healthcare delivery system, as I am educated in just that.

    The main drag on the system is people's inability to navigate it.

    I have blood tests done a few times a year, and when I see the explanation of benefits for them, it is completely different for services rendered @ a hospital versus an outpatient free standing lab.

    I choose to have things done a la carte, and my insurer is glad that I do. I go get tests done elsewhere because it costs less (a lot less) such as having those tests done at in network facility versus @ my primary's office.

    Same test, totally different cost.

    Unfortunately, physicians use the pay for service model and exploit it to no avail.

    Also, and more importantly, US consumers don't educate themselves and prepare adequately so as to benefit from the minutes they actually spend with the doctor.

    They simply take what a physician says as truth, as opposed to knowing the ins and outs. If they knew they and their insurer could save a ton by simply having imaging and bloodwork done at a free standing clinic, consumers would make a more conscientious choice.

    A single payer system would solve the payer issue, but is completely against the capitalistic enterprise and free market that America was built on.
    • Emre Erkut
    The problem is simple. It's not consumers that are making consumption choices. It's some other party doing that on behalf of them -- typically insurance firms. The same problem plagues the credit rating industry. The same problem plagues primary and secondary education in the US. The solution in all cases is to let consumers choose.
    • Kelley
    Admittedly, there are many problems with the existing healthcare system in the US, but taking away many of the rights patients now enjoy is not the way to find a solution.

    Patients (ie. every American) need to be educated on their health, healthcare services, how much these services cost, and how payment is being made for these services. Americans, especially those with insurance or public assistance, have been far removed from the actual billing and payment of medical services. People should be aware of what services cost and how these costs are covered. This would solve many problems that we are now plaguing this industry.

    This would let patients know exactly what they are being charged each time they visit their physician. Many people do not know the charges they are incurring, because they have never seen the original bill. The usual procedure is: patient visits physician, patient is seen by physician, patient goes by front desk to pay copay, patient leaves doctor's office, patient goes by pharmacy to fill prescription, patient presents insurance card, patient pays drug plan's negotiated price, finally patient goes home, hopefully to recuperate. Please note that nowhere in this procedure does the patient ever set eyes on a bill. The patient is insulated from the actual medical costs they are incurring due to the system that is now in place.

    Patients need to ask for itemized bills and the only way anyone ever is interested in itemized bills is when it is their money being requested. The closest thing in our current system to this is the new High Deductible Insurance Plans with a Health Savings Account. I am a huge supporter of these plans simply because they tear down these walls built around medical consumers. Finally, patients see their bills, because they are responsible for payment up to the high deductible. This would reduce duplication of services by medical professionals simply because they patient would make sure those records were properly delivered between physicians. Test results, radiology procedures, and on and on. This is not the only problem informed, educated consumers would solve, but a significant one.

    Educating consumers would not be the magic bullet to fix healthcare, but throughout history it has been the key to moving any system and civilization forward. More than an overhaul of healthcare, we need an overhaul of our mindset. Healthcare is not a privilege, it is a right. HOWEVER, as a people, economy, civilization, we cannot continue to consider our healthcare worth whatever price is placed upon it. Especially when the model of antiquated, inefficient, closed systems that have lead to either the innovation or demise of other industries is the system which we have built for our healthcare. This industry too must evolve to meet the needs of an evolving nation.
    • Michael Otten, PhD
    • Recent Retiree
    I'd like a more objective view comparing various health care approaches and results around the world (esp. French and Swiss systsems).

    I am told that the US would be possibly #1 in terms of life expectancy and cost effectiveness if we were to remove non-citizens (who routinely come to major city hospitals from their countries for 'free' emergency room care) and death due to accidents or homicides. Further, I know that Defensive Medicine is a direct result of the unrestrained malpractice situation in the US, which I do not believe is addressed by President Obama's 1,100 page health bill.
    • Harry Gage MBA '51
    • Retired
    Overlooked in this mess is the fact that for many millions of Americans, myself included, the healthcare system is working just fine on a daily basis. Under Medicare, my wife and I have unencumbered access to doctors of our own choice as well as top tier hospital and medical services at a nominal out-of-pocket cost consisting of premiums for Medicare, supplemental coverage, and prescription drugs.

    However, the money wasted in operating the system is beyond imagination, and there are millions of Americans who are uninsured. What to do? Rather than declaring the healthcare system to be broken and mandating universal coverage, start out by recognizing that the US healthcare system currently produces and delivers the best healthcare in the world, but is nonetheless deteriorating and very poorly managed. Then attack and reduce the areas of massive waste.

    As savings are achieved, plough back the savings into expanded coverage. An approach of this nature by our national leadership would be supported by a hefty majority of mainstream Americans, liberals and conservatives alike. At the risk of sounding politically naive, may I suggest that policitians of both parties must recognize that a bi-partisan effort is the only means available to fit, fashion, and shape a healthcare agenda that can be supported by mainstream America?
    • Richard
    • Retired economist
    Re comment 17 and others' misinformation:
    I grew up in the UK and my parents still live there, now both 83. If old people get no service in the UK it would be news to them, and to my other relatives, who between then have had 3 pacemakers, 5-6 hip replacements, knee replacements . . . all after retirement age, all on the NHS (free). There are differences from the US: you don't get free cosmetic procedures except as the result of accident or disease, and the pacemaker came later than it would have in the US: the doctor told the patient the odds of the pacemaker extending life compared to the risk of the hospitalization, and waited for the balance to favor the pacemaker before proceeding. In the US this is not possible because of malpractice risks. (My wife is a US physician.)

    Follow the money is a good way to understand industry structures, but it is not enough. Following the incentive structures gives a more complete picture. The US industry is best understood as a system converging into oligopolies bargaining with each other, and rapidly concentrating to gain market power. Such a structure cannot possibly yield an efficient market outcome, but it does yield very high profits for some of the players, and it drives many consequent market distortions and inefficiencies.

    Primary care doctors in the UK receive incentives to keep people well and out of the hospitals. This works because the same agency that saves the money pays the incentives. In the US this is not so. An insurer has no reason to suppose that any particular patient will be his enrollee next year, so there is absolutely no way to recover the incentive payments when the savings may go to some other insurer.

    Another incentive structure issue arises with testing and medical equipment. In the UK, Canada, etc these are placed using reasonable engineering-economic efficiency criteria: expected numbers of users, catchment areas, etc. The result is many fewer of the machines, used more intensively. In the US specialist diagnostic equipment results in at least three separate billing components: the physician, the fee for use of the machine, or the test itself, and the fee for the use of the space. I have listed them in the cheapest-first order. This space charge is the result of bargaining between entities with market power: hospitals and insurance companies. As a result of these distortions it pays doctors to create inefficiently small surgicenters and diagnostic center so that they can capture some of the economic rents in this area. For the system as a whole this is inefficient, but it explains some duplication of tests etc.

    (Note, though, for those who think all test duplication is wasteful: the first thing to suspect with abnormal test results is measurement error. All results have a confidence level rather than absolute precision.)

    These incentives could be adjusted by public regulation of pricing: equipment fees could be set based on market (not list) prices for the equipment, appropriately depreciated, its expected life, and an efficient utilization rate. Space charges could be based on typical private sector commercial rental rates in the area, adjusted for sterilization costs. Hospitals and insurers would both find it more difficult to game these rates, but never discount human ingenuity!
    The biggest problem in the US is the incentive to drop expensive patients from the insurance rolls, even if it takes employers firing them. Chronic conditions often have nothing to do with patient conduct: some people just lose in the lottery of life. In the UK even the standard prescription copay charges are waived for the chronic conditions, and of course the NHS negotiates what it will pay for drugs in any case.

    If I could wave a magic wand and change the US system I'd start with incentives. Private for-profit insurance does not have incentives that align with good patient care: quarterly cost minimization doesn't do it. Private for-profit hospitals with market power are not likely to lead to efficient outcomes either, but outside the very largest cities the minimum efficient size for a general hospital would probably result in a monopoly.
    Fee for service may still be an incentive problem for physicians: but payment systems in the UK and elsewhere could be adapted to the US if malpractice and educational costs could be taken care of.

    I do not see the current political process leading to any efficient outcome: the process seems to be accommodating all the participants with significant lobbying power, who are also the major oligopolists. Nothing good will come of it.
    • Mary Parker
    • Adult Nurse Practitioner
    1. Ala carte menus for services.
    2. Culture change.
    a. Individuals need to see how their actions and behaviors affect others.
    b. Personal responsibility: exercise, healthy diet, stress management, weight management, dental management (simply brushing and flossing).
    c. Open and honest communications about health and goals.

    Regarding point 2c, as an adult nurse practitioner and former staff nurse, I see families who want everything done for their family members in the ICU. They have unrealistic expectations of outcomes (their 80-year-old father, who is incapacitated with a major stroke and now on a ventilator) is not likely to get up and walk out of the hospital as good as or better than his arrival, yet we are intent on life-prolonging therapies instead of focusing on palliation (symptom management like pain control rather than cure). While it is very distressing to everyone (family and providers), we need to have these communications long before these events happen so we can make decisions in accordance with stated desires. We cannot have this mandated by the government; rather, it is something that needs to be debated amongst families and in the public domain so it becomes a commonplace and routine discussion.

    Chronic conditions consume a major chunk of healthcare delivery and they can be delayed or prevented, for the most part, through individual responsible actions as listed in points 2a and 2b.

    My family knows what I want, should I become incapacitated, and I have indicated what I want done with my body upon my death. I am in my mid-40s with children. Death is a natural part of life and should be openly discussed, no matter how distasteful it may seem.
    • Ben Hedenberg
    • Big Ben Venture Partner Inc.
    Being borne in the Socialist Kingdom of Sweden having a single-payer system since the 1950's I have a firsthand experience of a system that has failed greatly.

    The problem with a socialized system, like the Swedish, is that you don't care about the costs and efficiency since you do not pay out of your own pocket for the services. The Swedish system next to the US is the most expensive in the world, but is failing to provide healthcare when you need it.

    All socialist systems have a built in problem: they produce shortage and fail to meet demand. A socialized system is not the answer to the present problems with US healthcare.

    Only a system that is controlled by the individuals' own wallets can work effectively. Insurance companies and governments cannot run health care as perfect as a market place depending on individual decisions.
    • Lisa Manners
    Jim, this is a very good question. While a great many of us, myself included, are quite satisfied with our current insurance and the health care we personally receive, at a national level we are in far worse shape than other developed countries and declining quickly as we spend even greater sums. We are reaching a crisis in communication, coordination, and cooperation among the fragmented entities that provide and pay for health services. Physicians with skyrocketing medical school debt opt for specialties rather than primary care. Hospitals are driven to eliminate ICUs. Doctors may have a case-load of 2000 or more patients, with little time to do more than order tests for the most pressing complaint. And information on treatments may be shaped by the pharmaceutical or device companies with little emphasis on risks or reliability.

    As you point out, nearly all the OECD countries have greater government involvement. That need not mean single payer, nor even a government insurance option available to all (we already have a well-regarded government insurance option for the elderly.) Let's look at the US versus just France and Japan.

    In 2000, the World Health Organization rated France's health care system number 1 overall and number 3 in level of health attainment (or results). Japan came in number 10 overall, but number 1 in health attainment. Where was the US? We rated number 37 overall and number 24 in health attainment.

    France provides universal health care for all legal residents and a choice of providers. Most MDs are private and reimbursed on a fee for service basis. Hospitals are both public and private. The French are required to contribute to sickness insurance funds based on their location and profession. Most employers also provide voluntary supplemental insurance. France also has about 2000 clinics operated by Medecins sans Frontieres providing health care to illegal immigrants. To encourage wise consumer choices, France charges no copay for prescriptions for "effective drugs" but charges a 65% copay for "questionable drugs."

    In Japan, employers fund insurance plans for their employees--the largest companies set up individual funds and the goverment manages a fund for small businesses, one for the self-employed, one for public servants and private school teachers, and one for the elderly. On the provider side, MDs are independent, providing fee for service. Hospitals are private, often physician-owned. The Japanese government sets a national uniform fee schedule, so hospitals compete on quality and technology rather than price.

    In 2003, the US spent 15% of GDP on health care, France spent 10.1% and Japan spent 7.9%. The US had 8.6 MRI units per million people, France had 2.8 and Japan had 35.3!
    Your point number 3 "individuals decisions regarding wellness affect the rest of us" is something it is easy to forget. Public health is extremely important and has been responsible for many great strides in medicine, including vaccination campaigns for polio, TB and the elimination of smallpox worldwide. Yet in many ways we have underfunded public health and are exposed should a virus mutate into a new lethal form and spawn a global epidemic. In the US we have almost no surge capacity to handle the demand for beds and emergency care.

    I applaud the efforts to involve government more closely in guiding our fragmented system and tweaking the incentives to improve the public health outcome. I hope that includes funding comparative research and registries that will provide both doctors and patients better information on which treatments are most effective and which pacemakers or joint implants last the longest.

    While many OECD countries coordinate and direct funding of health care at the national level, often much discretion is left to local programs. I think there is an important role for local clinics and public health at the community level. Preventive care and catching chronic conditions early can save money in the system, particularly if there are community resources for education and supporting change.
    • Greg Bownik
    • Teaching Partner, Bethel University
    I think the current health care system is based on providing services to an economy that is rapidly disappearing. No longer do employees work in a manufacturing environment for forty years and are given benefits such as health insurance that will keep them reasonably healthy throughout their careers. In the new economy, the knowledge-based economy, employees switch jobs frequently, work as temps or contract workers, and are not always offered health care coverage by their employers.

    A new type of health care system that meets the needs of temporary, part time, and sometime workers needs to be created. The current system works well for some while excluding others at the same time. If not provided by government, the health insurance industry should combine forces and design a new system based on how work takes place in the new economy. This will mean that health care will need to be practiced in a manner that takes the new realities of the knowledge economy into consideration. And what that means exactly is open for debate and needs to be determined by numerous stakeholders.
    • Maggie, Carissa, Amy, Brian, Aaron
    • MA Organizational Leadership Program - Leading in the Knowledge Economy Course, Bethel University
    The problems associated with our medical system are much deeper and historical than simple capitalism or issues of equality or what some people are challenging to be socialism - and too much to cover in a simple post here. Somewhere, the focus shifted to profit versus purpose - capitalism versus care. That is not to say that every American does not has the right to make money off of their skills. But every American also should have the right to fair care. We don't HAVE the answers. That much is certain.

    Medical care demand has increased and changed in the knowledge economy. We are a more litigious society. We are a more informed society. We are a larger society with a huge technologically controlled system of supply and demand. Want to know about a new drug? Watch the commercial of the couple frolicking in the sprinkler. Have a headache? Go online and diagnose a brain hemorrhage. Our knowledge economy has impacted our health care system and so we must fight fire with fire.

    To understand the knowledge economy's impact, we have to use the knowledge economy. We need more communication, more individual awareness and concern about the issue, our role in it, and our buy-in....as much as we self-diagnose and are aware of our headaches and the site to go to to find answers. We need to exercise adaptability to this medical market and adaptability to the solutions. We need a deep strategic analysis through knowledge acquisition. We need to hold learning conversations and assess new strategies by creating new knowledge - not just by looking around the globe and picking pieces of knowledge that we THINK may apply.

    The current situation developed over time and it will take time to unwind it. Again, we don't have the answers, but we do know that the time should be taken to do it right the first time. Or as close to right as we can get.
    • Mark, Mary Jo, Molly, and Miller
    • students, Bethel University
    Perhaps we can look at this from a different angle. Today we live in the knowledge economy, and consumers have more information and tools at their disposal than ever before. With information and tools, consumers should be able to make decisions about healthcare. For example, today we have a plethora of information available on medical websites on the internet. Is it possible that one day we will use technology to "see" a doctor rather than physically going to a doctor's office.

    Could our economy develop communities of interest that empower consumers to seek out information to make informed decisions about what level of service they need? In summary, rather than focusing on whether the government, insurance companies, or health care providers control health care, let us allow consumers to dictate what the best care is.
    • Anonymous
    If we are to have a public health care system, the following points need to be reviewed: There are too many people in the middle making money off of the system, all stakeholders need to be reviewed, weighed to reduce a biased system, and America is an individualistic society. How can a public health care system meet all these needs?
    • Richard A. "Tony" Eckel
    • President, Systems Synergy, Inc.
    Healthcare in the US is an unholy trinity of the worst free market, regulatory, and professional organizations can produce. Excess costs (i.e. unpaid bills) are shifted to other patients as "overhead" and to the taxpayer as subsidies for public institutions. This trinity operates to maximize the revenue stream while obscuring the value of the treatments.

    It took two courageous doctors in Australia to identify stomach ulcers (the businessman's stress disease of the 70's) as a bacterial infection. All the while Pharma produced all manner of antacids, surgeons created treatments to remove the "diseased" tissue, and hospitals created specialty wards to support patients until death. Their "reward" was a Noble prize decades later, less than a million dollars for saving countless lives and untold fortunes otherwise spent on useless expensive therapies that rarely prevented death. The most striking aspect was the decade it took to change ulcer treatments in the US following scientific proof. Almost no one dies of ulcers anymore, but not because of the efforts of our system.

    Free market approaches do work; the lesson of Anesthesiologists is very instructive. Once the darlings of the medical litigation game, and therefore malpractice premiums, anesthesiologists as a group took action to systemically and systematically improve practices and thereby improve patient outcomes and lower adverse events; it's called "professional quality improvement". By standardizing administration methods, differential efficacy studies, and critical evaluation of adverse events, they improved the practice (read: reduced the risk) to the point where claims and premiums where cut in half. It's hard to argue with that kind of improvement. Except that it threatens stature and revenue of medicos who count on the aura of their brand; specialists.

    Medicine must re-organize to produce more of the professionals needed, rather than the lucrative specialists who are essentially one-trick-ponies. Artificial doctor shortages and over specialization drive up costs while limiting basic access to large portions of the population, not necessarily the poor (e.g. Elderly). Part of any "Public Option" must be the expansion of low cost medical education capacity producing practitioners with an obligation to practice in low reward segments of the patient population in return for a subsidized education. Society cannot afford the cost of a system that focuses primarily on producing elite professionals from elite institutions for elite consumers.

    There will always be the need and value for the "public" option. This option must provide preventative and basic support for indigent and working poor to reduce the social cost of the under served. The trick is to set an appropriate entitlement formula that neither inhibits upward economic migration, nor encourages employer/employee cost shifting.

    While its always easy to be prescriptive - the bottom line is that pricing needs to be based on net present value rather than effective market tolerance; Free markets need regulation to support the public interest. Healthcare pricing would require sophisticated economic modeling and regulatory enforcement to drive the market to produce more effective delivery of affordable services that represent society's needs, rather than specific interest group greed. Consensus on the vision for the health care system MUST therefore precede the prescription in order to manage the competing "therapies".

    Change needed to Healthcare is as economically striking as the industrial revolution when the application of cheap energy to mass production eliminated the artisan producer in favor of the low cost high quality mass produced products of today. Consumers must demand the same market participation and choice for Healthcare that we enjoy for buying a television: price comparisons, standards compliance, operating costs, and safety. But inertia is tremendous as existing producers will resist anything that threatens their revenue stream, even with the promise of greater prosperity in the future; that is the nature of a mature business and product.
    • Jack Slagle
    • Senior Manager, L-3 Communications
    I look at a government that has failed at two attempts to run healthcare programs, Medicare (bankrupt) and VA very poor service. Add to that its dismantling of the active military medical services resulting in a very strained and over extended medical corps and their need to be sued to give the military retirees the heatlhcare that they were promised and you have a very poor healthcare track record. As a trained aircraft accident investigator I can tell you that the current bill is a disaster that attacks symptoms but not causes...it fails to even identify any causes but merely lists "goals" that fail to really solve the true issues: access and cost.

    Having lived in Germany and having been subject to their healthcare I can tell you that our system may be broken but the quality is there if our people could just get to it. The current administration needs to quit trying to fulfill a campaign promise quickly and rather try to do some critical thinking to solve the access and cost problems without destroying what good healthcare we have. This bill when read is indicative of the incompetence of our current legislative branch to do any clear thinking.
    • Scott A. Beaumont
    • MBA 1977
    I am firmly against a single payer system with the federal government in charge.

    My oldest son is an infantry officer in the US Army. He is in Iraq. My son has had a full battery of 11 immunizations performed SIX times in less than four years because the Army does not have a coordinated record keeping system of immunizations of active forces in the Army. My son has had full immunizations at his officers' basic training, his infantry officers' basic training, his Army Ranger School, his mobilization for leaving for Iraq and on other occasions. President Obama, in a recent Press Conference on health care, cited the main reason for a single payer system is the federal government would eliminate the duplication of effort and cost that occurs in the current fragmented system. If the federal government cannot manage a coordinated record keeping system of immunizations among Army personnel, what possible reason should we believe the government, or any single payer system, would increase efficiencies and lower costs?

    My niece is an Air Force pilot, also serving in Iraq. She has had the same experience with multiple immunizations in the Air Force.

    A first step with improving the health care system in the United States is to eliminate the tax preference on employee provided health insurance. This should be accompanied by a general reduction in tax rates at both the corporate and individual level that would avoid any increase in taxes as a result of the reduction of the tax preference on employee provided health insurance. A major problem with health care and insurance in the United States is the consumer is too far removed from the cost of the health care. Not only does the consumer not pay for health care directly, most consumers do not pay for their health insurance directly.

    Health insurance should be carried and paid at the individual level rather than provided at the corporate level. As consumers shop for different health insurance, they will seek different levels of coverage, deductibles and cost. This will provide some element of competition into the consumers' health care choices.

    The current tax preference on health insurance provided by corporations leads to overly rich health insurance plans. In the current tax situation, health insurance is deductible at the corporate level, but not taxable at the individual level. Effective compensation strategies lead corporations to provide generous health insurance to compensate employees. If a company provides an employee a raise of $1,000, the employee needs to declare this as income. If the company provides an additional $1,000 in value in health insurance, this does not need to be declared as taxable income by the employee.

    Changing this tax preference is the first step toward health care reform. This will not in and of itself solve all of the issues, but it is a first step toward putting incentives in the right place.

    Regulated monopolies simply do not have a track record of success in the US. Innovation did not flower in the phone industry until the regulated monopoly of AT&T was ended. Who could possibly want the Post Office to take over the services of UPS and Fedex? The public education system in the US, which is largely a regulated monopoly, is not distinctive on a world-wide scale. The college and university system in the US, where there is competition and choice, is the envy of the world. That is why so many international students attend universities in the US.
    • Christy Hitchens, MBA '77
    I agree with many of the comments, especially with #45 and #53.
    I think what's still missing from a whole systems view is what leads to much poorer health than should be expected in a pretty wealthy country compared to that in most other countries which are still following their traditional diets and using their traditional foods. Michael Pollan and others have done a remarkable job (see Pollan's In Defense of Food) detailing how the American or Western diet makes us sick. This is actually subsidized by our own government.

    We want cheap, abundantly available food, so we subsidize agricultural products that can be processed and made into cheap, abundantly available food-like substances, though as Pollen describes, these are making us sick (type 2 diabetes, heart disease, cancers, obesity), diseases that have only become epidemics in the 20th and 21st centuries, as we pursued the processing of foods and other substances into food-like materials. Now the big agribusinesses lobby for continuation of these subsidies and against any regulation or funding of inspection of their practices or their products.

    They are thereby helping the health industry become an obscenely profitable disease-management industry. Both animals raised on non-natural foods (things other than green plants, and animals raised on green plants), and people who eat these processed foods are sick and getting sicker, therefore needing antibiotics and more and more drugs and health care. Animals fed grains rather than grasses get sick. Most of us don't know where our food comes from or how it is grown/raised. If we did, there would be an uprising.

    These outcomes are seen in other parts of the world as soon as the population switches to a Western diet. So the first place to start is with making healthy food more easily and cheaply available. Then educating people about good food and bad food, linking their understanding to health and food-related or diet-related disease.

    Then we can begin to tackle the so-called healthcare issue from the point of view of the provider and the customer of health care. Prevention first as a focus on medical providers, then treatment. Also we need to remember that health insurance does not equal health care.

    As I became unemployed late last year, I went on COBRA, and now pay $7200 for the equivalent plan I had with my employer. When my unemployment insurance runs out, I doubt I can afford to continue it. I am insulin dependent Type 1 diabetic, so the costs of care, supplies and insulin are very high. So be it. In any other industrialized country in the world, I would not have to face this. In America's individualistic culture, I'm on my own. It's an awful thing to face. Sometimes the so-called free market is not the best solution. Single payer for me.
    • Olu Olanrewaju
    • managing director, Genesis Housing group
    I have limited experience of the US healthcare system but I have read and watched on TV with interest and dare I say amusement the debate about Obama's proposals.

    As a UK citizen with access to the NHS and via my employer private health care, I have never had any recourse to use the private health care option because I have been blessed that the NHS have always been there for me and my family.
    Over the past 20 years I have worked and lived in 3 different cities in the UK and we never had a problem with quality of the service received.

    So when I read ridiculous claims made by anonymous contributor 17 and some of the hysteria displaced by some of your newsmedia outlets, I wonder whether we are talking of the same NHS that we in the UK are very proud.
    It is not perfect by any means, but I am glad we have access to a service that is created to cater for everyone no matter the size of your purse or your position in society. Ask our prime minister and leader of the opposition why the NHS is a national institution that we Brits cannot do without.

    The market is not a panacea for everything and I reckon this is one of those.
    • Patrick Geiger
    • President, CGF Industries
    I suspect that given the opportunity, a private system will grow and prosper even in a single payer driven health care environment. The masses will be relegated to the waiting lists (like those who get their care in emergency rooms today) while those with private insurance will bypass "the system" and get their health care needs in the private sector. In Fact... this is exactly what happens in the UK where over half of all major corporations offer BUPA private health to their employees.
    • Kendra
    Anyone try to get health care in Canada? They have a socialized system, and it doesn't work for them. There isn't a lot of choice for their patients. My niece needed tubes put in her ears for the ear infections that were happening. She should only need the tubes for a year and the pre school didn't want her to attend anymore since she had ear infections. My sister brought her back to the states to have the procedure since she was going to have to wait 9 months to have the procedure completed in Canada. How is that helping anyone?
    • Anonymous
    If we are to extend healthcare to all Americans, make it portable from job-to-job-to-retirement, keep the high maintenance and critically ill in the plan, provide relief to businesses and lower cost, we must consider adding a government plan.

    Personally I would appreciate more transparency in what a plan covers that could come with a public plan. Continuing to have these decisions behind-the-green-door of insurance companies should be disturbing to anyone. If the government plan could help refocus health care on prevention and health vice fee-for-service that would be a plus for me. My father's doctor said that his profession had lost control over health care. That is also disturbing. I want no one between my doctor and me. The patient-doctor dialog should be informed by science and analysis of what would be the best practice, but not controlled. Again, this would seem easier under a public plan where the protocols were less a corporate policy.

    Anyone watching Canada, the UK or France with an objective eye would see where the system is responding to complaints about access to services. In Canada, providers are private entities. They respond to where they see the need based on the public structure. We don't have to replicate these approaches, but can craft an American approach that is informed by these systems and practices.
    • Tom Dolembo
    • consultant, Crisis Planning Assoc
    If the US strategic mission were to produce unhealthy people, our food/lifestyle/healthcare feedback system would be described as very effective and efficient. Broadly described, our food system, supported by intense chemical applications, begins a cycle of unwellness that further drug chemistry builds into a final human who requires extremely expensive procedures to maintain life as one ages. Not to make a rant of this, but not to be sick is the only way to be healthy in the US. Many have no choice. No sane person with the slightest knowledge of socomial diseases, drug resistant bugs or MRSA would engage in any medical visit without serious trepidation. Viral unhealthiness is so embedded in the system front to back, we can not conceive of anything else. The average hospital is a sea of wicked microbes rivalling any bloodsoaked surgeons bench at Gettysburg, and they know it.

    We are a healthy, vibrant nation, in fact, made systemically ill by the very process intended to keep us nourished. Forget the healthcare endpiece until the raw materials (we the people and our children) are capable of being healthy, and until the medical centers are safe to visit. We have a great, smart, highly capable healthcare professional community, awash in a strategically ill-focused septic culture.
    • Anonymous
    Fantastic read, I am really enjoying the articulate, thoughtful dialogue. We need to figure out a way to provide incentive to the physicians, pharma, hospitals, employers, insurance companies and the patients' themselves to all work toward the same goal; a system of healthcare, not sick care. Otherwise, we'll continue to have this disgusting cash grab at the expense of the patients.
    • Roger Chan
    • President, Evergreen Global Group, LLC
    We Americans can not get health care reform right because we refuse to include all parts of the problem. We waste an inordinate amount of time on insurance reform. The insurance industry is already highly regulated and they pay bills, they do not directly drive the expense of medical care. Doctors, attorneys, and anti-patient policies and regulations directly drive up medical expenses. Therefore we need to seriously examine medical practice fees, earnings, liability issues etc. American doctors have a higher incentive to overtest and over treat than they do to help patients practice preventive medicine and self regulate. We now have a culture who are absurdly over medicated. Attorneys fees and compensation, tort reform, and litigation needs to be examined for how they drive up the cost of medical care and patient treatment. The fear of medical malpractice claims can force doctors to transfer their risk onto patients via excess testing and treatments.

    Legislation and policies must be examined to make sure they do not unnecessarily drive up cost as well. Hospitals must be allowed to perform triage and be able to re-direct non-emergency care away from emergency rooms, alternative care facilities and clinics must be added to the list of acceptable care facilities. Until these components are included in the discussion there can not be any meaningful reform. Now that so many of our political leaders are attorneys it has certainly made that piece of the puzzle that much harder to be included.
    • Allan
    • Consultant
    When I was working in the health insurance field three decades ago, there was a requirement that any employer we insured for health insurance also had to buy life insurance from us. I can't recall why -- it was likely for profitability. Perhaps there should be a requirement that all health insurers also be on the hook for a significant amount of life insurance-- not for profit but as an incentive to provide care at least adequate to keep the insureds alive.
    • Anonymous
    I beleive the problem with health care is an age old issue, between the haves and have nots. If you find yourself as a low income individual or upper class individual health care is not an issue. It is the middle class that always suffers in this country regardless of the discussion. Middle class people are always in the position of having to defend themselves against both sides of the argument. When we as a country learn to honor our working class individuals, the age old questions of the haves and have nots will be answered regardless of the issue, health care included.
    • Tom Witt
    • Managing Member, Quilted Care
    I agree with the comments made by Adam Hartung. The key problem has been the double separation of the customer from the provider and the loss of normal market forces associated with that separation. The "double" separation represents the employer funded payment of insurance plus the insurance payment of providers.

    Consumers have (appropriately, given the current system) come to perceive health care as essentially free (somebody else is supposed to pay for it) and therefore wants the best and doesn't care about the cost. To make healthcare efficient and effective we need to put the consumers back in the position of actually making decisions and paying the costs of those decisions.

    The appropriate role of insurance should be like house insurance, it covers the catastrophe (the house burns down) but not normal maintenance (the drains are plugged). Consumers should understand that to pay for a routine doctor visit "someone" has to pay for the doctor visit plus an extra 20% for insurance overhead. If the "someone" was the consumer, he would quickly decide that it's not worth paying extra for insurance on routine costs.
    • Anonymous
    I agree with the statement that to reduce the overall cost of healthcare to consumers we need to put the negotiation and responsibility for use back in the hand of the consumer. I am a relatively healthy person and take diet and exercise serious as part of my healthcare. I would love to have healthcare that I could afford to purchase on my own so that if I move to another job, my healthcare goes with me. Employers that want to match the current benefit could than give me a health care allowance. Any time I have seen the government get involved I have seen quality go down and cost go up. If the federal government does get involved I don't think it wise to have them both supply and regulate it. I would agree to some sort of assistance for the poor. One problem with that is that once you start giving that sort of assistance, it is impossible to take it away.
    • Anonymous
    VERY interesting discussion. It appears to me that one of the root problems, as was identified in a post, is that health care has moved from privilege to right. I would go one step further - the debate and cry of "it is a right" is rooted in our lack of taking personal responsibility for our actions.

    It is my right to receive health care regardless of what I might have done to contribute to my unhealthy state. Someone owes me health care. We have the tendency as a nation to make others responsible for our health vs. taking personal responsibility. Why do we, as a nation, have so many habits and lifestyles that lead to illness? We believe it is not our responsibility! Why do we cry so loud about health care being a right? We believe that someone else (the government in particular) is responsible to take care of us no matter what we have done or what we don't do.

    I have high triglycerides due to a hereditary condition (my dad and my grandmother had them too). I control them through a $17/month prescriptions (generic) and exercise/diet. It is VERY tempting for me to just scrap all exercise and diet and let the little pill take care of it because taking responsibility for my health is harder than shoving it off on a doctor or drug. I know that this is not right, so I have to make lifestyle changes to make sure that I stay healthy for the long run.

    I know that there are those who cannot manage their health by taking responsibility for their actions (me being one of them). However, this should be the minority rather than the majority.

    Another radical question....What if we denied health care to some one who didn't take responsibility for their actions? That opens a whole other discussion, but we seem to avoid it because it is hard. We do this in other areas - you don't pay your rent payments, we repossess your car; you fail to pay your car license registration, you receive a ticket and a fine, etc. - it doesn't seem that we do this in the health care arena!
    • Anonymous
    Many of those in Congress are bought and paid for by special interests. As long as this practice is so rampant, health care reform is nearly impossible. It is the old story concerning the foxes guarding the chicken coops.
    • Noel Lee Chun
    • M.D., UCLA
    The fundamental problem is political dishonesty on the part of the Administration and his party.

    The president says we need healthcare reform because 1) '40 million Americans' do not have coverage 2) The current system is 'bankrupting' people, businesses and the government.

    The government proposes to address this problem by a massive expansion of Medicare/Medicaid/CHIP, etc. WITHOUT 1) Interfering with the doctor-patient relationship via a bureaucratic superauthority 2) Cutting services or rationing care 3) Increasing taxes or fees on anyone who makes less than $250,000 per year.

    The conundrum comes to this:

    1) If 40 million Americans do not have health coverage, that means 260 million do have coverage, most of whom are happy with it.
    In a democracy it is difficult to get the majority of citizens to make a great sacrifice that will primarily benefit only a minority.

    2) Some people can add. If entitlements (primarily Medicare/Medicaid) are 'bankrupting' the nation, how are we going to save any money by massively expanding these programs???

    If the Administration and his party are asking the country to make sacrifices to make the country a 'better place' to rationalize healthcare; live within our means; give up this for that, etc... They have to come out and say so. They will not get away with promising the moon and stars to everyone and promising that on top of everything else it will be free. No one with any sense will believe them.
    • William Freyd
    • Consultant
    The problem is structural. Unlike any other business that I can think of, in healthcare the people who make the spending decisions are not responsible for paying the bills. That structure has to lead to uncontrolled spending. In my opinion, the problem cannot be solved until the structure is changed.
    • Jan Fersing
    • retired business owner
    Disruptive, game changing technology is what can give a company a significant competitive advantage. HBS cases were written around examples. In the health care profession, however, it creates problems for physicians, insurance companies, Medicare, and especially a patient trying to obtain better treatment outcomes.
    I have just completed treatment for prostate cancer using a relatively new radiation treatment called CyberKnife, developed by Accuray, a California company.

    It is available here in my hometown, and performed in 5 separate out-patient treatments - no hospitalization, no cutting, no infection, risk, no prescription drugs, and minimum side effects that are already going away. My insurance company would not cover it, because Medicare in Texas does not cover it, although it IS COVERED in 37 other states. The treatment process ordered for me, which I refused to accept, consisted of 42 separate out-patient treatments, with a much greater risk of side effects and of course a complete disruption of your lifestyle, particularly if you happen to be working and especially if you have to travel 50 miles each way to be treated. Completely computer controlled to compensate for normal body movements, it is 10 times more accurate than alternative treatments and really takes the physician skill out of the picture after initial setup is completed. After each treatment I resumed a normal lifestyle of golf, swimming, exercising, etc. And of course my choice is much less expensive. So what's not to like??

    The problem is the radiation oncologist that performs my treatment also performs lung cancer treatmens on the same machine on the same day, and can provide treatment for livers, pancreas, brain tumors, etc. So he's taking potential income away from surgeons, neurologists, urologists, pulmanologists, etc - you get the picture. This is where the resistance originates - it's an economic issue, and the insurance companies have no incentive to fight the will of their physician partners. The result is that the patient priorities are placed last. You much be an informed consumer, willing to fight, and I have been appealing since last November.

    A friend of mine runs a division of St. Jude Medical Co (NYSE) in Dallas, and confirms the same obstacles with patients who might benefit from his unique medical devices. The patient comes last, and cost be damned as long as someone else is picking up the tab.
    • Ben
    Let the states compete for clients nationwide in medical services like they do for auto plants etc.
    The key deregulation is to allow out of state health insurance. Some of the 50 states will specialize in medical services and will capture patients nationwide.
    • Karen
    Until a time comes whe we are unwilling to allow organizations to make a profit on illness, we will never get it right. Insurance companies make huge profits on insuring various populations and then fail to use those profits to provide care for those less fortunate. More money is spent on pharmaceutical advertising and marketing than on the drugs themselves - and Americans pay more for drugs than any other country.

    There are too many stories about coverage being denied to people for current (not experimental) treatment because of an insurer decision -- here's your current "death panel". Drugs are developed based on their profit making potential (e.g. Viagra) rather than assessing the overall benefit to the population. Drug companies also want you to use their newest (patented) drug rather than a simple aspirin or vitamin - because it's the new drug they make a profit on!

    Finally, we are a culture that likes the silver bullet - the pill or the treatment that will fix us. In reality, we need to change through better choices on food and exercise. We need to hold the mirror up to ourselves as individuals and make changes to ourselves as well.
    • G.P. Misra
    • AGM (HR), SAIL, Rourkela Steel Pant
    Let Americans not think of the U.K. system of health-care for the common masses.. It's worse than it used to be.

    Cretainly every human being needs health-care at some stage or the other. This cannot be eliminated as each one of us may face this inevitability some day or the other.

    We have become more materialistic for security, needs or greeds, with growth & improvised living conditions, after Max Weber propounded his theories about a hundred years back. For all I know Jesus Christ practised the religion of serving human beings. Are we drifting away from HIM with the likes of Max Weber? We perhaps need to think deeply on this drift, as all of us will go back to the dust one day, irrespective of cicumstances, age, conditions that divide or unite us. Perhaps certain eternal truths have withstood the vagaries of time, as medical needs has been the oldest requirement of Homo Sapiens from its formative stage till now.

    Why not fix a percentage of our income (tax-free) for providence on medical needs. Please give this some thought. The sages have tought us multi-purpose YOGA therapy /practices to stay healthy, fit or eternal youth etc., but not on any unforeseen happening or disabled or when age does not respond to medicare, or as was the case with Michael Jackson.

    Let's be introspective about the wisdom of the past while looking forward to the future with an issue common to all of us.
    • Anonymous
    I thought one of the key problems with providing health care was the FEAR of being sued and the COST of malpractice insurance. This results in more tests that drive up the costs. I would start with fixing this problem. It seems to me that this is a problem that can be solved by legislation. Or is this not a problem that our community of lawyers and politicians wants to address?
    • Keith
    • Interested reader
    I also have real concerns about our (US) ability to have what could reasonably pass for intelligent and informed discussion and debate on such an issue as this. In a day of sound bytes and "headline news", it seems the work involved to get to the underlying "facts" may just be too time-consuming and difficult to make it a realistic goal.

    One of the issues to be addressed is the imposition of manufactured timetables. Other than the possibility of political gamesmanship, what is the real harm in taking the time (which may be more than 6 months) to get an understanding of the issue and encouraging input that may not agree with "conventional wisdom" or other preconceived notions? There's a campagin promise involved? A "legacy" to be considered? Attention to be diverted from elsewhere? I remember a tour of the US Capitol when I was younger and they told us we were in the chambers of the "greatest deliberative body in the world". How much deliberation can there really be applied to an 1,100-page bill when there are so many somewhat disparate ideas embraced by it?

    Folks are criticized (and called ignorant) for failing to have understood how the whole fits together for a purpose. But the politicians can't seem to reduce the package to a clearly-stated set of steps. In fact, when you have multiple proponents of the current version(s) of the drafts, their synopses and answers on specifics seem to indicate there may be a lack of common understanding from within as well.

    The imposed short turnaround deadlines may contribute to this apparent confusion and conflict.

    President Obama also seems to put forth very few words on the specifics. He does champion a need to change and lists some goals but is leaving the specifics to the legislature.

    What exactly are the intended purposes of the proposed solution? Is it greater strength for "my" party -- whichever one that may be? Is our goal universal insurance coverage or is it universal accessiblity to care? Or is it just to reduce the costs?

    There have been some very interesting points raised in this discussion and I applaud them.

    The New England Journal of Medicine published an article in Feb. 2008 which concluded that preventive care is not always an indicator of lowered costs.

    When we speak of prevention and lifestyle choices and their impact, we collectively point to the evils of smoking and obesity. Too frequently those making the point appear to ignore the fact that breathing and circulatory diseases will not disappear if we all become the ideal weight and don't breathe within 30 miles of the nearest smoker. There is very seldom any mention made of other significant lifestyle choices that impact our increased need for health care. Where exactly does alcohol and 24x7 choices of 297 cable TV channels operated by a remote control button fit into that discussion? I believe it has a place but doesn't get mentioned. I would also think some mention should be made of those who participate in snow skiing, football and maybe even computer typists.

    There also appears to be an absence of discussion of personal responsiblity (except in the areas of cigarettes and donuts).

    I am a firm believer in helping those who cannot help themselves but am much less comfortable with the idea that I should increase my contribution to the US government (which also seems to charge a "handling fee" on my tax dollars, much as the insurance administratvie costs do on my premiums) to cover the self-employed indiviudal who failed to take into consideration his/her own health costs in the business decision on whether to become self-employed or the youngsters who believe themselves invincible or to some lesser extent, the person who chose not to worry about insurance when they were without symptoms but are quite concerned now that their condition requires expensive treatments. We need to be talking about those lifestyle and financial choices, too.

    The point has already been made by others that universal insurance coverage does not equate to universal accessiblity to quality health care delivered in a timely fashion.
    • Paul A Lepley
    • HBS MBA '71
    Much of what I have read here has been very informative. I would like to see a health-care system where:

    1. Everyone would receive care: basic and catastrophic coverage - medical, dental, mental, vision, drugs.

    2. Pre-existing conditions would not be a factor in obtaining coverage.

    3. Everyone would have multiple options for both basic and catastrophic coverage, one at no cost and the others with premiums/copayments/cost-sharing.

    4. An independent federal agency would be established to regulate coverage plans and to decide when new protocols are covered (appointees for life or age 75, whichever comes first).

    5. Individuals would be rewarded for making sound decisions (e.g., exercise, nutrition, not smoking, not overusing the system).

    6. Health records would be consolidated, not fragmented, and under the control of the individual.

    7. Coverage would be owned and paid for by individuals, not employers.

    8. Any individual purchase of treatment beyond basic or catastrophic coverage would not be deductible on tax returns.

    9. Legal settlements would be capped; "pain and suffering" would be limited.

    10. Drug companies would get longer patent protection, but pricing would be regulated.

    Unfortunately, I doubt that we (as citizens) will get a better system because:

    1. "I'm okay so don't change anything" (in other words, it's okay if someone else is bankrupted by the system).

    2. Politicians get substantial campaign money from special interests (insurance, lawyers, MDs, pharma, AARP).

    3. Misinformation campaigns are effective in blocking any action.

    Wouldn't it be marvelous if people looked beyond their narrowest self-interest to address a pressing need that will benefit most every individual in the longer term? I'm not holding my breath. A few people (mainly for financial or political reasons?) will do whatever they can to scuttle or eviscerate this process of change.
    • Anonymous
    We have become a society that wants the quick fix, the quick meal, the quick everything, but at the cheapest cost. We want what we want NOW. We believe we deserve it after all, we live in the United States of America. But sometimes things are broken that can't be easily fixed in a few short months.

    Somewhere along the way, someone or some group has to pay for the fix. It's usually that group that has very little say in what happens regardless of what they relate to their respresentative. It would appear that is what is happening in this case. Rush to get something passed and in place, but at what cost? What is going to be the real cost to a universal health care system? Will it fix all the evils out there associated with health care? Probably not. Will we find the cost to see a doctor, buy medications or go into the hospital any cheaper? Probably not. Will it leave my children any better off financially or will there be a bigger debt for them to be handed? Will it provide more jobs for the average person? Probably not.
    There are so many questions that need to be answered and answered honestly, not they way someone wants us to hear it or perceive it.

    So why don't we just slow down and look over this bill piece by piece and make sure it's what our country needs at this time. Is there any pork in it that needs to be stripped away?

    I want to see the best care readily available to anyone, but will that really happen? Who can say? Are we willing to take that risk?
    • Anonymous
    Several comments have raised the issue of acknowledging that healthcare is a right rather than accepting that it be treated as a commodity. Postings 11, 18, 28, 42 and 50 make this point, while posting 68 attempts to refute it.

    President Obama was hesitant: when asked in the 2nd debate during the campaign by Tom Brokaw whether health is a right, a responsibility or a privilege, Obama responded, "I think it should be a right for every American." The rest of the world does not have to "think" whether it "should" be a right. It is acknowledged in constitutions and by an international treaty guaranteeing the "right to the highest attainable standard of physical and mental health." (International Covenant on Economic, Social and Cultural Rights, article 12).

    More important, it is widely believed by the citizens to be a right. The US is a relatively backward country in this regard, which is all the more inexcusable considering the wealth the US enjoys and the unmatched quality of healthcare for those who can afford it.

    An important lesson of the experience of other countries is that most attempt to build their health systems with a view to realizing the right of everyone to health. They may not succeed very well but the starting point is the duty of government to do the maximum possible to realize the right to health. The starting point in the US seems to be to satisfy the constituencies bring the most pressure at a given moment in the politics of healthcare.

    Proclaiming a given standard of healthcare as a right doesn't mean by a long shot that that health is accessible, available, affordable, appropriate and of an acceptable standard of quality. But it does mean that the starting point for individuals and for policy-makers is that the former have a right to conditions giving them access to health (preventive and curative) and the latter have a duty to take necessary measures to the effective enjoyment of that right.

    The "public option" is a red herring in the current debate. The VA hospitals, Medicare, and Medicaid are examples of the US government providing access to care where the market failed to do so. Now we have 47 million uninsured and others whose right to health is denied. Where is the logic of those who have good health insurance fearing "socialized medicine" if they are allowed to keep their coverage while those suffering horribly without care and losing all financial security to respond to a medical emergency have coverage or care provided at taxpayers expense? Most studies show that the ultimate cost to the taxpayer is much more if the "losers" in the current arrangement are forced into bankruptcy or to use emergency services for normal care or when their condition has seriously worsened due to lack of affordable care.

    The error of many postings and of the broader debate on this issue is to affirm that the goal is universal insurance coverage (for liberals) or taking personal responsibility while allowing the market to remove inefficiencies (conservatives). By placing the right to health as the ultimate goal, the agency problems, moral hazards, sources of excessive costs and other key issues are placed in a different perspective.

    It is time for the US to emerge from the ruinously expensive and morally backward rejection of the normative foundation of the right to health.
    • Hugh Quick
    • Man, seated, Home
    It seems to me that in USA many, if not most, health care professionals have their own welfare as top priority. In Europe the patients' welfare takes precedence.
    • Stephanie
    • Interested person with international experience
    One aspect that seems to be overlooked is the competition - or lack thereof in some cases. In a large city, there are many choices for providers - many doctors, many specialists, many hospitals and clinics, etc. Market forces can work well. In smaller towns, there may not be much of a choice, so there truly isn't much competition. Even in a small town, you might have 2-3 gas stations, but you might be lucky to have even one clinic with very basic services.

    That is why, despite not being a fan of government intervention, I believe there should be some sort of minimum standard of care which the government should ensure. Medicare/Medicaid are providing some of that, but I am also talking about structural minima, perhaps with one objective being prevention.

    Beyond the basic service provided by the government, I firmly believe that competition and private entities should be the primary provider. The places I have seen where socialist systems work relatively well are smaller, more manageable countries.
    • Edward Hare
    • Retired Director, Strategy and Planning, Fortune 250 Mfr'r.
    Post 71 (William Freyd) gives us the answer why America can't get healthcare "right" from a high level perspective. He calls the problem structural.....and the structure resists change that does not benefit it. And Politics is part of the structure.

    Politicians can't even agree on who they want us to vilify. One day it's the insurance companies. The next it's the drug companies. Then it's the lawyers. Then it's the American lifestyle. Then it's the debate about "rights" which seems to mean things we are somehow entitled to ... so long as someone else pays for them.

    What I fail to understand is the lack of conversation about doctors in America. I've seen IRS data that suggested that 9 of the 10 highest paid occupations in America are medical doctors of one specialty or another. How can that be? In France, doctors make between $50K and $100K and, are expected to make house calls. Doctors deserve to make a good living but ours seem to feel entitled to be an aristocracy of some sort. Mine seem to have no embarrassment with handing over a $10,000 bill for which they accept $1,000. What other business do you know of where pricing is so opaque it has to lie somewhere between fiction ... and fraud.

    Just look at the practices of our system ... and it's clear it's abusive. And it starts with the billing for the price of "services". Somehow, we've tolerated it for too long that it has simply become accepted. My own doctor (who is an equity owner of his large, multi-partnered, doctor owned facility acknowledges that it's a game. The question ... why is it tolerated and how does one stop it? No doctor or hospital wants to see their income drop. Much like our obscenely compensated CEO's I'd add.

    In Pennsylvania, we even subsidize the cost of doctors' malpractice insurance! Imagine that, publically subsidizing a cost of doing business! Incredible.
    Why do we sue doctors and why do plaintiffs get insane financial awards? Because medicine has evolved into the big business doctors want it to be. The doctor has become part of a big machine that will charge you $15 for a Tylenol. That behavioral dynamic doesn't get the attention it should. But it does influence the minds of a jury you can be sure.

    Healthcare in America is a mess. It's making us uncompetitive and turning us against each other. And the solutions, if there are any, revolve around re-setting expectations and abandoning the silly notion of getting something for nothing. Whose ox will get gored is the only question. Usually, it's the nameless, faceless "taxpayer" ... the safe way out, in the short term.
    • Al Rossow
    • HBS MBA 1957, Rossow Associates
    We can all identify things in the US system that can be improved ... either from our own experience or by using statistics and anecdotes from other countries.

    I think Prof. Minkiw has it right when he forecasts the impact of the so-called "public option" ... as that which would drive out all other options.

    The bottom line is: "Do you want the government to run another 20% of the economy?" If you do not, there are a number of straightforward steps that can be taken, e.g., reasonable limits on malpractice awards so as to further minimize the need to practice defensive medicine; portable policies; removing state restrictions on purchasing insurance from vendors in other states; tax credits to those who do not have employer-provided insurance, to name a few.

    Today is August 18. It looks like the common sense of the average American will prevail. Herman Kahn would be proud!
    • Anonymous
    Poster 80, one of the key founding principles of the U.S. that is applicable in this debate is: people have equal rights, not equal things. Healthcare is a thing if you are honest about its definition and with yourself. It's a thing created or provided by someone else, in the context we are discussing it. Your argument falls apart with the contradiction of violating one person's rights to provide "rights" to another.

    You speak of a right to health, with which I agree. Everyone has a right to live his life making choices that maximize his own health, without impairing the rights of others. It's where you confuse the right to health with the right to healthcare that *your* claim becomes the immoral one. How can you claim that it is moral for certain members of a society to be entitled to the work and efforts of other members? Those members of society with the brains (and years and years of specialized training) to diagnose health issues, apply healthcare treatments, invent new treatments, and set up administrations to provide treatments are the ones whose rights are violated when the erroneous claim you make, that healthcare is a right, is acted on.

    With your incorrect definition of a right, should everyone have the right to three nutritious meals a day? One house? One car? Where does it stop...from each according to his ability, to each according to his need? Think about where your thought process ends when you assert healthcare as a right.
    • Bill Schrader
    • Retired, AMP 84
    Congress is not focusing on the fundamental drivers of the high costs of our current medical system, namely pay-for-service as exemplified in Medicare, lack of choice for individuals, contrast Switzerland, fear and cost of lawsuits benefiting the legal profession more than injured parties as contrasted with no-fault systems in New Zealand and Sweden, and the lack of electronic records, telecommunications networks and payment systems.

    Further, we should incent good patient behavior given that such behavior, i.e. obesity, smoking, lack of aerobic exercise, etc. results in over half of U.S. medical costs today.

    Correct these fundamental system and behavioral flaws and the current outrageoous costs of our system dramatically decrease allowing all U.S. citizens to be covered for less than the nation spends today.

    Rationing needed health care services does nobody any good, does not address the underlying issues and tends to punish the innocent to support the misbehaving.
    • Katherine Daley
    • teacher
    Thank you for providing this forum. I appreciate reading other people's views here, especially #41, #49, and #60. Health insurance being tied to employment began with big factories providing a doctor for their employees, but it grew to be a major industry during World War II because wage freezes made it necessary for employers to find other ways to attract employees.

    As #49 points out, we have outgrown that system. People change jobs and move many times during their lifetimes, and employees and employers do not have the lifetime relationship that they used to have. In the last thirty years, I have had twelve different plans, and others have had more.

    Our current system is not a free market system. Most policies have limited lists of providers, and bad doctors can stay in business by courting insurance companies and providing services for less. There is no incentive to cover people who are between jobs or who have preexisting conditions. Most people cannot choose their own doctors or hospitals, and doctors are hurried through appointments and barely have time to talk to their patients. Doctors are paid a fraction of their fees and raise their prices so that they can make a living.

    I would like to go back to having a doctor for the whole family who knows their patients for years and can spend time with them and help them through illnesses and promote health. One possible way to provide that kind of service would be clinics run by RNs who serve as lifetime health care professionals helping people to handle minor health problems, administering vaccinations, providing preventive care, and referring patients to specialists and overseeing their care by those specialists.

    Planned Parenthood provides that kind of care for pap smears, breast exams, and other basic health care needs for women, and they do an excellent job. For seniors, RNs serve as case managers, going to all doctors' appointments and helping their clients to understand what their medicines are and how to take them. Seniors who have case managers receive more consistent care and are less likely to be given a drug that is not compatible with another drug or treatment. The clinics could be paid for by charging for services on a sliding scale or by paying an annual subscription.

    I think we need to move away from the employer-based health care system and provide more choices. I think people should pay for basic services, like physicals and visits to the doctor for colds and minor illnesses out of pocket and buy insurance to cover health crises and chronic illnesses. Money that each person pays into the system should be used to cover health care for others and not to pay a huge executive salary. People who have contributed to the system for years would not be denied coverage when they need it most. I, personally, would not be sad to see the end of private insurance, except for catastrophic events. They are the only winners if health care reform is stalled or killed, and the American people will be the losers.
    • David Physick
    • UK contributor
    I thought a comment from 'across the pond' may be useful in light of the recent reports in the media about the US wanting to emulate the UK's NHS. It is interesting to see how in the past 20 years, the number of Brits taking out private health insurance has rocketed. In my own case, I used to be covered by the policy of my large organisational employer. I become self-employed a while ago and took out my own policy but have let this lapse due to escalation of premiums. If a UK resident has need for a major operations, often this is done throught the NHS not the private provider. So our situation is not 'clear cut'; the shape of the sector is in flux.

    Funding via taxation is generally regarded as fair but, of course, we do not seem to have the same degree of clarity regarding hypothecation of taxes to specific purposes as I have seen when I have been in US. A massive issue of contention over here is the growth of management within the NHS, being paid higher salaries than the medical practitioners. There have been some appalling cases of reward being completely out of line with performance, including some situations were people have died because management organised things in order to achieve state mandated targets rather than putting the patients first.
    Perhaps what is needed in both markets is some fresh thinking - some 'creative distruction. Demand continues to escalate as population rises and ages. How can this be staunched through improved social conditions, i.e. access to good diet, education, exercise etc? This demands change to a whole array of other factors, i.e. the whole food production cycle.

    Supply appears to be dominated by a desire to make money and lots of it. Where there is a convoluted service-profit chain, as is pictured by the array of other comments in this discussion, all that happens is the individual profit margins compound and the end-user faces a price hike. Hopefully, the US trait for competitive markets can combat this together with a drive to simply the service-profit chain. Also, how can the supply side deliver prevention not cure, which help reduce perpetuating demand?

    Jim Collins recent book, 'How the mighty fall' points to organisations failing because they loose sight of their fundamental reason for being. In the medical profession, is this not dominated by the hypocratic oath.? This sense of clarity of purpose is so crucial that I would encourage all to concentrate upon ensuring complete buy-in to that principle. Then, perhaps, the economic modelling can begin that will concentrate upon delivering fair returns to providers and equitable pricing to consumers.
    • Anonymous
    Some posters want to frame the debate as "whether" the taxpayer should pick up the bill for those who fail to provide for thier own healthcare or make good decisions about lifestyle.

    We could get into a discussion about the limits of choice, but it's unneccesary, because the real question is already "when" should we pick up the tab.

    We currently pick up the tab for the care of our elderly through medicare and the underinsured in our ER's. It would cost us less to pay for care earlier: before diseases have progressed with age and before symptoms have become so severe that ER visits are made.

    Some posters point to the spiraling costs of medicare as an example of why any kind of public option will fail. I'd suggest that the lack of a public option is part of the reason why medicare is failing. Unless we intend to eliminate medicare and let our elders simply die of their infirmities, we'd be better off intervening sooner and saving money in the long run.

    It's good to argue about what should be a right and what shouldn't. But we still need to evaluate alternatives against the actual status quo, and not just against an ideal that doesn't exist.
    • Ulysses U. Pardey, MBA
    • Managing Director, Am-Tech, S.A., Panama, Rep. of Panama
    Why, in a country that provides more medical research to the world than any other, can't Americans get health care right?

    In some northern European countries, there is the legal obligation to subscribe to the State-run health system which is of excellent quality. Private health-related providers do exist and they are optional.

    Are we assuming that there is always a win-win situation in every activity we undertake or in the way it has been developed? How to define what win-win could be in an already-established seem-to-be very difficult win-lose situation as per the above introductory article?

    What has happened in the USA to those businesses which have been proven to be to the detriment of consumers, i.e. the tobacco industry? How was the tobacco business, the general public and legal attitude toward smoking in the USA in, let us say, the 60's when compared with today's situation? Nowadays, smoking seems to be an illegal behavior/activity in public places and there are even rooms for "smokers only". The marketing of smoking has changed dramatically and in some countries it is illegal, something which is now generally accepted.

    In general terms, when it comes to our health, we are either sick or not-sick.

    These two states-of-health seem to exclude from each other - sick or not-sick - and seem to frame our health-related nature in which profit and health (or treatment?) are deeply involved in the USA. Are these two states-of-health two separate businesses, a "sick"-market and a "not-sick" market?

    Do profit and health exclude each other? For instance, more profit because less access to good treatment, less profit because more access to good treatment? Is it a win-lose situation? Therefore, could profit and health develop simultaneously avoiding an either/or approach in favor of a steady win-win oriented solution? There seems to be three distinct parties involved: profit, health and treatment, but the source(s) of problems could be somewhere else.

    Is there a common ground - evident or not - to develop for health (sick or not-sick) and profit?
    How to establish the priorities, if any, in order to find it? It is possible that a workable solution-minded approach is not government against private business - which reads as a win-lose battle field - but rather finding the key success factors which favor the identification of this common ground. Which is the most appropriate set of cause(s)-effect(s) (logic/rational) in order to fix, as intented, this profit-health (sickness) and profit-health (not-sickness) situation?

    From exclusion to inclusion. Everyone's business?

    Is there a legal definition of a health-related patient besides the individual's proven medical conditions and under whose metrics? When does someone stop being a health-related consumer or not-sick person (prevention-treatment) and becomes legally a health-related patient (illness-treatment) or sick person?
    How could this relate to the making of selling prices to the market(s), costs to treatment-providers, and the nature/quality of the corresponding treatment?
    Could such a legal definition be a useful guidance in this respect? Who/what could prevent this from happening as a useful contribution to a long-lasting solution?

    Is someone weak when sick and therefore entitled to protection from predators?

    Is government a better protector and solution provider at lower prices than profit-oriented private companies? An either/or approach - either government (protection-oriented) or private sector (profit-oriented with room for consumers' "choice" and competition which is guaranteed by the government without competing) - could generate inadequate solutions as it reads as if some good vital things are lost because of the exclusion of either the government or the private sector. Therefore, perhaps a solution which provides a proper bond of protection, accurate cause-effect information (logic/rational), quality, choice, access, fairness and competition might lead to a more acceptable solution for the parties involved. Not necessarily more or less government, but rather added-value positive-minded initiatives from all the parties involved.

    Is a government-goodnesses and private-goodnesses bond in a health-related consumers and health-related patients environment a feasible answer to the quest of framing a steady win-win oriented and long-lasting solution in today's win-lose scenario?

    If greed is bad, how wrong is pride?

    Perhaps accepting that getting sick and therefore weak is part of our human nature - regardless of our way of life - could open unexplored avenues in order to solve our health-related needs and the associated problems. Besides and in general terms, health-related solution-providing firms seem to be far more competitive than individuals when it comes to defending their business interests as this present health-system crisis proves it abundantly. Consequently, whom to turn to for understanding, benevolence, guidance, support, and competitive tackle-power in order to team up with for a badly needed touchdown?

    When it will come down to business details - profit - some "things" might have to be "recycled" and other "things" might have to be improved.

    What makes prevention-treatment different/similar to illness-treatment? What makes a consumer different/similar to a patient? Are people today paying in order to remain not-sick and/or to recover health? Will these two exclusive states-of-health - sick or not-sick - be legally and business wise separated in order to make room for a useful bond of government-goodnesses and private-goodnesses?

    How to make money accordingly? Considering that a franchise is a distribution system, are health-related businesses "franchisable" from the federal government to the private sector in order to spread the American dream nationwide? What business are we in?
    • James Kuperberg
    • Chair, Soc., Behav. & Admin. Sci., Touro U-CA College of Pharmacy
    We fail at the organization and financing of health care for the same reason we are failing at education, roads, and other infastructue services. As complexity rises to these high levels we have both market failure and conflict with unrealistic expectations driven my our lack of civility and sense of community. The concept of individualism that drives much of our nation is disfunctional with shared needs and shared solutions.

    For example, a major deep driver in health care cost is the vast variety of benefit plans (far exceeds the number of payers). This creates approx. 25% of the administrative overhead for many providers. Even the most market driven economies with successful national plans offer universal coverage with a single (and high quality by USA stds.) benefit plan structure.

    If we can get past the concept that every large employer and every HMO and Ins. plan should offer a broad range of plans we could sig. improve health outcomes and reduce non-productive administrative, accounting, and intermediary costs. We need to face the facts that our current system is not sustainable.
    • Anonymous
    The elephant is healthcare itself.

    I believe health care should be made 'universal'. However, I also believe individuals should be free to choose the kind of care that they receive---significant here, as no one within this discussion has questioned healthcare itself.

    Please realize that medical science is an extremely incomplete body of knowledge, and any recommendations that arise from it should be considered 'in flux'.

    Unfortunately, in the US especially, medical recommendations are made absolutely, forcefully and as though they were final. This is unfortunate, and so much so that even very intelligent people begin to believe the loud voices of the medical science collective. Question how many times dietary recommendations have changed drastically in 30 years. Question the forcefulness with which certain chemicals have been declared 'safe' only to be quietly declared unsafe several years later. Question the medical science that for whatever reason embraces yoga today but in the very recent past forcefully dismissed it as quackery!

    How can we possibly create regulations based on a--fascinating and important, yes--but very incomplete and changing body of knowledge? To do so would be both myopic and dogmatic.

    We need the right to healthcare, but individuals also need the right to choose the kind of care--and the kind of lifestyle--that they feel is important to them. It is a mistake to think that everyone wants to extend their lives to the maximum length. Everyone does, however, want a good life, and it is not up to the government, or medical science to dictate what it should be.

    People are scared of diversity and market inefficiency, yet it is very much tolerated already. How much more efficient would the US economy be in theory if everyone held the same religious views and the same values in conducting their day-to-day lives? Very efficient indeed, but as we know it doesn't really work in reality. Similarly, we cannot dictate a 'healthy lifestyle' or 'step to quality care' in any part of a proposed national healthcare plan. Leave that to individuals and to society at large.
    • Gerald Nanninga
    • VP, Retail Ventures, Inc.
    Health care is a business, not an institution. The money currently spent on health care is not going into a void; it is creating profits for a health care business. If you want to lower health care costs, you have to either:

    1) Eliminate Profit Opportunities (ways to make money in health care).
    2) Lower Profits on Remaining Opportunities.

    These are tough to do in a capitalist society.

    On the first point, we need to look at ALL the areas which find ways to profit off of healthcare, including lawyers, malpractice insurers, media (who benefit from pharmaceutical advertising), food processors (who sell food that is not good for us), health care insurers, pharmaceutical companies, ambulance services, and so on. We may be able to take a huge chunk of the costs out of the system without touching actual health care by just creating disincentives for profits from the non-health providing part of the ecosystem.

    Second, many aspects of the health system are less profitable in the rest of the world than in the US (which may explain why there are so many foreign health care providers moving to the US). Perhaps more balance is needed here (especially in pharmaceuticals?)

    Finally, there is the area of improving efficiency. There are lots of opportunities here as well, but again, people move to where the money is, and productivity in this industry often leads to lower profits. That needs fixing.
    • Daniel P Michel
    • Ethics Professor, Taylor U. MBA
    In Outliers, Malcolm Gladwell implies that a strong factor in our past health care options is Hostede's cultural dimension of Individualism. The US scores highest on the individualism-collectivism scale. This implies that individuals look after themselves. Gladwell suggests that prehaps that is why we are the only industralized country in the world that does not provide its citizens with universal health. One might attribute our US health-care process over the past 200 years to this cultural aspect of individualism. What has changed?
    • Anonymous
    All, please open your eyes and minds, the world does not just confined to US/Canada/Europe.

    Heathcare, is caring for ones/everyones health, which is caring for our whole species/universe's well beings.

    There are also more than just the existing medical science/systems that are being practiced within this narrowly confined view.

    For those who loves to analyze to death on every little issues, then just look at the top 3 most healthy and all rounded/well adjusted human cultures, and adapted their best practices as our healthcare system.
    • Anonymous
    It seems that as long as the healthcare industry is profit oriented the altruistic benefits will always take a back seat to the need to meet Wall Street's expectations. In that context I think a single payer model with a non-profit structure would be an interesting approach. This doesn't necessarily have to be a government run initiative though it could be initially catalyzed by their sponsorship.
    • Anonymous
    My friends and I believe that government should simply expand Medicare to cover those who do not have access to health care but need it, as a first step. The money is already being spent when the uninsured go to the emergency room, and since FQHC (federally qualified health centers) are now the first resort for low-to-mid income residents, both legal and illegal. This could reduce the pressure to come up with a brand-new program, while allowing time for tweaking and reorganizing the whole system, or come up with "medical tiers".
    • Anonymous
    First, let's stop calling this "health care" reform -- this is "health insurance" reform. The health care that is provided by the medical industry is generally very good to excellent. That's why people come here from all over the world to get treated. The major problem is how it its paid for, which is a broken insurance system. So, let's start calling it what it really is.

    Second, another major problem that no one seems to ever talk about is the need for tort reform. When lawyers draft laws to protect their own interests, the only ones truely protected are the lawyers. Let's face it, doctors "practice" medicine. They don't always have the answer and they try different things. That means they don't always succeed and people die. The medical community has to be so overinsured for this liability that their only option is to pass along price increases to the patient community.

    Pharmaceuticals come with warnings, yet people take them and suffer from the side effects. Every day there are TV commercials by attorneys who are willing to take on a case because of a negative side effect caused by a drug. More liability to the medical community and more dollars in the lawyers pockets.

    If we would take a look a step back and approach this reform as a surgeon would approach a highly complicated operation, we could snip out bits and pieces that are causing the disease without killing the patient.
    • Vanitha Rangganathan
    • Malaysia
    Um, Jim. It's not merely a U.S. problem. You might want to consider expanding the parameters of discussion for a better appreciation of global healthcare blues.
    • Steven McArthur
    • Senior Manager
    Health care needs to be above the partisan politics in countries such as the USA and Australia (I am in Sydney). In scoities based on the notion of a fair go for all of its citizen health care (as well as education) needs to be subject to a bipartisan approach. Consequently this requires a high degree of government involvement to ensure equality throughout the system. This thought then extends into the requirement for some level of cost management as continuous priceing growth above the prevailing and historical inflation rate leads to a reduction in access to health care, especially for those on lower pay/salary scales.

    The scare mongering needs to cease and the present and future Administrations in the USA need to tell patients not to fear this process as the government will underwrite access for all Americans to quality healthcare. I hope all Americans rise to the challenge and accept that as a country this will bring you and all other citizens closer.
    • Jeff Balash
    • Chairman, Comstock Partners LLC
    One of my key concerns is that Government involvement is not an efficient way to operate any business. The Post Office enjoys legacy land costs and doesn't have to make a profit. If it were doing its job reasonably well, there would be no need for FedEx, UPS or DHL. The US has even contracted out significant portions of its Defense mandate, e.g., Blackwater.

    I believe that the health care solution could be straightforward and accomplished through private insurance without the costs, both financial and lower customer service, of a Government provided plan. This would parallel the auto insurance model:

    1. Each citizen must have his/her own health insurance, which would be purchased from insurance companies, just as auto insurance is purchased.

    2. There would be an assigned risk pool, just like in auto insurance, for those who are deemed "uninsurable."

    3. Companies would compete on price and customer service, so that customers would realize that the cheapest might not be the best alternative--just as in autos.

    4. The Government would provide subsidies to families/individuals who couldn't afford to purchase basic health care insurance.
    a) By basic, I mean just that. The insurance plans that many employers offer: low deductibles, broad coverage, etc are benefits paid to employees, not insurance. Therefore, the basic plans won't be gold plated but would provide for standard HMO care with a co-pay and/or a deductible, so that patients would think about the cost of seeing a doctor, but not be deterred by the expense when important health care issues arose.
    b) The plans would encourage/reward healthy living. Lower premiums/deductibles for: Non smoking; weight control; healthy eating and exercise as measured by heart rate, blood panel tests, etc.
    c) I would also consider not insuring self inflicted diseases: issues related to drug abuse, drinking, obesity, smoking.

    5. A national healthcare system that standardized what physicians could earn would not be necessary. This would increase the number of talented young people who would enter medicine as a career with the expectation that they would never be "rich" in an entrepreneur's sense, unless they became one--and those opportunities will be there. However, the could earn a good living which would enable them to live comfortably, send their kids to good schools and enjoy a comfortable retirement.

    6. Tort reform would also be an important element of this package, since it would reduce the cost of insurance that physicians need to purchase for potential malpractice suits, which would in turn, reduce the cost of health care, since the insurance premiums are one of the "cost of doing business" elements that must be included in the fees to the patient.

    My overall philosophy includes the following precepts:
    1. Social liberal and fiscal conservative: we need to make a lot of changes, but need to finance them prudently. We have no more room for additional debt--period.
    2. The only way to be a powerful nation is to be a healthy nation.
    3. The only way to be a powerful nation is to be an educated nation, which will include multiple mid-career training for most workers
    a. Retirement age will likely be 75 to 80, with a life span approach 100, which I suspect that most current high school students will reach
    b. Rapid business and technological change will increasingly shorten the useful lives of individuals' skills

    Thank you for listening.
    • L. Boulware
    • HBS '80
    One reason we don't get the value for our healthcare dollar is that insured Americans have no incentive to manage the cost of their care. They don't have the expertise to make complex medical decisions on their own and they only have to pay a manageable fraction of the cost. Even if anyone were interested it would be very difficult to understand costs. A look at an insurance company statement for healthcare services demonstrates that these statements aren't designed to be understood.

    Pharmaceutical and other health technology companies have too strong an influence on which healthcare products reach the market. Their focus is on profits, with a sub-theme of helping patients get better. This is the right choice for a corporation but does not necessarily lead to better healthcare outcomes.

    Companies significantly impact the market through funding physician-led research and other activities. Many leading physicians get a sizable portion of their income from working with pharmaceutical or medical technology companies. Once a company expresses interest in a therapeutic area, physicians know that lucrative contracts will follow. Physicians who could have been working on more clinically promising therapies will be redirected to the areas where the money is flowing.

    For the reasons above, I think that this discussion really needs to be about reforming the delivery of healthcare. A focus only on reducing costs will only result in lowering the quality of care if we maintain the same delivery system.
    • Beverley
    Yes, the VA hospitals do a reasonable job providing health care to a lot of veterans. However, the VA hospitals are in the news again for providing incorrect cancer care to veterans, issuing diagnoses for the wrong illnesses, mismanagement of funds, and other such problems that are rife in a bureaucracy.

    The point of the matter is this: the federal government has never run any business into properity or efficiency. What in the world makes us think that it can do any better with health care? As things stand today, our newly senior citizens are having difficulty finding physicians who will accept medicare patients. This problem will only grow as more and more babyboomers enter their golden years. Medicare and Medicaid are buckling under the weight of the patients they carry now, and is constantly losing money (so say the politicos). Add all those babyboomers and it will suffer more. Add all of us to the program, there's no way it can survive.