To solve a problem, it often helps to lay out the major challenges and tools on a table. Here are the challenges, in no particular order. Some may seem unrelated:
1. Everyone must have access to healthcare; currently 50 million Americans don’t (including me).
2. Healthcare costs keep rising, which is the reason for #1. If healthcare were cheap enough for everybody to afford, we’d have no crisis.
3. Unfortunately, hospital-based care, which America excels at, is very expensive. Most people think of this as America’s peculiar strength. But it is, in fact, our particular problem. (This is true for the entire First World). Since 70% of healthcare dollars are spent in the last year of a patient’s life, the care is largely useless, besides being expensive. I don’t consider the poor quality of life in a patient’s final year as a victory for anybody but the healthcare system. Medicine, and Society, have long had a phrase for this situation: “You can’t cheat death.”
4. Healthcare’s business model is payment in exchange for treatment. Removing a disease eliminates the basis for a financial transaction. TB and polio were cured in the 1950s, and stopped being the profit centers they once were. Currently there’s no business model for prevention. We don’t pay an extra fee for being free of polio. It just costs a few dollars, the price of a polio vaccination. No health insurance company, private or public, spends any money on prevention. Politicians may call for prevention, but it won’t happen. Doctors have called for it for the past 50 years, and still nobody is willing to pay for it. The business model needs to be changed somehow so that prevention becomes valuable.
5. Patients want better outcomes, but the healthcare system, like any business, thirsts for more revenues. The two are opposed, since the best outcome—continued health—means staying out of the hospital and hence spending little money, just enough for cheap generic drugs to stay healthy.
Among the completely undiscussed strengths we have are the following:
1. The generation that fought WWII and the Korean War are reaching the end of their natural lifespans. Although this is a cause of great personal sadness, it creates a once-in-a-country’s-lifetime opportunity. The vast healthcare infrastructure built up by taxpayers to support The Greatest Generation, the Veterans Administration (now the Department of Veterans Affairs, but still called the VA), now has too much capacity (read, too few clients). It will soon be down-sized by as much as 50%, like the military base closings of the 1990s. Besides an irretrievable loss of invaluable healthcare assets (150 hospitals, 300 clinics and nursing homes), it will also mean the demise of perhaps half of the nation’s medical schools, all 130 of which have a VA hospital for teaching and research purposes.
2. The VA got its vast infrastructure from the Public Health Service (PHS) in 1921, to care for the many WWI veterans that overwhelmed the VA. Few realize that this was a loan, not an irreversible gift. Certainly nobody in the VA remembers that it was a loan.
3. Genomic medicine is uncovering the steps in disease pathways, making clinical medicine much more effective than it ever was. This true medical revolution--as opposed to electronic medical records--can lower costs and improve patient outcomes. My company, GenoMed, happens to be leading this revolution, and I fancy myself it's--that's right, David Washington Moskowitz.
So here’s my advice for Washington, DC:
1. Scrap the three or four bills currently circulating around Congress. They’re all bad ideas, and ignore important facts (cited above).
2. Leave the private, employer-based insurance sector alone. It’s a business, and it doesn’t like being told how to run its business. True, it looks like it’s pricing itself out of existence, but that’s its problem, not the government’s. Private insurance isn’t GM yet.
3. Concentrate on expanding the public sector to care for the 50 million uninsured (including me).
4. Be very careful how you build up the public sector. Forget about unproven “cooperatives” and “health insurance exchanges.” After all, the Massachusetts model is failing; costs are sky-rocketing. Why not be as conservative and as American as possible, and just return the VA to the Public Health Service, making good on the loan of 1921? The PHS is as old as America itself, having been chartered in 1789. Plus, its mission is already to care for every American who walks through its doors. Ramping up from 3 million to 50 million patients will only cost $100 billion a year, just $70 billion a year more than the $30 billion a year currently being spent. I'd be glad to show the PHS how to do it.
5. Order the reporting of simple outcomes for each patient paid for with federal or state monies. Is that patient alive at the end of the year? Who was his/her doctor? Did the patient go on dialysis during the year? Was s/he hospitalized? For how long? How much did it cost? Then post the outcomes for each doctor and hospital so that patients can vote with their feet. This will give value to outcomes; currently, what patients consider to be a good outcome has absolutely no value in the healthcare system.
6. Do NOT pay for performance, as in the current healthcare plans. That’s a vestige of managed care. Performance is no substitute for actual patient outcomes. Who knows? A doctor in Podunk may develop a way to keep patients with lupus out of the hospital. If that doctor were penalized for trying anything new, s/he’d never be able to advance the treatment of currently untreatable diseases.
7. Encourage people to die at home when it’s their time. Medically, it’s an easy call. If you’re 100 and need a liver transplant that costs $300,000, most doctors would concur on what to do: nothing.
8. Do not penalize people when it comes to healthcare. If somebody doesn't want to prevent disease by walking into the nearest free PHS clinic, leave them alone. Do not tax, fine, or jail them. The minute healthcare stops being voluntary, it becomes assault and battery. We don't punish people who don't floss.
Preserving a robust private and public sector will allow competition on outcomes. Only that will drive down prices and improve outcomes in the long run, the two new features we want for our new healthcare system.