How about we start here?

Dear United States,

Is there anyone left willing to talk about health care reform calmly?  At this point, the dialogue has become so partisan and stained that it seems that the only decision anyone needs  to make is which team they’re on; then it becomes just a matter of saying anything you have to in order to win.

I’m not a politician.  And while I have my opinions on health care reform, I try every day to remove them from my work.  I’m a health services researcher, so it’s my job to study how we can improve the health care system.  And the one thing I can tell you about the way we are talking about reform is that it’s backwards.  We’re looking for solutions, when we haven’t yet decided what the problem is.

When looking at health care systems, the three biggest factors are always access, quality, and cost; these are always in competition with each other.  On all of them, the United States performs terribly.  Our system costs about two to three times per person what most other countries pay.  Our outcomes are middling at best and sometimes shockingly bad.  And, as one of the few countries that does not have universal coverage of its citizens, our access isn’t good.  Any system that fails on all three of these pillars isn’t just bad, it’s irrational.

Further bad news is that (short of scrapping the system and starting over) any movement we make to improve any one of these three things is likely to negatively impact one of the other two.  Anyone who tells you that they can increase the number of people with coverage, improve quality, and reduce cost is lying – or a politician.  If we want to have an honest debate, we have to be honest about the repercussion of reform.

Want to do this right?  First, we need to decide which of the three – access, quality, and cost – are most important.  Then we need to decide what we are willing to sacrifice in order to achieve that goal.

Do you want to improve access?  Then you need to admit that it’s going to cost money, and you have to discuss how we are going to raise that money.  You may also want to address how this will affect the quality of everyone’s care, because it might.

Do you want to bring costs down?  Tell us how.  It’s going to have to come in the form of either covering less people or spending less on health care.  That can negatively impact quality.

You know what you can’t do?  Scream about the cost and then lose your mind whenever someone discusses limiting coverage (rationing) or removing the profit incentive from insurance (public option).  Both of those things have been shown, empirically and theoretically, to reduce cost.

You know what else you can’t do?  Demand increased access and then lose your mind whenever someone points out that costs may skyrocket and that quality may suffer.  Sure you can overcompensate with even more spending, but can we really afford that?

So decide – what’s the most important thing to fix first – access, cost, or quality?  It’s easy to imagine our elected leaders disagreeing, honestly and sanely, on those priorities.  Then, let’s have a calm and reasoned discussion about how we get there.  Wouldn’t that be nice?



P.S.  Alternatively, we could scrap the whole system and start over, doing better in all three domains.  Pretty much every other comparable country in the world does so.  Seems pretty rational, so it’s ironic that not doing that is the one thing everyone in this fight seems to agree on.

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