President's Letter

Tags: Tricia Elliott, tafp president, presidents letter, september 2017

What kind of system do we want?

By Tricia Elliott, MD

In his seminal book “The Signal and the Noise,” renowned statistician, Nate Silver, examines the world of prediction, investigating how we can distinguish the truth — the signal— from the noise, which he describes as a universe of ever-increasing information, relatively little of which is useful.

Any candid observer of the now nearly decade-long effort to reform our health care system will readily admit that the health care debate we’ve been engaged in has generated a lot of noise and useless information for political gain. Our elected leaders, on both sides of the aisle, have been busy creating this noise and are now trapped in a political vise of their own making. They’ve sadly left the public with a binary choice of whose health care solution is better, that of the Republicans or the Democrats.

This politically simplistic way of trying to fix our health care system — your way, my way, or no way — has largely avoided engaging the public to answer the single most fundamental question that must be addressed before any long-term solution can be designed: is health care a right or a privilege?

Right now the answer is that health care is both a right and a privilege, which has created a system that is completely inefficient and really expensive.

Health care is a right — an entitlement — if you are 65 or older. It’s called Medicare. If you are poor or disabled, it is a right. It’s called Medicaid. Combined, these two programs cover more than 112 million Americans. Health insurance is an employment benefit that covers  another 156 million Americans, though their employer may choose what benefits to provide and how much employees should have to pitch in.

But if you are one of the unlucky 22 million Americans who don’t qualify for Medicare or Medicaid, and aren’t fortunate enough to have access to affordable health insurance through your employer, or are simply priced out of the individual market, then health care is a privilege based on one’s ability to pay.

Health care reform doesn’t have to be an either/or, binary choice. Both universal coverage and the private market have their pros and cons and both require trade-offs.

If health care is a right, then how do we finance it? What services, treatments and medicines are covered? Do we regulate the prices physicians, hospitals, drug makers, and others can charge? Who makes these decisions?

If health care is a privilege, are we willing to allow people to suffer or die from a disease or medical problem because of an inability to pay? Are we willing to allow families to go bankrupt to pay for health care?

How we design and finance our health care system doesn’t have to be an all-or-nothing, one-size-fits-all approach. In many countries, a universal public program works in conjunction with the private market.

This is a question that has vexed the American public for over a century and we still don’t seem ready, willing, or able to tackle it. Our elected leaders can continue attacking symptoms of our dysfunctional health care system and calling it health care reform, but until we answer the fundamental question of whether health care is a right or a privilege and have an honest debate about the trade-offs, we’ll be stuck with a costly, inefficient system that serves no one particularly well.

As W. Edwards Deming, the celebrated management consultant once said, “Every system is perfectly designed to get the results it gets.” We can design a much better health care system once we can agree on what kind of system we want.

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