THE WRONG WAY TO DESIGN A HEALTH CARE SYSTEM?

It’s hard not to be impressed.

The effort to enact national health care reform legislation has become a massive political crusade.

Starting even before the 2008 election, dozens of Senate and House committee members, along with scores of congressional and administration staffers, have been working to identify elements of a reformed health care system. A parade of experts from academia, business and the health care industry have testified before congressional committees. Senate and House and administration staffers have developed hundreds of pages of proposals for change. The Congressional Budget Office has weighed in with its own hundred-plus options for improvement. Thousands of hours have been spent in meetings in Washington and across the country to consider what reform might look like. And now President Obama is becoming increasingly personally involved.

So, why might the end result be a disappointment?

The staff issue papers from the Senate Finance Committee and the Senate Health, Education, Labor, and Pensions (HELP) Committee provide a clue. Three hefty papers from Senate Finance spell out in a hundred and fifty detailed pages scores of possible changes to our present system, while Senate HELP has released its own dozen-page issue paper and is circulating a 171-page draft bill.

The focus in each issue paper is on repairing what (in the opinion of the authors) is wrong with today’s system. In fact, the HELP Committee paper is subtitled “Strengthening What Works and Fixing What Doesn’t.” What’s missing? Not one of these papers provides a vision of what we’d like our health care system to be—the system we’d like to have if we could forget some of our current dysfunctional model.

Why is such a vision so important? Without it, like physicians treating a sick patient without ever having seen a healthy one, we run the risk of just applying band-aids to something fundamentally diseased. We’re not going to get our ideal system—there are too many entrenched interests to allow that—but starting the design process by defining what we want is essential to creating a system that does more than just limp along until the next crisis hits.

It’s not that such visions can’t be found, even ones that retain the traditional roles of insurers, business, consumers, providers, and government. The Dutch health care system is a prime example of a cost-effective universal coverage system. Nearer home, Fuchs and Emanuel have proposed a comparable system, but with radically different financing. Senators Wyden and Bennett have written a bill that includes similar elements. The common feature of each of these is a simple cohesive competitive approach –not a multiplicity of discordant elements patched together in an attempt to please as many constituencies as possible.

There are other perils to the Senate Finance and HELP committees’ starting-at-the-wrong-end approach. The more complex the system—and imposing layer on layer of band-aid repairs will make it very complex indeed—the more opportunities there will be for manipulating it. If there’s one thing we’ve learned, it’s the health care system balloon effect: squeeze costs in one area and they are likely to explode in another.

There’s another problem with the band-aid approach. Complexity is a hard sell to the public. As the Clinton administration discovered, the more complicated reform becomes, the less likely it is to gain public support. Sadly, there are few signs among the various congressional papers that the authors understand this. The 150 pages of detailed proposals from Senate Finance for “fixing the system,” but leaving almost every present feature in place, epitomize the problem (perhaps not surprising given that these are the folk who brought us the United States tax code) but hardly give hope for a cost-effective future for American health care.