The uninformed public, led by the misinformed 'experts'
posted 7-29-2010 2:51 p.m. Central

 
Sometimes, disinformation is spread by perfectly well-meaning people who are less informed than they think they are. And they don’t even realize they’re doing it. Trouble is, if their credentials look good at first glance, the rest of us may not realize it, either. This is one of the frustrations of covering health care reform.

Case in point: a New York cardiologist volunteers to provide aid for several months in Haiti after the earthquake. He’s part of a team helping to reinstate cardiac care at a city hospital in Port-au-Prince. A noble deed, well and good. While he’s there, he notices that the “sudden availability in Haiti of free high-quality care from foreign doctors put enormous competitive pressure on the private local doctors, who had already been working under difficult conditions.” This influx of foreign aid causes local clinics to lose business. The cardiologist wonders “if the same would happen to private medical services back in the United States were our government to suddenly provide high-quality, low-cost health care.” So he writes an op-ed piece for the New York Times with suggestions for our health care reform efforts, based on his experience in Haiti.

I begin to see where this guy's argument is going and shake my head, but I keep reading, giving him the benefit of the doubt for the moment. Yet already the misunderstandings are piling up.

In his column, the physician notes several features of Haitian health system – features that generally are not present here – and suggests that we develop public-private partnerships to deliver services to Americans “without destroying our private medical sector.” Sounds good, but it’s misleading on closer examination.

Reading his article, I think: This is what you get when someone who only knows how his own small part of the health care system works pontificates about changing the system as a whole: bad advice from the insufficiently informed. I ask myself what prompts a physician to do this; does it come from the same mindset that makes some doctors give each other stock tips and take their own financial advice instead of consulting prudent money managers? Is this the arrogance that medical schools instill while training young recruits to be assertive enough to get patient compliance?

The cardiologist mentions the concept of a single-payor system, noting: “Many private health care organizations – primarily for-profit insurance companies – strenuously resisted [including single payor in the reform bill], fearing that if the government suddenly provided high-quality, low-cost care for a significant part of the population, they would lose profits or go out of business. Worries about competition between public and private medicine, in other words, are universal.” Well, not completely, Doc: it’s not what I’m worried about.

There are three errors here in his argument. First, the overwhelming majority of health insurers are not health care organizations. They don’t provide medical care; they merely pay for it. This is an important distinction. Only a comparatively small handful of health plans – namely, staff- or group-model HMOs that operate their own clinics and/or their own hospitals – are in fact health care providers. In short: health insurance is part of the financial services industry, not medicine or the health care industry.

Second, during the last 30 years while I’ve been covering health care and health policy, nobody has ever seriously proposed creating an alternative delivery system as part of our reform effort. That was never part of the discussion (except maybe in the fearful imaginations of people who want to block it all out and not change the status quo. Well, guess what? The status quo is changing anyway; health care reform is an attempt to deal with that). The Feds were never interested in running the present delivery system, either: Congress really doesn't want the headache that would be involved in owning all the hospitals and clinics, and neither does President Obama, so you can forget about that red herring. Third, single payor is not a delivery system: it is, like traditional health insurance, a financing mechanism, and the cardiologist-columnist’s failure to understand the difference between the two is both critical and widespread. The man needs a verbal smack upside the head to get him to start seeing sense.

We have two systems in the U.S. that need reform – a financing system that pays for care, and a delivery system that provides care. What’s needed to fix the financing end is different from what would fix the delivery part. Moreover, improving care to get better results for our money is a much longer, more complicated process than changing how we pay for care in order to cover everyone and hold down health premium prices, medical expenditures, and the costs of educating and maintaining the professionals and institutions that make up the delivery system. Are you beginning to see yet that this two-pronged attack is a necessary but not a simple undertaking? If you are, then you understand more than this doctor-columnist did. Which is scary.

In Haiti, an alternative delivery system, however temporary it was, was necessary because large parts of the local delivery system had been disabled or destroyed by a natural disaster. Given that the aid doctors provided higher-quality care than the local clinics, it’s unsurprising that Haitians would prefer the foreign doctors for as long as they were there. In that case, setting up a partnership with local physicians and clinics would have helped the Haitians without hurting their providers, who will still be needed there long after the humanitarian volunteers have left.

But that’s not our situation. And single-payor financing doesn’t dictate anything at all about what our delivery system should look like. Single payor merely means that only one entity is responsible for paying the cost of insuring the entire population. National Health Insurance, or Medicare for everyone, or even letting everyone into what is now the Federal Employees Health Benefit Program (FEHBP, which is adept at negotiating with health plans) would all be ways of accomplishing universal coverage, and none of them would change a thing about the delivery system. Moreover, this could be done in a way that still lets for-profit insurers participate (although that wouldn’t save us much money; but that’s a separate discussion).

We have here a well-meaning, respectable doctor who does good works, compassionate and well spoken. The reader naturally attributes a great deal of credibility to his argument. But he's bloody well wrong: this man either hasn’t been following the reform discussion in enough detail, or he hasn’t had enough education or involvement in health system operations to realize that there are really two systems involved. Or worse, both are true. And he doesn’t even know enough to realize that he doesn’t know. This guy needs a severe reality check before he writes any more pointless editorials and confuses more people.

If you don’t grasp that there are two systems that need fixing, you’ve misunderstood the very core of the health reform discussion. Moreover, most of the public doesn’t get this distinction yet, either. So how are readers supposed to tell that this doctor’s prescription for reform is erroneous and useless? Answer: They can’t.

Which is why so much of what I write about health care reform involves disabusing well-meaning people of their cherished beliefs. And of course, they still want to shoot the messenger.