×
Theodore Marmor, Jonathan Oberlander, and Joseph White are pretty big names in health care policy, and they have a depressingly realistic editorial in the latest Annals of Internal Medicine.
Claims of savings from health information technology, prevention, P4P, and comparative effectiveness research are politically attractive. Their political appeal lies largely in the embrace of widely supported goals, including better health and improved quality of medical care. In theory, these reforms—more research, more preventive screenings, and better organized patient data—sound like benign devices to moderate medical spending. For many purposes, such reforms are substantively very desirable. But these reforms are ineffective as cost-control measures. If the United States is to control health care costs, it will have to follow the lead of other industrialized nations and embrace price restraint, spending targets, and insurance regulation. Such credible cost controls are, in the language of politics, a tough sell because they threaten the medical industry's income. The illusion of painless savings, however, confuses our national debate on health reform and makes the acceptance of cost control's realities all the more difficult.Full paper here. There is a political economy theory at work here: Imagine you pass the Obama plan but you don't save money. Health information technology, prevention, P4P, and comparative effectiveness research all succeed in increasing the value of our health dollars but they don't lead to us spending fewer of them. Meanwhile, somewhere near 97 percent of Americans are in the system. Suddenly, the cost choices become explicit. Right now, they're implicit. We add two million people to the rolls of the uninsured every year. That's how we deal with costs. But there are no collective decisions or articulated tradeoffs. It just sort of...happens. If you have a system, however, there are tradeoffs: If it costs too much then costs need to be brought down. You enter the realm of preference. Would voters prefer lower subsidies or government bargaining with device and drug companies? Would they prefer that we reduce benefits or that we set spending targets? Someone, somewhere, has to choose. The largely silent ranks of the uninsured cease making our hard decisions for us.
