U.S. health care in conflict — Part I: the challenges of balancing cost, quality and access - Policy

Physician Executive, July-August, 2002 by Mary L. Dombovy

The United States health care system is a product of our unique social, political, economic and cultural environment and values.

In the United States, we value pluralism and choice, the market and competition, but are ambivalent and mistrustful of big government. We value individual freedom and the responsibility it entails. That translates into: "If people choose to be uninsured, it's their problem." We desire the latest technology, drugs and access to the best care immediately on demand, all at minimal cost to our own pocketbook.

With its large number of payers and providers, growing consumer expectations complicate our pluralistic system. That results in excessive overhead costs as compared to other countries. (1)

Other developed countries face the same challenges of improving access and equity and reigning in costs while enhancing quality. Their health care systems reflect a unique approach based on their own environment and values, but all share some important differences from those of the United States.

Social good

Most other developed nations operate under the construct of health care as a "social good," which underlies the concepts of universal coverage and equity in access and services. (2)

The concept of health care as a social good also leads to an understanding of why markets fail and an acceptance of a broader role for government in health care. Global budgets function as the mechanism of cost containment and result in rationing. In these systems, relatively unproven technologies, treatments and pharmaceuticals are not reimbursed if they fail to pass the tests of both efficacy and cost-effectiveness.

Many health care policy experts assert that the central problem in our health care system is the lack of consensus on the major values that would serve as the basis for policy formulation. (23)

In the United States, there is no societal consensus on issues like:

* Is health care a right or a privilege?

* Is health care a profession/public service, or a business subject to the market?

* What is equity? Equal access? Equal benefits? Equal quality?

In addition to the lack of the principles of social justice as a bottom line, the failure to distinguish between "health" and "health care" feeds our desire for access to the latest technology under the erroneous impression that new technology is what's responsible for our improved health.

The reality is that health correlates most with socioeconomic factors such as education, income and access to basic services.

Throughout the health care debates in the mid-1990s over the Clinton health plan, these key principles were not adequately addressed. As a result, we have no current operational theory for health policy development and no strategies to reform the current system.

Managed competition, the default policy under which we have operated for the past 20 years, has fallen into disfavor with both providers and consumers. The result is regulation that erodes managed care's ability to contain cost.

As we head into the 21st century, we are faced with an explosion of expensive medical technology and pharmaceuticals, the emergence of information technology, an aging population and the arrival of the informed consumer.

Along with the threat of rising costs comes the reality that our health care system will become even more tiered with a growing information gap, lack of insurance security and lack of access between the "haves" and the "have-nots." (4)

Despite the clamoring about the speed of change in health care, we are still in the Ice Age compared to other industries.

All of the reorganization has been around the fringes and focused on financing mechanisms rather than any serious restructuring of health care service delivery. Disparate values and the concepts of distributive justice have not been addressed.

The United States health care system faces many challenges in trying to find a viable future. Among the critical issues are:

* Achieving consensus on the constructs of health care as a public good and the definition of "equity"

* Resolving the tension between health and health care

* Reorganizing systems/communities of care to foster prevention, coordination and management of chronic conditions

* Reducing clinical variation/ enhancing quality

* Addressing the issue of the uninsured/underinsured

* Finding a theoretical framework for health care financing and delivery

* Addressing the solvency of the Medicare program

* Financing new technology and drugs while limiting the rate of increase in health care costs

* Managed care was ill-prepared to supply the leadership needed to address these issues and we still deliver care using ancient models and systems. Health care leadership lacks diversity, while stakeholders trying to preserve the past pull policy formation apart.

Physicians are tremendously resistant to structural change and are feeling disenchanted and disenfranchised. Our small, incremental successes continue to lead us down the same ineffective path, avoiding the difficult fundamental issues.