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Friday, January 22, 2010

The collapse of health care "reform"

I've had a draft of my "final" blog pending since roughly the middle of November, awaiting administrative action on a future incarnation (stay tuned). Now political events in Massachusetts have eclipsed my opportunity to appear prophetic -- so trust me, this is what I wrote back then:

As I write this, Washington is on the cusp of health “reform.” I want to go on record, so I can say “I told you so” in a few years, that this reform (praised by the Academy) will be an abject failure. Before long we’ll be back to the drawing boards for a do-over.

Here’s why: All legislation currently under consideration has no provision for cost control, and medical costs are going to bankrupt us within the decade.

The predicted cost of Medicare in its first year (1962) was $12 billion. The actual turned out to be $110 billion. So much for the prophetic ability of the Congressional Budget Office. The projected figures you read in the paper every day are sheer fantasy. Hardly anyone points this out – certainly not the AAFP, which would forfeit its (assumed) place at the trough.

If you want a good laugh, followed by a gut ache, read
Dr. Epperley’s letter to Rep. Pelosi on Nov. 3. He praises HR 3962 for a few provisions that will not survive the legislative process, while begging for the biggies to be added: tort reform, permanent payment increases for primary care, and CMS’s most recent skewering of family medicine. And don’t make that 21-percent cut in Medicare payments on which the entire phony edifice of cost savings depends!

There are only two ways to control costs. One is a single-payer system, with the federal government the payer. Control would come through denial of cost-ineffective services and rationing, leading to queuing. I could live with that. I enjoyed my five years in the U.S. Army, and if they had agreed to let me stay at Ft. Bragg for my career, I’d be a retired Colonel by now.

For a good example, consider the response to the USPSTF recommendation that routine mammography not start until age 50. This recommendation is not unreasonable. It is based on cost-effectiveness, including the costs of false-positive tests. Now witness the outrage. Get used to it, if ObamaCare passes.

Seven or eight years ago my wife and I spent a delightful week at the Stratford (Canada) Shakespeare Festival. We stayed at a small bed-and-breakfast run by a gourmet cook who once served as the top health official for the province of Ontario. He was chuckling after breakfast at the newspaper headlines, in which the Canuck version of USPSTF had just recommended that women no longer be trained in breast self-examination. "Just wait till you see the response tomorrow," he laughed. Oh, my. Full-page pictures of women who had -- guess what? -- discovered their cancers by self-examination. Every such recommendation becomes a political football.

The other way is self-rationing through health savings accounts, or something similar. That’s the only way to avoid the specter of elected officials making medical decisions, which seems preferable to me. I spent a couple of years fighting a law in Kansas that mandated the exclusion of students from school if they had nits in their hair, despite authoritative evidence that the presence of nits, after treatment with a pediculicide, was irrelevant. Turns out that the law has a hard time keeping up with science.

Does that sound like fun?

Now I'm going to say again what I've said many times over the past five years in FPM or this blog. The only rational approach to reforming our system is to start the long-term project of teaching our patients to be consumers of health care, like they are consumers of food, shelter, automobiles and electronic devices. 

The insurance industry has strayed so far from the principles of insurance that our patients have lost their minds. Health savings accounts can teach them to think again. If everyone had a high-deductible HSA, with a $25 co-pay for routine visits to their primary care physician, the insanity would cure itself in a decade.

Price signals would govern the introduction of new procedures, drugs and devices -- without bankrupting the country through profligate consumption of Other Peoples' Money.

The government would have to replace Medicaid with contributions to the personal accounts of the poor and uninsured, who would become smart enough to spend this money responsibly. Everybody would be covered, and everybody could afford primary care, which is dirt-cheap, relatively.

Barbara Starfield told FPM what needs to happen to fix this problem, but she didn't say how. Health savings accounts are how. All of the things listed would happen automatically, without bureaucratic oversight, through personal private initiative, if everyone had an HSA.

There. Now I feel better.

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About the Author

Doug Iliff, MD, is a family physician in solo practice in Topeka, Kan., and a former member of the FPM Board of Editors.

Note: This blog is no longer updated; this is archived content.

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Making It is a Family Practice Management (FPM) blog. However, the views expressed here are those of the individual authors. They do not necessarily reflect the opinion of FPM or the AAFP. The FPM blogs are not intended to provide medical, financial or legal advice. For more information see Terms of Use.