Forum on Health Care Reform: Doctor Allan Wilke's Thoughts

Editorial Note: The National Conferences on Primary Health Care Access on April 12-15, 2010 will conduct the Twenty-first National Conference in Koloa, Kaua’i.

Doctor Allan Wilke (pictured below) of the University of Alabama’s medical school in Huntsville is a permanent member of the faculty of the National Conferences. His forum was launched after the election of President Barack Obama, who has made health care reform a central goal of his administration.

National Conference participants and the public at large are invited to contribute their thoughts and reactions.

ALLAN WILKE, MD: MAKE AN OMELET OR RAID THE REFRIGERATOR FOR LEFTOVERS?

Doctor Allan Wilke of the University of Alabama Huntsville

The economy is in the crapper, our health care system is broken, we’re fighting two wars half a globe away, and the new president will be inaugurated in less than three weeks. The Chinese symbol for “crisis” is the same as “opportunity”, and if this isn’t a working definition of crisis, I don’t know what is. Let us live in interesting times!

Over the years I’ve become cynical about the prospect of changing our health care system. This goes back at least to Clinton’s first term and the Hilary Clinton-Ira Magaziner debacle, and I’ve been coming to the National Conferences on Primary Health Care Access more for condolence than insight.

Earlier this week, I participated in one of 4000 (yes, 4000!) meetings of physicians, patients, other healthcare workers, and public officials organized by the Obama-Biden transition team to discuss what’s wrong with medicine in America.

The cynic in me was saying, “Barack is throwing us a bone.” But I went anyway, and I was very surprised to find myself in a room with 40 other physicians, primarily primary care, but others, too, and to a person, everyone complained about how bad it was. The main issue was lack of access to care, but there were other concerns.

A radiologist joked about defensive medicine and how he’d have a lot fewer partners if we in primary care weren’t trying to cover our asses. An ER doc complained about patients using his ER like a private office. Others complained about patients not taking personal responsibility, insurance companies jacking up premiums and deductibles, the usual stuff. It was all very refreshing.

We’ve all heard the litany of problems: skyrocketing health care costs, large medical bills forcing patients into bankruptcy, US manufacturing firms paying twice as much for employee health care as their foreign counterparts, problems with healthcare quality, 47 million Americans without insurance, too many specialists and not enough primary care physicians (in particular, family docs). We spend more per capita on health care than any other country in the world, and what do we have to show for it? Bupkis!

A couple of decades ago there was a miniseries on Masterpiece Theater about a British G.P. at the turn of the century (the other turn-of-the-century) who became frustrated treating an epidemic of dysentery in his small town and one night blew up the well that was the source of the problem.

For a long time I’ve been advocating something similar for the US health system. Blow it up. Sure, some people will be hurt, but collateral damage is unavoidable to get us to a more rational, patient-centered system. I’m not sure how hurting people is patient-centered, but you can’t deny the visceral pleasure in blowing things up (rent Tropic Thunder for details).

This Christmas I suggested to my brother that he buy me Sen. Tom Daschle book, “Critical — What We Can Do about the Health-Care Crisis”. He’s always complaining about how hard I am to buy for, so I thought this would give him a break. My thinking was if Daschle is going to be the new health czar and he actually wrote a book about his plan for health reform, it may be worth the read. It was.

I’m not going to discuss his plan, but he got me thinking about the “sausage making”. Now, before Daschle lost his reelection bid, he was Senate majority leader. My guess is you don’t become Senate majority leader without knowing a little bit of deal making. His theses are that the conditions are ripe for major change and that we should not allow the perfect to get in the way of the good.

So I’ve changed my metaphor. Are we going to break a few eggs to make an omelet or are we going to rummage through the refrigerator and assemble the unspoiled leftovers into a feast? I might be able to make a perfect omelet, but that leftover HoneyBaked Ham is looking mighty tempting.

Your comments are invited. (All published comments are peer reviewed.)

For more on the Twentieth National Conference, see: Twentieth National Conference on Primary Health Care Access in Monterey

8 Replies to “Forum on Health Care Reform: Doctor Allan Wilke's Thoughts”

  1. It is a privilege indeed to be the first to comment on Dr. Wilke’s culinary metaphor and also to contribute 2 words to the deciphering of dubious texts (that is what you are doing whenever you type in those passwords on ticketmaster and, apparently, here). Having consumed far more than my share of barbecue with him, I know his tastes, and appreciate them.

    I, too, have been noticing that there seems to be a little more to the Obama method than politics as usual. The community organizing techniques he is using are evidence based, and therefore intrinsically threatening to the people who have been in power for the last 8 years. Typically one thing that clearly emerges from the sort of process his team is using is a workable set of priorities in some kind of order of relative importance.

    Many of the “kvetches” about the system are not new, and Dr. Wilke has listed some. Lack of access, ER as sole access point, a lawyer behind every bush, patients not taking responsibility for lifestyle choices, irrational health insurance hassles and cost control via obfuscation, and many more. To solve them all, we would have to break the irrational market power of the insurance companies (who sell a product no one wants at prices no one can afford), eliminate the American Bar Association, raise taxes, create a totalitarian system of health behavior control, and lots more. In short, we would destroy any chance of maintaining a political coalition. Much less 60 votes in the Senate.

    About what should clearly be the top priority, extending coverage to everyone, there can be little doubt that there is very high agreement, and very little chance that all of the Republican Senators in blue states are going to be willing to stick their neck out to be the 40th vote against cloture. Primary care physicians should certainly press for a bill that includes some protection both of our power to determine what is medically necessary and our freedom to say “no” to what we know in our heart is not medically necessary–in other words, some method for determining the standard of care other than the test of court. But, politics being the art of the possible, we need to be open to the idea of accepting universal coverage without any of the other desiderata.

  2. Now that Daschle is no longer the sausage-maker designate (I like that a lot more than “Health Care Czar”–we all know what happened to the last czar), I am worried that the reform we’ve been seeking will be put on the back burner (to extend the culinary metaphor). Since I wrote the original piece, and Dr. Lazar commented on it, the economy has sunk further and the fighting over the stimulus package has grown more rancorous and partisan. Who should replace Daschle? David Durenberger has the chops, but the ethical lapses that led to his resignation from the Senate may not sit well with the Obama administration. Kansas governor (term-limited) Kathleen Sebelius was the state’s insurance commissioner in a prior life and took on Blue Cross, so that gives her so credibility, but does she have the stature to take on this job?

  3. Gentlemen,

    I am curious, as a past economist and future doctor, as to what the “best” option is here. What should I be considering? Also, if you have any good material to get caught up on the issue, I’d appreciate a point in the right direction, as this issue clearly hits close to home.

    Naturally as someone who tends to side closer to the classical economic way of thought, I’m constantly thinking, “what’s most efficient, how can we set this up for the markets to drive this the right way?” but finding myself worried about a number of issues:

    1) I’m going to have huge debt when I get out of school. Will reform cut doctor pay significantly (i.e. am I going to need to worry about paying loans the rest of my life?)

    2) What is “best”? Well, idealistically as a doctor, the health of my patients, but what are the positive and negative attributes one should consider?

    All-in-all I suppose classical economics is out the window at this point, especially in this economy and political environment, but that’s an entirely different topic.

    That said, I guess my real problem is that I don’t even know what to think. Maybe it’s one of those things that won’t come until I’m in the trenches, but why should it be that way?

    I do know that lawyers do appear to hurt the medical field: I have many friends (doctors) who have been sued for mistakes (we’re all human after all…), which is very disheartening as an individual who is preparing to dedicate his life’s work to helping people. What kind of reform will help this? I guess the greater issue are patients who feel “wronged” even when no mal-intent was passed.

    So too, how do insurance companies really impact the health care sector? They clearly seem to be forcing someone’s hand, but whose and how?

    I guess I’m leaning towards a new omelet. Sad thing is, I’m usually fairly definite in my convictions, but this one has me stumped.

    Matt Leberer

  4. Matt,

    Classical economics is probably the right place to start to frame the debate over proposals to “reform” the “health care system”. I think there are many points where the debate gets confused, and it’s quite a trick even to decide in what order to introduce these points into a discussion of the matter.

    However, I do think early on that it would be useful to try to separate “what the federal government does” from the everything else that goes on in the health care system. Any Obama plan or plan by any individual member or group of members of Congress or, indeed, any advocacy group, should begin with a understanding of how federal laws, tax policies, health care reimbursements, and the like impact the system.

    Perhaps both a free market classical economist or a socialist economist observing the state of health care in the United States will agree that it is not an efficient system, as “efficiency” might be defined by either the classical economist or the socialist.

    To understand what I mean here (and this should be of great interest to a medical student making future career decisions, such as choice of specialty), how do services get priced? In a market-based system they are determined by what the classical economist calls “supply and demand”, which, conceptually, can be identified by the classicist’s supply and demand curves.

    A socialist economist would seek to price services “rationally”, perhaps bringing into the analysis a theoretical structure for maximizing the welfare of the greatest number of people in a “commonwealth”.

    But American health care is not priced by either the market or by government planners. The person who was the highest ranking health care administrator in President Lyndon Johnson’s administration at the time that Medicare and Medicaid were enacted (Dr Philip Lee), has stated that every part of the American system is the unintended consequence of some particular public policy initiative or another.

    The fundamental problem of the American health care system is that a high percentage of its revenue streams are based on federal policy – and if a given policy has unintended results, the revenue stream could be radically altered if intentions were suddenly brought into concert with policy (i.e., if suddenly the Feds said – this is what we want to happen, so this is what we will pay for).

    The government role becomes even trickier to analyze when we begin to discuss “rights” to health care. In many private sector industries – take videogames, for example (as far as I know, no one asserts a “right” to access to videogames). You pay the price demanded for a popular game or you go without. If enough people go without, the price is lowered until demand is in balance with supply.

    But in the U. S., there are certain implied rights to health care, or, at least, government imposed obligations for you to receive health care services, whether or not you can afford them.

    Say, you collapse in public. Someone dials “911”, more likely than not an ambulance will arrive and carry you off to an emergency room. Not knowing who you are or why you collapsed, the E. R. staff will conduct tests to try to figure out what has happened.

    In some urban areas, there are examples of persons who suffer from diseases related to alcohol abuse who would collapse on the street several times in a single day, each time requiring enormous amounts of public funds to transport them to health care. Perhaps there is no direct public subsidy for the emergency room services, but those costs are absorbed somewhere as “hidden subsidies”.

    The curiosity of the current debate on “health care reform” is the disconnect between some of the rhetoric and the reality. It is one thing to say that everyone in the United States should be “insured”, but we have not even agreed as a society as to what “health care insurance” is supposed to be.

    In the 1970s, as the apparent advantages of the Kaiser-Permanente health plan began to be appreciated, a movement accelerated for insurance companies, who historically were in the business of developing life insurance risk pools whose “premiums” were based on pre-determined actuarial tables, to take on the task of constructing risk pools for health care reimbursement, which would be packaged as employee “health care plans”.

    Because most employers do not seek to assemble sick workforces, employee health plans seemed to be actuarily advantageous, and could be marketed at relatively low cost. However, we never as a society have had such large numbers of elderly people before, and, to the extent that these plans continue as retirement benefits of the previously healthy workforce, it is unknown what ultimately their actuarial costs may turn out to be. Actuaries might guess, but we won’t be reasonably sure until the baby boom generation moves into their 90s.

    But the preceding remarks only relate to the “cherry picked” healthy employees risk pool. Here, the current political rhetoric gets particularly muddled. When one talks of “rights to health care” or “universal coverage”, especially in a plan that mandates that employers cover health care, one is talking (or more properly is not talking) about hiding costs, subsidizing large numbers of persons with whom the employer has no perceptible relationship.

    We need to inform the debate with much more information on how things really work, and why they work the way they do. (We need to “follow the money”. We also need to understand precisely how things get “priced” in our current system.) I had never considered trying to apply classical microeconomic price theory to the health care system, and do not know for sure where such intellectual exercises might lead, but it might be worth the effort to spend some time there.

    I suspect that, whatever one’s politics, that the “sound bites” distort that person’s position. This is a precarious time for those who desire an enlightened, informed debate, but it really should happen. Perhaps the Internet is the only place where some of that could occur.

    Unfortunately, much of the political debate will not just be getting carts before horses – it is assembling convoys of carts, with all their horses asleep in their stables.

    That is where you, Matt, with your classical economics training, should spend time articulating how that discipline can help us clarify our thinking as we try to decide “what is to be done?”

  5. Well having seen some of Obama’s plans and comments in the news I think there’s quite a bit more to discuss now.

    Back on the topic of making an omelet or raiding the fridge. It seems to me that raiding the fridge is more akin to raiding a refrigerated warehouse than a kitchen fridge. The more I hear about health care policy, the more it sounds like a diluted mess of regulation.

    So, when it comes to economics, I guess the question now is can we even apply economic thought? If we go so extreme as to have government run health care (which, if the way Obama has been taking, will be cheaper than public and therefore drive it from the market should it be unable to compete), it would seem we don’t have market forces driving down prices, but government doing so. Let us not forget that nothing is free – when the government offers cheaper health care, what they’re really offering is health care that costs less for a certain group of individuals (typically those on medicare/aid and the poor).

    As a young individual who takes care of himself, exercises regularly, and has no health conditions, I personally argue for private health care (e.g. no health care if I chose, or whatever other kind of care I chose). The disparity that exists because not everyone is in my position (elderly, genetic disorders, druggies or other addictive types who have messed up their bodies) – this disparity begs the question of what’s fair. Should I subsidize the care of those who drink, smoke, and do drugs? Who should? Don’t get me wrong, I’m for helping people and giving second chances, but let’s face it…a system that can be abused will be abused.

    So where’s the sweet spot between government aid and private health care? Let’s look around the world. Who has the best health care, options, etc? Well, we do, of course – but the problem lies in the fact that we spend SO MUCH more on our care than any other country.

    Would removing some diluted regulation help? Possibly. Would more taxes help? I’d argue not. It’s like fighting fire with fire… we need to stop thinking about how to spend money to save money. Let’s get more transparency in our government and the regulations and policies that affect us.

    Where are we at now? I guess we just have more questions to answer. Luckily some are partially answered. We have a more democratic/socialist (and I say this matter-of-factly, not to instigate argument) president/government now than in recent years. So it’s very likely that such policies that tend to the poor and the have-not’s will prevail, but my plea and hope is that we do so with more care and forward thought and planning to ensure we don’t dig ourselves a new, bigger hole for me and/or my kids to fix later.

  6. The most obvious consequence (at least to me) of health care reform is “Where will we find all the primary care physicians should it pass? We have only to look at Massachusett’s experience to see the problems ahead.

  7. 1. The real problem here is finance reform not heathcare reform. Ask yourself the following simple question. Where does all the money/profits go? I am okay with profit.?But our lending/borrowing system has been out-of-kilter for a long time.

    2. Just think what happens when you buy a house. A bank borrows our own taxes from the FED at prime (practically free), and then according to “fractional reserve lending” lends 10X that amount back to us with an amortization schedule that collects 95% interest for 20 years on a 30 year note. And this affects business, car, equipment, and school loans.

    3. Therefore, the only way to gain principle is for the price of the house to go up. This is a major driver of inflation. And this inflation which affects all sectors of the economy put pressure on families for women to enter the work place.

    4. With both Mom and Dad working full-time and noone home with the kids, kids are not having their emotional needs met which leads to addictive and self-destructive behavior, and they are not being taught basic life skills which is the true primary prevention. What doctors due is not prevention but detecting disease early which will make you live longer but all screening and treatment has a QALY. If you die in 6 months or 6 years, the cost of dying is the same.

    5. We need tort reform, let doctors tax deduct charity care, allow consumers to buy insurance across state lines, and let doctors bill patients directly and have insurance companies reimburse patients. And set up a more equitable banking/lending system that allows people to barrow and pay back loans easily.

  8. David Brosnahan asks the question “Where does all the money/profits [in the healthcare system] go?” and then raises some issues that at first seem off the mark – the inflation in housing prices, and the separation of mothers and infants for economic reasons. His perception that the emphasis on medicine on disease diagnosis rather than prevention is probably not stated in a way that many readers of this forum would wish to endorse, but there may be broader agreement in the sentiment underlying it.

    I suspect the strategists for the two major American political parties would agree with two propositions: 1) that federal policy had something to do with the crisis in housing prices and the subsequently the availability of mortgages and credit based on housing prices, and 2) that the federal regulatory apparatus proved inadequate to police what many describe as a “housing bubble”.

    Of course, since both parties have been in positions of executive or legislative leadership at various times during the build-up of the “bubble” each strategist will be seeking the phrases that inflict the greatest political damage on the other party.

    The ensuing battle of sound bites about government involvement in the private sector (the issues in the housing sector resulted in unprecedented federal involvement in the banking system and Wall Street) have caused anxiety for both those who wish to see something changed in health care and those who like the status quo ante. Of course, the sharpest of the political operatives on both sides have found a demand for their services at a time other than the even-numbered election years.

    But the political debate has not provided the information to answer Brosnahan’s first question: “Where does all the money/profits go?”, nor to illuminate the “collateral damage” issues that Brosnahan somewhat hazily perceives (mothers separated from infants because their housing costs so much).

    I think there is a another question that precedes the Brosnahan question. “Where does all the money come from?” When it is understood how much of that is federal money, through Medicare and Medicaid, and how little thought is given to the policies (or lack thereof) or social consequences of how that federal money is spent, then there may be opportunities to develop a more rational discussion.

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