Policy Spotlight
Healthcare Reform: The Real Problem
Everybody knows that America spends far more than other nations on healthcare and has failed to control costs to the point of serious crisis. But it is rare to find an essay with the explanatory power of Atul Gwande's "The Cost Conundrum: What a Texas town can teach us about health care," which appears in this week's New Yorker. Gwande, a Boston-based surgeon, writes of traveling to McAllen, Texas, a mid-size city that, for no apparent reason, has some of the highest healthcare costs in the world. His objective, based on researching public health statistics, interviews with physicians, hospital administrators and virtually anyone who would talk to him, was to discover why patients in McAllen received vastly more medical services—from specialist referrals to breast biopsies to cardiac surgeries—than a similar population in nearby El Paso. His conclusion: "The primary cause of McAllen's extreme costs was, very simply, the across-the-board overuse of medicine."
What distinguishes Gwande's analysis, though, is that he delves deeply into why physicians in McAllen provide so much medicine that is of little or no value. In this regard he compares McAllen to the Mayo Clinic, which experiences superior outcomes and a much lower price per patient. The crucial difference, he suggests, "is whether the doctor is set up to meet the needs of the patient, first and foremost, or to maximize revenue." Driving through the outskirts of McAllen with a cardiac surgeon, he passed "a series of office plazas that seemed to be nothing but home-health agencies, imaging centers, and medical-equipment stores." The surgeon remarked, "Medicine has become a pig trough here…we took a wrong turn when doctors stopped being doctors and became businessmen." Ultimately, he argues that American medicine is engaged in a culture war, with some groups like Mayo focused on eliminating waste and improving quality even when doing so means providing fewer tests and treatments, thus less revenue, and others who are determined to wring the most they can from a payment system that rewards sheer quantity.
Healthcare Reform: Terms of Engagement
Healthcare reform is at the top of President Obama's domestic agenda and House and Senate committees are working on sweeping legislation that could be introduced as early as mid-June. Meanwhile, behind the scenes, party strategists are engaged in a struggle to control the debate. For a fascinating look inside the GOP playbook, it's worth reading Frank Luntz's confidential 28-page memo, "The Language of Healthcare 2009" (May 5). Luntz is a pollster who specializes in finding phrases and slogans that resonate with voters, the subject of his book, Words That Work: It's Not What You Say, It's What People Hear. A perfect example of his rhetorical deftness was renaming the federal inheritance tax the "death tax." Luntz outlines his prescription for opposing the Democratic healthcare agenda as "10 Rules for Stopping the Washington Takeover of Healthcare." Based on recent polling, he suggests that winning arguments for Republicans stem from public distrust of government, especially when it comes to Washington bureaucrats interfering in the doctor-patient relationship, setting standards and rationing care. His 10 points in brief:
Healthcare is not about a system, but about people. "Individualize. Personalize. Humanize."
Acknowledge the "crisis" or suffer the consequences. But make the crisis personal: "If you have to wait weeks for tests and months for treatment, that's a healthcare crisis."
Time is the government healthcare killer. Care delayed is care denied.
Avoid economic theory and talk of free markets, tax incentives and competition. Make the message about Washington, politicians and bureaucrats.
Use examples of rationing from Canada and Europe, but personalize them. In England, politicians decide if you're disqualified because you're too old or a treatment is too expensive.
Healthcare quality means getting the treatment you need, when you need it. Characterize the Democrats' plan as denying people treatments and making them wait.
"One-size-does-NOT-fit-all." Fight for a personalized doctor-patient relationship over government bureaucratic standard-setting.
The focus of controlling costs should be waste, fraud and abuse (which are rampant in anything the government controls).
Americans want government to help the truly needy. "A balanced common sense approach that provides assistance to those who truly need it and keeps healthcare patient-centered rather than government-centered for everyone."
You have to explain what you're for: "more access to more treatments and more doctors . . . with less interference from insurance companies and Washington politicians and special interests."
Not to be outdone, Democratic strategist and CNN commentator Paul Begala responded with a rebuttal to Luntz entitled "Countering Republican Orwellian Rhetoric on Health Care" (May 19). The GOP has three basic goals, he wrote: (1) Co-opt our messaging; (2) Confuse voters; and (3) Kill healthcare reform. In a briefing to Hill staff before the Memorial Day recess, Begala urged Democrats to direct their attacks on what he characterized as Republican "mendacity" about their plans, adding "Your job is to smoke them out." Begala's memo is organized as a point-by-point commentary on Luntz's memo, some of which he agrees with, for example, personalizing the issue instead of talking about systems. His tactics boil down to these points:
Make the GOP own the status quo because Luntz's own research shows that 69.5 percent of Americans think the healthcare system is in crisis.
Link Republicans with the insurance industry; talk about insurance and HMO bureaucrats denying coverage and care; call the GOP plan "a blank check for insurance companies."
Don't allow Democratic reforms to be defined as "bureaucratic." "Our reforms are quality, affordable health care."
Emphasize President Obama's principle of "choice" and a "uniquely American solution," not a Canadian or European single-payer system.
Begala underlines Luntz's warning that "if the dynamic becomes 'President Obama is on the side of reform and Republicans are against it,' then the battle is lost." His advice to Democrats: "Do not let the Republicans kill reform by co-opting our message. . . . President Obama is for reform and Republicans are against it."