The Health Reform Speech Obama Never Delivered

Barack Obama in the Oval OfficeFor the past two years, I’ve been trying to ignore criticism suggesting that President Obama did an inadequate sell job on health reform and should have spoken to the American people more directly and candidly about what he was up to.

Until now I’ve contested these comments, responding that the very complexity of the issue and the secret war against overconsumption made such a speech impossible. Despite my best efforts, the criticism keeps coming. So I’ve responded with a draft of what an honest recital of the issues would have sounded like. I invite reader comment on whether this would have made the sale.

My fellow Americans. A lot has changed in the century since Congress first began debating legislation to provide adequate and affordable medical care for all of us. It is time to finish the job. But before we can take the final steps forward, there’s a need to take stock of how far we’ve come and appreciate not only the many problems our efforts has solved, but candidly assess some of the new obstacles our initiatives have created.

During this period, American life expectancy has increased by more than 50%. Modern medicine is one reason that trend continues today. Diseases that used to be killers can now be cured. We’ve seen revolutionary changes in the roles played by doctors, who can see into the body and diagnose and reverse conditions that their predecessors only vaguely understood. And we’ve seen hospitals transformed from feared institutions where people only went to die to hopeful places that typically extend life.

Not so incidentally, we’ve also created a health insurance system that didn’t exist at the beginning of this period, providing a way to pay for modern medicine whose growing sophistication has increased costs to a point where many of us simply can’t afford to directly pay for the care we require when we become sick.

On balance, I would characterize today’s system as one we can all be proud of. Not just the doctors and nurses and X-ray technicians who directly provide the care, but also the employers who help insure most of us and even the politicians who created programs like Medicare and medicaid that help pay for the care needed to cure us when we become ill. But these elements created in the 20th century are not meshing well in the 21st.

We can build on this structure to make our system even better – both more affordable and more accessible – by using American ingenuity that has built the world’s most vibrant economy to streamline and rationalize the way we deliver health care. But to do so, we have to also acknowledge today’s defects.

It would be irresponsible of me to end my description here without describing the other side of the coin. A large and growing minority of Americans lack health insurance, which puts them in a very vulnerable position if they get sick. They may be denied the care they need. The cost of care is rising much faster than other prices to a point where it threatens to crowd out our ability to pay for other necessities. This is a growing issue for government at all levels that drives much of our political debate. But that’s only an echo of something employers who provide insurance learned a few years ago and growing number of individuals are beginning to realize.

The fact is that there’s no health fairy who’ll pay all our bills. Ultimately we’ll have to, either directly or through broader programs. And there’s no evil dragon responsible for driving the bills up who can be slain in a dramatic, liberating battle. Instead there are a lot of well-meaning individuals and institutions who don’t work together as well as they should and often ignore the costs they’re creating by ascribing responsibility for them to someone else.

Red warning flags quickly pop up when you consider some numbers:

The cost of medical care chronically rises twice as fast as the consumer price index. If you graph that trend, you’ll quickly understand why that’s unsustainable and why medical costs are starting to squeeze other priorities.

Medicare’s cost per beneficiary more than doubles between high-cost areas like Miami and low-cost areas like Minneapolis but patients entering the system in the expensive regions are neither sicker when they enter the system nor healthier when they exit it. If we could make practice patterns in the more efficient areas the norm, Medicare cost pressures would virtually disappear.

Every year the intensity of care – that means the number of tests and procedures done for a given diagnosis – increases, but there’s no commensurate improvement in health status. In other words, we’re spending more money and inducing more discomfort without making patients any healthier.

We spend an extraordinary amount of money on patients during their last months of life while they’re suffering from an irreversible condition. Physicians understand that both a long life and a good death are important goals. Despite medical advances, we cannot live forever.

Because the odd historic way the payment system is organized, patients are often unaware of how much things cost and providers can maximize their incomes by doing more.

Only 20 percent of what doctors do is based on strong scientific evidence. Many of their decisions are based on no evidence at all beyond personal experience. We need to know more about what works and when so we can create optimal treatment plans. Medicare has made a beginning by refusing to pay for unproven care or innovations that increase costs without improving health.

These are difficult challenges, but they are hardly impossible in a nation as flexible and sophisticated as America is. They’ll require everyone in the system to change the way they’re operating and we all have a natural tendency to resist change. And while I can’t now paint you a picture of precisely what the new improved system will look like, I can sketch its outlines.

First, we need to do a lot more research on what works best and then find a way to more quickly drive newer, better, more efficient ways of doing things into common use, acknowledge that the latest and most expensive option isn’t always the best one – in fact, often the old way is safer and better.

Next, we need a payment system that makes things more affordable by getting away from the a la carte system where we pay for each procedure, pill and test and replace it with payment for incident, a system Medicare already uses successful for hospital stays. Allowing those who provide services to maximize their income by maximizing what they do leads to overconsumption and inefficiency.

And finally, we have to change the broader environment. That means encouraging our families to eat more wisely and exercise more. It means providing universal insurance coverage so that those with coverage aren’t hit with a big invisible tax to fund care that would otherwise be uncompensated and use our movement toward evidence-based medicine as an opportunity to move away from today’s medical malpractice system that encourages defensive medicine that eats up resources in a way that protects providers without healing those who are sick.

These are all proven principles that can provide the basis for a real system – like many today I think the menu of services we offer today is far too disorganized to deserve definition as a system at all – that delivers all the care we need at a price we can afford. PunditWire Initials

For 16 years, Jim Jaffe worked for House Democrats who served on the Ways and Means Committee, apprenticing with Representatives Green, Gibbons and Gephardt before working for Chairman Dan Rostenkowski.

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  • Ron Cohen

    Mr. Jaffe …

    I would hope that, if Obama's advisers aren't telling him this, that your column somehow lands in his lap. I also would hope for follow-up columns with specific suggestions — I know you can do it.

    Ron Cohen

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  • Howard Singer

    The spirit of your commentary is impeccable, although I would modify it to this extent: The 14th paragraph can do without the first two sentences, instead stating "While most conscientious and informed practitioners strive to adhere to acceptable standards of care as described in conferences and current literature, many clinical decisions flow more directly from one's experience than from hard scientific evidence." And amend the second-to-last paragraph to endorse a "move away from today's medical malpractice system that encourages defensive medicine which eats up resources in a way that rewards insurance carriers and plaintiff attorneys, adding considerably to public cost, while protecting providers without healing the sick."

    • jim jaffe

      While I always defer to Dr Singer, who is an articulate physician, I've come to believe that clinical experience is sometimes overrated. As a friend says, the plural of anecdote is not data and often the physician's experience is quite limited. I'm in agreement with him about reforming medical malpractice, physician friends feed my doubts that any change will quickly change patterns of practice. One suggested it would take two decades.

  • Howard Singer

    Thank you, Jim, we agree that neither abundant data (especially the marginally relevant kind) nor clinical experience (particularly that which is limited) can be a sufficient replacement for hard science. Please don't misinterpret my commentary to be an endorsement of actions based solely on one's personal experience. Extensive clinical experience requires the input of many, and the analysis of thousands of patients' results, far surpassing the scope of most individual practices. After all, published clinical trials often constitute the scientific basis for clinical decision-making and provide the foundation for evidence-based standards of care. Thank you as always for your thoughtful writings.

  • Best undelivered speech ever.

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