Fixing Health Care Calls for Evolution, Not Intelligent Design
It is easy to assume that the future shape of the American health care system will be settled one way or the other by the November election. But in turns out that whatever happens in the election, and subsequently to Mr. Obama’s signature health reform, we will still be far from resolving some basic challenges facing the U.S. health care system.
One challenge is how to move away from essentially unrestrained spending and towards a workable process of cost control. Analysts on both sides of the aisle recognize the deep-seated problem, but there is little stomach for tackling it. One reason for this is that Americans, much more that the residents of most other countries, resist the idea of a real and enforceable health care budget for publicly funded health programs, especially Medicare. They oppose direct spending controls in the private sector even more fiercely. That helped create the conventional political wisdom that the best strategy for achieving major reform—nationally as well as in states like Massachusetts—is to lead with the “dessert” of coverage expansions and leave the “broccoli” of cost control for another day. The hope is that, once covered, Americans will then somehow be more open to the idea of limits. But there is little evidence that any such a public change of heart is taking place.
There’s another core issue, however, that is more subtle but even more basic: how to design a process that leads to continuous improvement and innovation in the structure of the health system itself. Without constant creativity in how we organize and deliver health services, we can’t hold down spending without curbing access or quality, and we can’t keep improving efficiency. It is not that innovation doesn’t occur in American medicine. On the contrary, when it comes to developing new treatments, pharmaceuticals and medical technology, America is a world leader. The problem is not in our research labs but in the environment for continuous structural innovation in the U.S.—such things as how we organize health insurance, or the ways physicians work together in groups and with hospitals.