Those of you that read this blog on a regular basis are no doubt aware that I feel very strongly about the need for the American health care delivery system to perform better. This is based on many years of working with a group of patients who would be in much better health had they had sufficient access to high quality health care. In addition, I have been training physicians for many years, helping them to develop the skills to deliver high-end family medicine interventions to a group of patients in need only to have them take jobs in lucrative areas of health care that lead to high patient satisfaction but do not improve health outcomes. Lastly, I work in a medical school setting where we deliver very expensive care very inefficiently. As a potential consumer of health care, I have to wonder why others can’t see what I am certain of: change is needed and fast.
In the 1990s, it was apparent that the health care system in America was causing a problem. As I have written previously, the high cost of health insurance led to lower real wages (all increases went to health insurance premiums), 15% of Americans were denied all but emergency access to health care, and care providers who were so inclined were able to game the system and make lots of money. Good managed care was able to co-opt the system and this resulted in better access, reduced costs, and better quality to a certain extent. We believed that the value of excellent managed care was self-evident so were surprised when the entrenched establishment was able to take several glaring examples of bad managed care and tar the entire care delivery process with them.
Those interested in care reform then took the intellectual high road. Crossing the Quality Chasm, published in 2001 by the Institute of Medicine, had as its opening paragraph:
The American health care delivery system is in need of fundamental change. Many patients, doctors, nurses, and health care leaders are concerned that the care delivered is not, essentially, the care we should receive (Donelan et al., 1999; Reed and St. Peter, 1997; Shindul-Rothschild et al., 1996; Taylor, 2001). The frustration levels of both patients and clinicians have probably never been higher. Yet the problems remain. Health care today harms too frequently and routinely fails to deliver its potential benefits.
Aside from a few headlines regarding deaths caused by medical errors, those in health care continued to deliver expensive procedures regardless of potential benefit to the patient. Kaiser Family Foundation began documenting disparities in 1994 and became one of the best sources of data documenting health disparities, but the disparities continued unabated through the 2000s.
President Obama took public interest in changing our broken health care system, combined with support for change from major corporations as a mandate. He took the evidence from the IOM report, the data from Kaiser, the support from industry and used it to convince Congress of the need for change. The passage of the Affordable Care Act is the consequence of these forces coming together. While not perfect, the bill offers a significant increase in access to health care with the potential to improve care and reduce costs. Unfortunately the hard work has not yet been completed. Building a framework for change into a law is one task. Convincing people that the framework is necessary and sufficient is another. The vast majority of people are fed up with the “system” but happy with their doctor(s). They are unhappy with the cost of other people’s care but unconcerned with the cost of their care. Why would they want to move out of their “comfort zone?”
In his important work Leading Change: Why Transformational Efforts Fail, John Kotter identifies the 10 reasons that large-scale change fails to occur at the corporate level. Error #1 is not establishing a great enough sense of urgency. In the 1990s, the HMO system was dismantled in many areas very quickly because of patient demand. A sense of urgency prevailed. Those who want to see “Obamacare” fail are doing their best to establish a sense of urgency for “repeal and replace.” Their case is not being made with data and policy suggestions but through hyperbole and outright deception.
Mike Huckabee, currently “not running” for the Republican nomination for the presidency, has come out against the “comparative effectiveness research” aspect of the ACA. Although
even Republicans [likely] recognized that we shouldn’t be spending so much money on drugs, devices, and procedures that don’t actually make people better than existing treatments.
But Republicans and their allies in the conservative movement no longer say such things. Instead, they say that government will use CER to deny people beneficial treatments–that it is, as Huckabee puts it, “the poisonous tree of which death panels will grow.”
What could be more urgent than stopping that?
Or what about the claim that if the federal government can mandate health coverage they can force broccoli ingestion as well. That should put fear into many Americans regarding the overreaching federal government as well as mandatory broccoli burgers. STOP THE BROCCOLI!
Those of who want to see most (if not all) Americans with access to high quality health as well as leave something in the national treasury for our children need to yell from the rooftops that the ststus quo is unacceptable and the ACA, while not perfect, is the best start on improvement we’ve had in 20 years. My friend Paul Grundy is doing his part. Don Berwick will likely lose a job as a result as well. Let’s all be real clear: #37 is UNACCEPTABLE.