Reforming the system

Suppose we want to reform the transportation system. Where would we start?

Would we begin with bridge repairs, fuel costs, or alternative energy? Would we consider incentives or taxes on rail, ship, airline or truck traffic? How would we reduce accident rates – by changing vehicle design or operator behavior? What about licensing criteria or insurance costs? Could we address the comparative value of different modes of transportation? What percentage of the nation's economy should be devoted to transportation?

The reform analogy, of course, applies to the "health care system." It sounds straightforward enough, but reforming the "health care" involves many different sectors – industries in themselves, really – sectors that function in technical ways and involve a web of risk, referral, production, regulation, and financing connections.

This is why the advocates (and opponents) of health care reform talk about so many different things. There are many things.

Consider:

▪ Extending insurance coverage to the uninsured ("access,” “universal health care,” and "the public option"),

▪ Aligning financial incentives involving doctors and hospitals ("quality improvement," "patient safety," and "efficiency"),

▪ Controlling the cost of government entitlements ("affordability"),

▪ Paying for additional coverage by taxing employer-paid health insurance benefits ("affordability"),

▪ Mandating insurers to cover preexisting conditions ("access"),

▪ Authorizing payments only for services proven to be clinically effective ("review board," "rationing" and "affordability"),

▪ Limiting the resources used by individuals in the final six months of life ("quality of life," "rationing," and "affordability"),

▪ Expecting lawmakers to use any public plan they create for others ("fairness" and "quality"),

▪ Increasing payments for primary care specialists ("access"), and

▪ Developing better ways to manage chronic conditions ("prevention" and "affordability").

The list goes on.

It's no wonder people are talking past one another. It is no wonder people are concerned about the feasibility of trying to do so much all at once.