Personal Perspective

An academic, apolitical approach to health care reform

Robert Alpern

Yale University School of Medicine, New Haven, Connecticut, USA. E-mail: robert.alpern@yale.edu.

First published September 10, 2009

The United States is on the verge of addressing one of the most important issues facing the country, its health care system. An underlying premise of the need for reform is a belief that all citizens of this great country should have access to excellent health care. To accomplish this, universal health insurance must be a component of any plan. Many controversial issues have arisen in the debate, most relating to how to pay for those presently uninsured. Opponents are concerned that this will require increased taxation and/or decreased support for those presently insured. The only acceptable solution will be one in which the cost of covering the uninsured derives from improved efficiencies in the delivery of health care.

Everyone accepts that there is much inefficiency in our present system, driven by a complex set of misaligned incentives, but the question is how to address this. While it is perhaps easier to identify the opportunities for improvement than the solutions, it is of the utmost importance that this be done correctly, and thus I offer a few guiding principles from my perspective.

First, the specifics of the plan cannot be driven by politics. While a certain number of votes are needed to pass a bill, we cannot allow this to be the dominant process that determines our future health care system. Perhaps the bill should lay down a plan to develop a plan rather than define it. Such a bill could prescribe time lines that must be met and milestones at which actions must occur, such as extending insurance to all. Our current health care system is exceedingly complex and will be difficult to fix. However, time is of the essence, and failure to pass a health reform bill would be devastating. Saddling a reform effort with too many limitations driven by political realities will doom it to failure.

Second, this process should be guided by the greatest minds in health care. Participants should encompass a broad group, including academics, the health care industry, think tanks, government, and industry. They should operate in an environment free from politics and develop conclusions that are based on a critical analysis of data. While participants should bring different perspectives to this problem, they must all be committed to the program’s success and must leave their parochial interests and conflicts at the door. In the end this could be the most important accomplishment in health care during our lifetime, and the opportunity to contribute must trump self-interest.

Third, very little about this debate is black and white. I have heard too much rhetoric expressing extreme views from both sides of the aisle in Congress. There is no component of health care that is evil. Most participants work in health care to make people healthier, and they derive satisfaction and reward from their efforts. This includes physicians, allied health providers, hospital administrators, universities, the pharmaceutical industry, the insurance industry, and probably even malpractice attorneys. Are there conflicts with personal gain? Certainly. Like everyone else, health care workers have families to support and wish to do that well. Like the rest of industry, pharmaceutical companies and insurance companies have stockholders to answer to. This does not make other industries evil, and it should not be viewed as making these companies immoral or malevolent. The costs of drug development are enormous and could not be solely supported by government or nonprofit foundations. It is the profits generated by the pharmaceutical industry that provide the necessary support to sustain drug development, and we should be very careful that we do not weaken this process.

Fourth, nothing can be off the table. Successful reform may require radical change. Perhaps primary care doctors should make more money than highly specialized surgeons. This concept is foreign to our health care system, but it should be considered. There has been a noticeable silence regarding tort reform. It has been argued that patients who have been mistreated should be able to reap a financial reward. I do not disagree, but perhaps there is a better system, with panels of trained judges making these decisions rather than juries with little understanding of the nuances of health care. These issues and others must be seriously debated, and the debate must include an analysis of their effects on health care quality and cost.

Last, the development and education of the health care workforce must be addressed strategically as part of the solution to the problem. The ultimate solution can never be achieved without a workforce that is aligned with and serves the critical components of health care. This process has been left to individual universities and has thus lacked any direction driven by a national health care strategy.

This is a propitious moment in the history of health care. The establishment of Medicare in the 1960s marked a transformation in how this country would take responsibility for the care of its elderly. One can argue that the system was not set up perfectly and costs have increased beyond expectations, but we did the right thing. We now are presented with an opportunity to once again do the right thing. We must do so, and we must get it right.

We must provide optimal health care to all members of our great country. We must do this in a way that controls the costs of health care. And we must not allow this to lower the quality of health care that our presently insured patients receive. Addressing these three priorities together is not a trivial exercise. The good news is that it does not violate the laws of thermodynamics, and thus it is theoretically possible to achieve all. However, the path to success is difficult, and we must use every tool available to achieve our goals. I believe that the process will be aided greatly if members of the academic community and of the ASCI play a pivotal role.