On one of the Sunday morning news programs Governors Spence Cox (UT) and Jared Polis (CO) promoted the National Governors Association initiative Disagree Better. The initiative urges that we practice more civility in our increasingly civilized political discourse. It’s hard to argue the point (although one can question why NGA thinks two almost indistinguishable, middle-aged white men should be the faces of the effort), but I found myself thinking, hmm, we really need to do that in healthcare too.
Credit: Mohammed Hassan/Pixabay
No one seems happy with the U.S. healthcare system,
and no one seems to have any real ideas about how to change that, so we spend a
lot of time pointing fingers and deciding that certain parties are the “enemy.”
That might create convenient scapegoats
and make good headlines, but it doesn’t do much to solve the very real problems
that our healthcare system has. We need to figure out how to disagree better.
I’ll go through three cases in point:
Health Insurers versus Providers of Care
On one side, there are the health care professionals, institutions,
organizations that are involved in delivering care to patients, and on the
other side there are health insurers that pay them. Both sides think that the other side is,
essentially, trying to cheat them.
For example, prior authorizations have long been a
source of complaint, with new reports coming out about its overuse in Medicaid, Medicare
Advantage, and commercial
insurance. Claim denials seem
equally as arbitrary
and excessive. Health insurers argue that such efforts are
necessary to counter constantly
rising costs and well
documented, widespread unnecessary care.
Both sides think the other is making too much money
and has become too
concentrated.
This is a pointless battle, one that confuses the
symptoms for the problem. The problem is
that we know too little about what care is appropriate for which patients in
what settings by which professionals, much less about who in the system are incompetent
or overly avaricious. Solving that issue is perhaps the most important thing
that everyone in the healthcare system should be focused on. If we knew those things, irritants like prior
authorizations or claim denials would cease to be issues, not to mention that patients
would get better care.
Disagreeing better would mean stop blaming the other
side and start addressing the underlying problem.
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| Credit: kahll/Pixabay |
It’s no secret that the U.S. has long had the world’s
highest prices for prescription drugs. Pharmaceutical
companies claimed they needed those prices to fund innovation, and to subsidize
those discounted prices in the rest of the world. They’ve played tricks like extending
patient protections, even on drugs
like insulin that are decades old. Their tricks led to the Lown Institute to create the Shkreli
Awards, highlighting the year’s “most egregious examples of profiteering and dysfunction in health care,”
naming the award after the disgraced
pharmaceutical executive.
In 2022, Congress
finally got around to allowing Medicare
to negotiate price prices – for a small number of drugs – and the drug
companies are responding as one might expect, “throwing
the kitchen sink” in their efforts to slow or negate such
negotiations. It would stifle
innovation, and take away their Constitutional rights, they argue.
We were all (well, most
of us) happy when drug companies quickly developed COVID vaccines, but it took $32b of federal spending
to accomplish that, and, speaking of greed, we’re seeing problematic
shortages of critical drugs because generic drugs aren’t as profitable for
the drug companies.
The reality is that Medicare
is pretty much the only major health insurance program (public or private) that
hasn’t negotiated prices, and it’s shortsighted to expect that could be allowed
to persist indefinitely. Meanwhile, we’re
seeing drugs whose prices are in the millions
of dollars range, and less than half of new drugs approved appear
to be of substantial therapeutic value over existing treatments. This is a state of affairs that cannot
persist.
Some
drug companies bit the bullet when Medicare capped insulin prices, applying
the $35 out-of-pocket limit more broadly, and the pharmaceutical industry need
to be similarly thinking more about their public image – and the public good – when
it comes to the forthcoming Medicare negotiations.
Disagreeing better
would mean acknowledging that there’s “reasonable rate of return” pricing and
there’s price gouging, so let’s find that line.
Abortion
This is perhaps the best example of disagreeing badly,
and deserves an entire article devoted to it, so I’ll have to try to make my
points succinctly. Look, I get that, for
some people, the belief that life begins at conception is a moral or religious
one that cannot be argued. It’s like the
19th century abolitionists believing slavery was wrong; thank
goodness now for their stubbornness then against the tides of society at that
time.
But pro-life advocates need to recognize that not
all religions or moral frameworks agree with theirs, and in America one
religion is not supposed to dictate to others. It’s also hard to understand a
religious or moral point-of-view that values the life of an unborn child above
life of the mother, as
some bans essentially do.
It should raise eyebrows that one consequence of
abortion bans has been an increase
in infant deaths. If we care so much about life, then our maternal
and infant
mortality rates would be much better. We’d
also do much better about postpartum
care, including ensuring Medicaid and other care, and would ensure adoption
and foster
care are viable alternatives. And we
sure as hell would not be complacent about 11
million children living in poverty. It’s hard to see what religious or
moral principles wouldn’t have as much fervor about these problems with as with
abortion.
Disagreeing better would mean both understanding that trying
to impose our beliefs on others should also include acknowledging their views,
and recognizing that preventing abortions creates consequences that moral
people cannot ignore.
Credit: Planned Parenthood
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Politics impacts all of our lives, but often does so
at a distance that many of us don’t easily recognize. Health care, though, impacts most of us
directly and visibly, both in our health and in our pocketbook. Cynical as I can be, I still believe that
most people in healthcare are trying to do the right thing, although sometimes
they get confused about what that may be.
We’ve got to stop trying to find enemies in healthcare
and start making allies, so that we can solve its problems. Disagreeing better is a way to start.
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