Good news, bad news in nation’s health care debate

By Ted Townsend

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Now we get to the good stuff.

When the federal Accountable Care Act was passed just over a year ago, most folks were confused and disappointed. Confused because the legislation was so massive that no one really knew what all was in it, and disappointed either because they were opposed to it or it didn't deal with the real problem.

That real problem is back with a vengeance. It's called Money. There isn't enough of it and never was.

While last year's ACA dealt mostly with solving the problem of inequitable access, it avoided what most citizens and virtually all health-care providers thought was the real problem: unsustainable rising costs of that care. Those unsustainable costs have become even more obvious over the intervening months as the full scope of exploding federal deficits and a continuing recessionary hangover come into public focus.

Whether or not you believe the Congressional Budget Office scoring that said the ACA would save money, what has become increasingly clear is that over a longer time span, the ACA will likely increase federal and state government spending on health-care entitlements. Combining this with continued deficit spending for the foreseeable future and escalating public debt now joins health care rightfully into the full debate on how we as a nation should restructure and reprioritize our spending.

And not a generation too soon. While many of us in Iowa can take considerable pride in our relatively high quality and low cost of care, as a nation we are getting a worse deal by the day. We spend at least half again as much as any other developed country and get less value for it. By virtually any other measure than access to care, our national outcomes are worse and declining. Why?

Many folks blame fee-for-service medicine driving more incentives toward volume of services than outcome, but that's too simple of an answer. I believe fee-for-service will always have its place, particularly for procedural specialist providers of all stripes. For other parts of the health-care system, moving toward payment for outcome or population health management (versus sickness-reaction medicine) could be a helpful part of the solution.

But the full solution will need to go beyond even that. As a nation, we are just beginning the Great Debate: What is government's role in health care? Should it be the daily arbiter of care? Insurer of last resort? Detached market regulator? Personal trainer? Except for that last one, most of us would probably say yes, in part, to all the rest, but the difficulty lies in the details, which are always downwind of personal philosophies and the politics they spawn.

The good news is that debate needs to happen. The bad news is that the differences are profound, the dialogue bitter, the answers elusive. As an administrator of a large, non-profit health-care organization, the greater part of my role is to ensure we are poised and flexible enough to weather whichever direction public policy turns. As a citizen, however, I also need to lend a voice to the debate.

Medicare, for example, exists because the elderly could not find affordable insurance before it existed. A good argument for the government as insurer of last resort.

Medicaid exists because the poor among us could not afford to pay for care or insurance. Perhaps another good argument for insurer of last resort, or for the roles of arbiters of care (who gets what).

These two programs make up more than half of all payments to health-care providers and the most out-of-control elements of government spending. They are entitlement programs on steroids and both providers and patients have become addicted to them.

The answer is in finding a way to rein in the entitlements without gross social inequities, balanced with redirecting the marketplace away from volume to value.

Sounds simple. It won't be.

Ted Townsend is president and CEO of St. Luke's Hospital in Cedar Rapids. Comments:

TownseTE@ihs.org