Why Is Fixing American Health Care So Difficult?

So, the problem is that, although we have a decent understanding of the steps we need to take to fix both the insurance system and the delivery system, it's like the old joke: How many psychiatrists are needed to change a light bulb? Only one, but the light bulb has to want to change.

There are no real incentives for any of the actors within the health care system to change, and the demands from outsiders -- whether they're employers, taxpayers or voters -- for change will have to be very strong to overcome the entrenched interests of the medical-industrial complex.

It is likely, though, that these demands will eventually get much louder. Most employers are increasingly pushing costs onto their employees and clearly want to get out of the business of managing health care -- ironically, this is called consumer-directed health care.

The baby boomers are entering their 50s and 60s, just when their health needs increase and the availability of insurance from their employers decreases. Consumers don't know much or care much about the problems with care quality or cost-effectiveness, but they are very aware of the disastrous financial consequences of needing care when they have no insurance. So, baby boomer demands for some kind of universal, guaranteed health insurance system will become a growing political force as they begin to realize that the uninsured are people who look just like them.

There is no realistic way to create a universal insurance system without the government taking even greater control over the system. Unless we somehow make the deficit disappear, there won't be a flood of extra money available. It's therefore likely that the techniques to improve care quality and costs, which various health care providers are adopting, will then become mandatory.

And, of course, this will mean, eventually, if not a reduction in the amount of money available to the system, then at least a slowing in the amount it will increase. And that will cause significant change, probably for the better, in how we organize care delivery toward a system that is organized around effective and preventive treatment of chronic illness, rather than episodic and costly intervention in acute cases.

But because the powerful actors in the health care system understand the concept that government control eventually means relatively less money and less profit, it's likely they will continue to fight this type of universal insurance reform all the way.

It will, therefore, require a powerful president and a Congress with strong public opinion behind it to undertake such a reform. Given the current political divide in the country, we will likely see a continued stalemate in the health care system for a good number of years ahead.

Matthew Holt is a health care consultant based in San Francisco and the author of The Health Care Blog

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