Thoughts on Health Care and Legislative Reform
What follows is my response to an article sent to me by a fellow physician. The original article follows my response in a separate blog entry.
I think I generally agree with the article. The first fact to be faced is that it costs to provide care. Someone has to pay for it. It follows; I think, that the ultimate reduction in cost will be in providing less care. There are free market examples that demonstrate some success in increased quality of care at lower cost. I'm specifically thinking of cosmetic surgery and Lasik. The problem with holding these two areas as paradigms for the salvation of health care economics is that they are in the realm of commodities. High volume, highly desired products that the general population is willing to pay out of pocket to acquire. We still live in a society where one is likely to find the public willing to spend money on a new TV, car, jewelry but reluctant to pay fair value for items of necessity such as a new water heater, auto insurance premiums, and other costly items that add value to the quality of life but very little value to the quality of image or fun.
The problem and power of a representative democracy is that the choices are decided by the populist vote. Politicians want; and in the case of the good ones, must, stay in power. That is an expensive proposition. Therefore, the populist vote tends to swing decisions to the tyranny of the majority rather than the most pragmatic solution.
I don't think that a general push toward redistribution of wealth will ever solve the health care issues because there will never be enough wealth if the system is free to mandate more and more expensive care without regard to the ultimate cost. I saw this all too often in my years as a Navy Physician where the "free care" prompted expensive visits so that patients could obtain a prescription for a free bottle of aspirin. What is there to stop such abuse and flagrant waste if the consumer is unchecked.
In contrast, what motive is there for true advancement in care if the profit for research and development is siphoned off to pay for care. Have you ever been to a medical meeting in a country with socialized care? I noted an almost absolute absence of product promotion in Ophthalmic meetings in Canada while I would have seen a great deal of world wide product representation in a meeting in the US. The reason was obvious. The Canadian physicians could not afford to invest in or adopt new technology or techniques. Many of these "products" were relatively affordable, quite innovative, and clearly beneficial to the patient. So who lost? The patient lost. Much as the individual who decides that a TV set is a better use of their household capital versus investing in indoor plumbing.
Realigning the incentives to health care coverage is complex and starts at the roots of financial appropriation. Along with an honest assessment, in my opinion, that health care is a privilege born of adequate affluence to pay for it, rather than an inalienable right such as those perceived by the founding fathers. We need reform in congress that separates the financial gain for voting for legislation from the public benefit of the legislation in question. As long as a legislator has to keep his financial war chest (and personal financial status) funded via the contributions of public and private organizations, we will never overcome the propensity to vote for the "highest bidder".
To date, campaign finance reform appears to have been punitive. Term limits that threaten job security. Who wants a job that leaves them knowing that they have to find a way to support their family in 8 years regardless of their performance? Attacks on benefit packages in what is a relatively underpaid, highly responsible position. Excluding the relative few who make large sums with PAC money and maintain a strangling power base. What incentive is there to attract talented, intelligent people to office for a mere pittance compared to the private sector. Does it cost the American economy so much in benefits that it is worth losing the access to the most talented. I propose that the concept of term limits be abolished; much of the real knowledge and experience required to make decisions in a very complex society take years to acquire. You don't train your best executives and then send them packing just as they achieve the necessary skills to be effective in their jobs. To that point, terms of 2 years for congressmen is counterproductive to the point of being ludicrous. No one can learn that job in 2 years; particularly in an environment where job one seems to be acquiring enough cash to mount a reelection campaign. How can one be expected to actually acquire the skills to provide meaningful insight in the work for which one was elected? I propose that the congressional term be extended to four to six years. The reduced number of election campaigns would actually reduce the economic burden on the electoral process and allow more time for new congressmen to establish a record of performance.
In related areas of job security; on a percentage basis, how much does it really cost the government to guarantee health care for a legislator and his family? Sure, tie it to the kind of care that the general population has available. The reality check is valuable. But don't tell the head of a family that their health care security is at risk and then expect to attract the brightest talent. In similar issues; does guaranteeing a pension for time served cost that much? We need legislators who are willing to leave the private sector and give two to six years at a minimum, hopefully more if they become good at their jobs. In that time, they lose seniority and competitiveness in the private sector. If we truly want talented people, we should be willing to compete for that loss of private sector mobility by guaranteeing a level of "retirement compensation" that is competitive. The colonial days of the agrarian legislator are long past and it is time to align the benefits of being in the legislator with the modern economy.
In short; let's revert to the time when becoming a US legislator was something to be admired and not derided. Lets recognize the complexity of the work, compensate for it and expect results. Let's actively work to realign the incentives to attract the best most dedicated minds to the job, rather than leaving the position as one that all too often seems to be defaulting to a mediocre attorney.
And as we align the benefits for legislators to fit the demands of the job; lets then assess and realign the role of the many other "players on the field". Lobbying efforts are self serving; but they often speak for a portion of the economic and social arena with real issues that need appropriate, and accurate representation. Who speaks for the physician, the carpenter, the medically disabled; and provides much needed perspective and factual insight if not for many of these groups. It seems the larger problem goes to the need to pay for the time to get the legislator's attention, rather than the quality of the message. And that problem goes directly back to how we manage our legislators compensation and job description at this time.
So a few, possibly, simplistic thoughts on the state of American legislature.
Dennis Breene MD
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