Book Review - Critical

Another influential book on health care reform and the model for new policy is Sen. Tom Daschle's book Critical. In this book, he outlines the history of failed health care reform efforts and lessons learned and points a new way forward that avoids some of the politicization on the details of the health care debate. The premise is that there needs to be a Federal Health Board to create detailed policy for the long term, analogous to the Federal Reserve Board for monetary policy. The main lessons learned from the Clinton administration's difficulty with health care reform were: 1) trying to encapsulate every policy detail in the health care bill, giving opponents a very broad target to attack and 2) being out organized tactically and financially by opponents in outreach to voters. Organizing for America is mobilizing to address the second of these, but the first still remains an issue that is currently being debated.

The idea of the Federal Health Board is that it could be somewhat insulated from the current political environment, even though the members would be political appointees. And it would determine the most contentious of issues such as what benefits would be paid, and what treatments would be approved, by clearing cost-benefit analysis hurdles. In our current system, Sen. Daschle argues that there is no good mechanism to screen new health care innovations on the basis of their value for outcomes and overall cost reduction in the system. So much of the current expenditure on health care is wasted on marginally effective treatments or worse, financially motivated prescribing or lawsuit avoidance measures. The Federal Health Board would determine which treatments are truly cost effective and should be provided to all as a benefit.

There is a discussion of the analogy to the U.K. health system office NICE which serves a similar function, and there is considerable data showing that money is spent more efficiently. But in their system, all are covered, all pay the same amount, and all receive the same benefits. This is not the model for the US. We value innovation more and the freedom to choose to pay the amount we can afford and select our providers. So they are two extremes, our system where marginal treatments are allowed to fail in the marketplace with some inefficiency, and theirs where a central agency determines what will be allowed to compete.

Following this logic further, Sen. Daschle outlines the excessive cost of high technology preventive interventions in our system such as advanced imaging scans, while failing to take advantage of the low tech preventions that might make a greater impact on chronic disease, such as programs for smoking cessation, diet modification, medication compliance, and so on. He states that it results from distributed gatekeepers that allow new innovative treatments into the market (CMS), but then fail to eliminate the ones that are not cost effective for outcomes quickly enough.

Regarding the health insurance issue, Sen Daschle favors the individual mandate over the employer mandate, and subsidies based on a percentage of income expended on health care. In addition, he favors the creation of a new public insurance agency modeled on Medicare to compete against private insurers and thereby lower rates. This is also being seriously considered by the Obama administration for the upcoming bill. While no one would object to a situation of increased competition in the health insurance market (envisioning Geico-like commercials as in auto insurance), over time the government run insurer will accumulate more and more of the undesirable insurees, as people lose their jobs, etc. And it assumes that there is some market failure in the current environment that makes health insurance non-competitively priced. So the real question is, what is the roadmap for the system ten years from now, a highly competitive insurance marketplace or government having the dominant market share.

Overall, this book is the political perspective on how to get health care reform accomplished, taking account of past failures to reach consensus, even though the need for reform was widely accepted. It serves well for this objective. Hopefully our organizing efforts can help us break through the logjam this time around. With regard to policy though, the analogy of the Federal Health Board to the Federal Reserve Board is a bit of stretch, and may in fact be incompatible with the majority values in the US, with our bias to encourage innovation and allow the marketplace to decide its success or failure.