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Sunday, January 11, 2009

Understanding the focus of Health Care Reform

I've learned to be more careful about focusing on the true end goal of health care reform. Often, it's phrased as health insurance for all. However, the end goal should be health care for all and ultimately health for all. Focusing on the wrong end goal doesn't just happen in health care as a Penelope Trunk blog post demonstrated. The post called "High Income women get more oral sex" focused on how income and other characteristics should lead to wealthier women getting down (on) more, so to speak. I felt the post missed the point as it focused on the wrong end goal. With any kind of sex, the goal is to have an orgasm (or is for most I shouldn't generalize). However the orgasm is achieved is really besides the point. Picking oral sex as a goal was picking the means rather than the end.

A Health Affairs article (paid subscription required) article succinctly phrased this framing of the question as "the conflation of health, health care, and health insurance". They are connected but not the same. Health insurance is simply a mechanizing for paying for health care by pooling money upfront and paying it out to those who need health care. The ultimate goal is that everyone can get health care and be healthy. Massachusetts reform demonstrated this as more people had health insurance but there wasn't enough primary care physicians to give everyone health care.

An article by Scott Gottlieb, a former CMS official wrote a recent article that further demonstrated the difference between paying for health insurance and paying for health care. He critiqued the Obama administration's proposed stimulus plan of providing more funding to the states for Medicaid, the health insurance program for the poor. However, outcomes for recipients of Medicaid have been demonstrated through research to be much poorer than the general population due to byzantine rules and reimbursement that didn't reward quality care. With demographic variables controlled, Medicaid bought worse health outcomes than other insurance programs. The following quote summarizes the main point:

"Insurance coverage has become the end itself, with states spreading resources widely but thinly -- without enough attention to the quality of care, accessibility, or whether coverage was actually improving health. States have no obligation to rigorously measure health outcomes in order to qualify for more federal money."

I used to work in the county health department that mostly saw Medicaid recipients so this was a tough article to read. However, the point of not investing more in a program that produces worse health outcomes for the dollar is an important one. Rather than invest in more health insurance, there should be investment in better health care.

Hopefully, we will have a vigorous national health care debate this year so it's important to remember what the end goal is. The focus will be on paying for health care but insurance should be viewed as just a vehicle and not the end goal.

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