Before discussing the solution to our healthcare problem, we must confront an inconvenient truth. Just as the United States is the undisputed leader in research and development in weapons of war, we are similarly the leader in research and development in healthcare. We have spent countless billions developing stealth technology, drones, laser-guided bombs, etc. This has made warfare safer and more effective, and the rest of the world cuts its defense budgets and instead relies on us for this technology and purchases it from us. (Whether this is fair or not is debatable and not relevant to our present discussion.)
Similarly, the U.S. has spent countless billions creating technology, pharmaceuticals, and procedures that has improved healthcare that is utterly mind boggling ― laparoscopic, robotics, gamma knife, MRI, etc. The world, in turn, buys this technology from us.
In other words, there is no free lunch. Whether fair or not, the U.S. is investing enormous resources into warfare and healthcare for the benefit of the rest of the world. If we decide to adopt a European-like system, the explosive advances we have seen in medicine and weapons of war will grind to a trickle. France is not going to develop the next generation of stealth bombers and Spain is not going to develop the next generation of cataract surgery instruments.
Nevertheless, the U.S. can still do what it does cheaper. Much cheaper.
Tort reform is the key. We doctors are ordering brain MRIs for a headache, even though the greenest intern can distinguish between a worrisome and a typical headache with a few questions and brief exam. We are ordering Lyme titers for every rash, regardless of whether the patient has left the city or not. We order ANA, ESR, and C-RP for almost every complaint, regardless of the very low pre-test probability, which we have been taught makes these tests worthless. Why do we doctors act so "foolishly"? Because if we miss that rare presentation, we will get sued and harassed by lawyers.
Instead, imagine if doctors could rely on their wits and common sense, and if they missed a diagnosis despite good medical judgment, not worry about a jury finding them guilty of malpractice? The over-utilization of tests and scans would plummet, and outcomes would not budge. We would save billions.
Tort reform requires a two-pronged approach. One part is like "no fault" ― a panel determines how much the patient was harmed and is compensated accordingly, regardless of fault. The second part involves a different panel of medical experts ― not judges, juries, or lawyers ― who review the case and determine if the doctor practiced below the standard of care, and if so, recommends suspension of license or training/supervision. This way, patients get compensated for harm, and juries are no longer pressured to find doctors guilty of malpractice so that they can award money to an unfortunate patient.
After tort reform, we need insurance reform that incorporates two critical ideas: "skin in the game" and the laws of capitalism where competition leads to higher quality and lower price, like with every other commodity and service out there.
Without skin in the game, patients will mindlessly go to doctors and submit to treatments for every little ache and pain, and that simply violates common sense and leads to enormous waste and over-utilization. Let's encourage Medical Savings Accounts ― high-deductible, cheap insurance plans ―where patients are motivated to give thought before going to the doctor, and are protected from financial ruin. Let people buy insurance across state lines ― so if some states are foolish enough to mandate all kinds of services that many people don't want, like chiropractic, hearing aids, drug abuse treatment, etc., at least those citizens can buy the insurance they wanted from wiser states.
To encourage competition, we need to scrap government-sponsored entities like Medicare and Medicaid, and instead give vouchers to every citizen, the amount of which can be tailored to income. Let insurance companies compete with one another for those vouchers. This fierce competition will lead to innovation, higher quality, and lower price, just as with televisions, automobiles, computers, clothes ― everything.
Just look at public education where the government and unions prevail, i.e., no competition, the quality is atrocious, yet we spend more per pupil than any civilized country in the world ― and they mindlessly keep demanding more money. Yet charter schools and Catholic schools, vying for vouchers, produce much better education at a lower price (Catholic schools especially — they spend literally half of what public schools spend per pupil), and the waiting list runs in the thousands.
Imagine insurance companies replicating the high quality and low cost of the Mayo Clinic or Cleveland Clinic and offering those products to citizens. Or, some will offer high-deductible plans with more freedom to choose a doctor. Some will offer lower deductibles and restricted access to some specialists. The critical part to understand here is that citizens, with voucher in hand, will be able to make informed choices of what suits them best, and insurance companies will keep coming up with ideas to improve quality and save money, and everyone is protected from financial ruin.
It is truly the American Way, and it always works. Always.
Ari Weitzner, MD, is in private practice as a general ophthalmologist. He also practices part time as a physician specialist at Kings County Hospital Center. He went to medical school at the Albert Einstein College of Medicine, completed a medicine internship at Beth Israel Hospital in New York, and an ophthalmology residency at Montefiore/Jacobi, Bronx, N.Y.