Healthcare Reform: Voting for Change

July 15, 2008

It’s an election year. And healthcare reform is on everyone’s mind. Are we finally on the cusp of systemic change? If so, what might we be changing to, and when? Here’s our examination of healthcare’s biggest problems - and suggested fixes from the top thinkers on reform, from all sides of the political spectrum. Plus: What do the presidential candidates have to say? We put Barack Obama and John McCain under the lens.


Are we finally on the cusp of systemic change? If so, what might we be changing to, and when? Here’s our examination of healthcare’s biggest problems - and suggested fixes - from the top thinkers on reform, from all sides of the political spectrum.

The cost of care

Can we agree, to begin with, that American healthcare costs too much?

It’s certainly not hard to make this point: Healthcare expenditures, which have exceeded overall economic growth for decades, accounted for more than 16 percent of America’s GDP last year, according to the Centers for Medicare and Medicaid Services, a greater percentage than any other country. It is now the largest sector of the U.S. economy, by far.

And the projected growth trajectory of healthcare costs continues at an alarming rate: Costs will grow another 70 percent by 2015, when nearly one in five dollars Americans spend, or about $4 trillion, will be spent on healthcare. In 1980, this sector represented 8.8 percent of GDP.

What is going on here? Why is it so much more expensive to get healthcare in the United States than it is anywhere else in the West? Is it because we have “the best healthcare in the world”? Even if that’s true - and we won’t dispute it, though many have - does that quality difference account entirely for the spending disparity? Consider that in 2004, Americans spent $6,100 per capita on healthcare, compared to $3,000 in Belgium (to cite one example). Is healthcare so much better in Boston than in Brussels that it accounts entirely for the difference?

A recent PricewaterhouseCoopers (PWC) report estimates that $1.2 trillion of the total $2.2 trillion spent on healthcare in this country is wasted. The top culprits, according to PWC:

  • Ineffective IT use;

  • Claims processing;

  • Defensive medicine; and

  • Medical errors and poorly managed diabetes.

Not everyone pins the problem entirely on these usual suspects. “The major factor contributing to rising costs is the federal tax code,” says Greg D’Angelo, a policy analyst at the Heritage Foundation. Favoring employer-based coverage “has created a payer-centered healthcare system in America, [and] driven healthcare inflation,” he says. “Either the employers or the government own health plans. It’s not patient-centered, so it hardly resembles a market.”

Additional theories abound: Our pill-popping, fix-it-now culture; our shouldering of a disproportionate share of the world’s drug R&D budget (thanks to other countries’ pharmaceutical price controls); our outsized malpractice fees and awards, to name a few. But many ultimately point back to medicine’s dearth of market forces.

The Washington State Board of Health, in a 2006 report prepared for the Blue Ribbon Commission on Health Care Costs and Access, notes that “most economic sectors in the country rely on the markets to drive decisions - we expect the ‘invisible hand’ of Adam Smith to guide us - but in health care, there is no functioning market; the invisible hand is either absent from the picture, or as is more often the case, guides us in the wrong direction because of false incentives or disincentives.”

A consumer-directed approach

Many have had high hopes that so-called consumer-directed healthcare would solve this problem. Force people to spend more of their own money on healthcare, goes the thinking, and pretty soon consumers will start demanding efficiency.

Consumer-directed healthcare often takes the form of a high-deductible, lower-premium health plan coupled with a health savings account. The lower premiums are attractive to employers looking to cut costs and the tax advantages of health savings accounts, which can be used to fill the gaps in high-deductible coverage, are compelling to consumers.

Family physician Brian Forrest has built a successful practice around this theory. The solo physician quit accepting insurance of any type in 2002, and instead developed a prepay system that gives patients access to a raft of primary care services for $300 a year and $20 a visit. Forrest says his concept is cheaper for uninsured patients and even for some who are insured with high-copay plans, and is more lucrative and simpler for him.

He says he encourages uninsured patients to enroll, if possible, in high-deductible, low-premium plans with health savings accounts to cover major health expenditures like a hospitalization. Now he’s helping other physicians set up similarly styled cash practices. (Read his account titled “Cash-only Healthcare Still Works.”)


But one key question is whether there are major price efficiencies available to be wrung from the current system with consumer-directed healthcare. You want your healthcare cheaper? Fine, health plans say: We’ll just pay doctors less. But that’s what plans have been doing for years now, and healthcare is only getting more expensive, and more physicians are getting fed up.

Another question is whether a sufficient number of high-deductible plan choices will materialize to encourage competition. “The difficulty is that the individual doesn’t have the ability to negotiate,” says Christine Ferguson, associate research professor of health policy at George Washington University. “It’s not practical - health insurers are not going to produce 100,000 different health plans.”

Breast oncologist Ezekiel J. Emanuel, author of the 2008 book Healthcare, Guaranteed and chair of the department of bioethics in the Clinical Center of NIH, says consumer-directed plans actually make matters worse. “If you’re relatively healthy, and you use a few thousand dollars a year in the healthcare system, you’ll strategize a little bit - you might not go to the doctor for every sore throat … but is that where the [cost] is in the healthcare system?”

He points out that the patients on whom most U.S. healthcare dollars are spent - those with expensive, chronic conditions - already spend well over the current $5,600 annual out-of-pocket maximum for a high-deductible health plan. “So what does this do for those patients? They have no incentive to economize.”

Most people with such plans aren’t opening health savings accounts anyway, and many of those who have HSAs are not fully funding them. We still don’t act like we care all that much about insulating ourselves from high healthcare costs, in part, observers say, because consumer-patients lack ownership in the system. Most proposals for decreasing costs include some element of increased individual responsibility, although that’s not likely to be a popular line with voters.

We Americans are a conflicted bunch, for sure. “How much should we be doing as a society about something that’s individual?” asks Ferguson. “And yet, we have a public health interest in having people healthy to defend the country, in not being sick so they can be productive workers.”

Creating the market

The cost discussion has largely moved beyond discrete products like high-deductible health plans and begun to employ a new set of catchphrases: patient-centered, “truly managed” care, transparency, value-based purchasing.

Conservative thinkers like D’Angelo believe that effective healthcare reform will put patients in charge by making them the true owners of their health insurance: “I think about it as reorienting the system. That doesn’t mean [patients will necessarily] get an HSA or [high-deductible plan] - they’ll get what they want. Patients can fire [their insurers] each year and get a new plan. Focusing narrowly on price or cost alone is counterproductive. The easiest, cheapest way to reduce cost is to deny care, which is what happens today.”

Perhaps a system-wide realignment of incentives is what’s called for. Assuming that administrative and marketing spending can be curtailed - a gigantic “if” in light of the number of players seeking power in this marketplace - improving the value realized for prices paid may be the route to reform.

Ideas for accomplishing this lofty goal come from both sides of the aisle and include a “truly consumer-directed system” similar to the 401(k) model and Emanuel’s “guaranteed access” - an idea outlined in his book under which all Americans would have private health insurance paid for by a 10 percent value-added tax (VAT) - in essence, a federal sales tax.

Cost-control elements in Emanuel’s plan include a standardized list of covered services (based on those currently enjoyed by members of Congress), an outcomes and technology oversight board to ensure appropriate care delivery, and a dispute-resolution center to supplant the malpractice system. Moreover, if consumers want benefits that cost more than VAT-generated revenues, they’ll have to lobby Congress to increase the tax or pay more out of their own pockets for supplemental coverage.

Emanuel cites two Medicare-covered colon-cancer drugs that don’t cure the disease, extend patients’ lives by only a matter of weeks, and cost up to $50,000. No one wants to talk about the rationing of care, but the implication is clear: Such a use of resources is not value-added and wouldn’t be paid for by taxpayers. Consumers could, if they wanted, pay extra for a plan that does cover such drugs, experimental procedures, and anything else, but this will inevitably lead to wrenching decisions over what “potentially life-saving treatment” is worth spending tax dollars on.

Although the reforms favored by conservative groups like the Heritage Foundation are in many ways the polar opposite of plans like Emanuel’s, a cost-benefit argument is on nearly everyone’s lips. Under a true consumer-directed system, explains Heritage’s D’Angelo, “Insurers would need to work collaboratively rather than confrontationally with providers to deliver better value.”


Like D’Angelo, many analysts favor gradually moving toward a system of individual tax credits, which people would use to purchase their own plans, and divorcing coverage from employment. Indeed, the concept is slowly becoming conservatives’ conventional wisdom on health reform; Republican presidential candidate John McCain has proposed such an idea.

Fewer than 60 percent of employers currently offer healthcare coverage, and many of those that do offer it restrict enrollee choice to a single (usually managed-care) plan. These observers argue that health insurers would be more responsive to consumers if consumers had more power to choose their health plan, notwithstanding their employment (or lack thereof).

But some feel that corporate contributions remain essential. Depending on whom you ask, businesses pick up the tab for as much as 60 percent of American healthcare.

To keep that money rolling in, employers are being advised to consider proactive programs such as:

  • Tools to enable employees to compare provider quality;

  • Premium differentials for participation in health management;

  • Plan decisions based on claims analysis; and

  • Health-risk appraisals and disease management.

Other cost-control strategies are more radical and include performance guarantees for prescription drugs, which would move pharmaceutical companies toward risk-assumption, and paying physicians for outcomes rather than treatments. “We cannot pay merely for services provided,” says Emanuel. “This idea that we pay fee-for-service is very bad vis-à-vis integration.”

The uninsured

American healthcare seems locked in a death spiral: Observers on all sides agree that our reliance on employer-based health insurance is one of the factors driving costs up, and those ballooning costs are forcing more employers to cut back on, or eliminate, health benefits.

With no healthcare safety net for most Americans and a market for individual insurance that prices most people out, is it any wonder we have 47 million uninsured? Add a slowing economy that is shedding jobs quickly - nearly 50,000 in May alone, the biggest single-month jump in unemployment since 1986 - and the uninsured problem seems likely to grow.

Massachusetts experiment

But not, it seems, in Massachusetts, where two years ago lawmakers enacted a controversial plan to require all residents to get health insurance, with subsidies available for low-income citizens, and penalties imposed on the noncompliant. The Bay State is the only one in the country to impose such a mandate so it’s worth an examination.

Is it working? That depends on whom you ask, but doctors in Massachusetts generally support the legislation because it increases access to primary healthcare, despite the pre-existing physician-shortage that the new mandate is exacerbating.

“It’s getting people insured,” says Dale Magee, a Shrewsbury OB/GYN and past president of the Massachusetts Medical Society. “Right now we are down to 5 percent uninsured, which is half of what it was a year ago.”

Magee argues that more patients insured means less potential heartache for patients and physicians alike. “We don’t want to be in the position to diagnose a patient and then find out they are uninsured and unable to pay for their meds and treatment. That can be heartbreaking. Now, that’s less of an issue, and we know that patients, even those with $2,000 to $3,000 deductibles, won’t be forced to go bankrupt to pay for their medical care.”

But patients and physicians are discovering that access to insurance doesn’t always equal easy access to care. The influx of more than a quarter of a million newly insured residents has led to overcrowded waiting rooms and overworked, overstressed primary-care physicians who were in short supply in Massachusetts (as elsewhere) even before the legislation.

Patricia Sereno, a primary-care physician in Malden, points out that “in other countries with universal coverage, they have extensive networks of PCPs. We don’t have that. We have a shortage of PCPs and have to find a way to build the PCP base to make this work.”


“The shortage speaks to the fact that we really have to look at how people choose specialties in residency, and encourage them to go into primary care,” says Magee. “In Massachusetts, we currently have one PCP for every three specialists. Residency programs are turning out six or seven specialists for every one PCP, so the problem may only get worse.”

The newly insured are waiting as long as 10 months for a new-patient or well-patient appointment, when they can find a primary-care doctor willing to accept new patients at all. Physicians are feeling the pressure, too. “I’m now seeing 24 patients a day, and it’s a heck of a lot busier than it used to be,” says Sereno. “But the patients are being squeezed on all ends - they can’t find a doctor, they have to wait, then, when they finally get to come in, they come with a list of 10 things to address, and yet they are not getting the time with a physician that they used to.”

The increase in patient load and paperwork has become so stressful that some primary-care physicians are choosing other paths, opting out of office-based medicine for jobs as ER docs and hospitalists, says Magee.

And that’s not all. “There are a number of PCPs between 50 and 65 years old who are considering retiring early because of the increased stress,” says family physician Dennis M. Dimitri, president of the Massachusetts Academy of Family Physicians. “We need to work to retain the PCPs we have by making sure people don’t leave because of the difficult environment in which they are practicing - low reimbursements, heavy patient loads, and administrative details having to do with insurance requirements for getting paid.”

Lawmakers, in search of a solution, are looking at ways to decrease the administrative burden on PCPs and improve reimbursement. They’re also considering loan-forgiveness programs and other incentives for medical students who choose primary care.

The increase in patient loads has an upside for physicians, too. After all, because these patients are insured, they are paying customers. “All of us have been providing some amount of care to [free or reduced-cost] uninsured patients,” notes Dimitri, “and now that many more people have insurance, that’s helping practices, particularly the smaller practices - it’s an opportunity to get paid for care they were already providing.”

Hospitals, too, are reaping benefits by decreasing the amount of unreimbursed care and easing the squeeze on their emergency departments. In 2007, the number of claims to the state’s uncompensated care pool for uninsured hospital visits dropped by 13 percent, and the cost of hospital claims submitted to the pool dropped 8 percent.

“We need to be realistic about the PCP shortage over the next several years,” says Dimitri. But, he continues, “If some of these legislative changes and incentives are put into place, we will see positive changes in the next five to seven years.”

Whether or not the Massachusetts model can be applied to the nation as a whole is up for debate. There were a number of factors that made it easier for Massachusetts to implement state-mandated health insurance coverage, including an already low uninsured rate of just 10 percent, compared to the 15 percent national average, a large and thriving healthcare industry, and a higher mean income than many states. But Americans are watching the Massachusetts experiment closely: If it succeeds, you can bet that reformers elsewhere will point to it as the prototype for a national healthcare restructuring.

“We need to think of the provision of good healthcare as crucial to the health of the nation,” says Dimitri. “We need to consider it a national asset that we all benefit from.”

Mile high model

That’s certainly how Gary VanderArk, a retired neurosurgeon in Denver who today runs Doctors Care, a large clinic for the un- and underinsured, sees it. The self-described conservative Christian says universal healthcare is both a moral and economic imperative, and he blames his own Republican party for America’s failure to attain it.

“Healthcare economics is very complicated, and [Republicans] just don’t get it,” VanderArk argues. “And the major thing that they don’t get is that if you take care of everybody, you save money. For example, in Colorado last year, we spent $1.5 billion on taking care of people without insurance. If you give me $1.5 billion, I can assure you that everyone will have coverage. The way we do it is crazy and expensive. What we do is keep people out of the hospital until they’re deathly ill. So when they come to the hospital, they have to be admitted.”

VanderArk’s dream for American healthcare, like most people’s, is a system that covers everyone affordably. He recoils at notions of a government-run system but says other countries have developed schemes that allow the private market to function under federal regulations that mandate coverage and basic benefits, and prohibit insurers from dropping people for getting sick.

“What we need to be learning from other countries in the world that have universal healthcare is that you can have private insurance, but you’ve got to have rules for those companies,” he says. “All the government has to do is say, ‘OK, everybody, we’re not going to change anything, but these are the … rules as far as healthcare is concerned.’ That would solve it.”


VanderArk, though, isn’t waiting idle. His clinic serves Denver’s growing uninsured population by providing free or reduced-price medical care on a sliding scale, using donated supplies and volunteer physicians and other providers. In 2007, Doctors Care provided $3.5 million in care, all donated by local physicians, labs, hospitals, radiologists, and pharmacies.

Most of Denver’s physicians volunteer at least some of their time at Doctors Care. Participation is high at least partly because VanderArk essentially shames his peers into doing it. If they choose not to, they are literally blacklisted. “Every year the medical society posts a directory,” he says, “and if you’re a participant in Doctors Care, your name is in red, and if you’re not, your name is in black. … It’s peer pressure. If your colleagues do it, you better darn well do it too. … This is expected of you if you are a part of our community.”

Competing priorities

Ferguson, of George Washington University, doesn’t think that attaining universal coverage would be quite as easy as VanderArk suggests. “Is it pie in the sky?” she asks. “It is certainly a reach to say that we can do universal coverage in the current system without a significant change in the finance and delivery aspects of it.”

Ferguson’s best-case scenario? “If the person who is elected president this year decides that this is their No. 1 issue, and if they spend all of their political capital and energy in the first year of their term to accomplish a health reform package that includes universal coverage, restructuring our financing system, and restructuring aspects of our delivery system, I think there’s a good possibility it could happen.”

There is no shortage of reform proposals among the presidential candidates. But our collapsing economy, the ongoing war in Iraq, and the housing crisis are surpassing healthcare as voters’ top concerns, says Ferguson.

“People are much more aware of those things than they are of the fact that they are teetering on the abyss when it comes to healthcare - that if they lose their job, they’re shot. But most people are not in that situation at the same time … and so you don’t have that same impetus or fear about healthcare as you do about these other things. That’s what makes the debate so difficult.”

Facing reality

Linda Blumberg, a principal research associate at the Urban Institute, a liberal-leaning think tank in Washington, D.C., is even less optimistic about major systemic reform in the near term, regardless of which party controls Washington in 2009.

Blumberg does think a system in which “a certain level of coverage,” financed through taxation or other governmental means and agreed upon from a political and social standpoint, could be feasible via a public/private partnership. This basic coverage might be provided by insurers reimbursed by the government. Individuals wanting broader coverage could purchase supplemental insurance.

“I think that is definitely a possibility and that we could make it work,” says Blumberg. But she adds, “You would have to think really hard about how to make sure that any supplements that individuals buy outside that system don’t impose greater costs on the public system.”

Also essential, says Blumberg, would be creating additional incentives for insurers being paid the same amount for the government-mandated “minimal package” of care. Such incentives, says Blumberg, are necessary to encourage providers who are not competing on price to deliver high-quality care in an efficient and effective manner: “There are ways to do it, but it’s not simple. You need to think hard about the incentives you’re setting up to maintain and create efficiencies in health insurance purchasing.”

Blumberg admits she’s a bit jaded. “So I think the most likely scenario is that nothing is going to change very significantly,” even if the White House changes parties next year, she says. “Comprehensive health insurance and universal coverage is, to me, a very worthy goal for us as a nation, and I hope we are moving in that direction,” she says. “But we can’t go into it thinking that it’s not going to require significant new government revenues. And I’m not quite sure that the country is willing to commit to that, given the other issues we need to deal with financially.”

“But,” Blumberg adds, “I hope I’m wrong.”

What physicians say

But what do doctors think of all this reform talk? Not the policy-wonk MDs who work for universities and think tanks but physicians who make their living in private offices diagnosing tennis elbow and getting people to say “aaah”? Doctors like you.

One survey found, to the surprise of some, that physicians view a lack of access to healthcare as the system’s biggest problem, and they’re mostly in favor of some kind of universal healthcare. But precious little data exist on the subject of physicians’ views of healthcare reform; the anecdotal evidence suggests that there’s not much more consensus among physicians than there is among the general population or on Capitol Hill.

To wit:

“The only thing that will save medicine is a good dose of free enterprise. Government regulations, entitlement programs, and HMOs are leading us down the road to socialized medicine.” So argues Steven F. Hotze, a family physician and founder of the Hotze Health & Wellness Center in Katy, Texas. “The solution is to return to a free enterprise system for medicine with doctors charging a fee for service, just like any other business. Beware of politicians who promise to lead us into the Promised Land by giving us universal health coverage, which really means socialized medicine.”

But wait.

“Since we’re humane enough to … not let people die on the streets, people are going to get some level of care. … We might as well just pay for everyone and get a better bang for our buck, no?” Such is the thinking of Graham Walker, who at this writing was about to head off to residency in New York after graduating from Stanford Medical School.

Hotze is emblematic of the conservative-minded physician who yearns for the day when doctors and patients had a relationship based on trust, unencumbered by third parties. Walker, writing in his blog, is the young idealist whose focus is on getting more people covered. Yet this goal is counterproductive if you believe, like Hotze, that the health plans that cover people just get in the way of good healthcare. But what’s so good about a healthcare system, Walker argues, where so many people can’t gain access to it?

Glad we could settle that.

Hotze and Walker represent opposite ends of the political spectrum but most of the debate over healthcare reform is taking place on ground between these views. Mainstream Republican politicians are not advocating a purely fee-for-service market-driven healthcare system that would, if taken to its logical conclusion, spell the end of Medicare, Medicaid, and even private third-party payment schemes, all of which, in the view of Hotze and many others, simply obstruct the doctor-patient relationship. Most conservative reform ideas would, instead, simply tweak the current healthcare system to make it more responsive to market forces without being at their mercy.

Nor are many Democrats talking about truly socialized medicine, if that’s defined as a system in which everyone is forced into government healthcare with all the bills paid by taxpayers. Most instead propose making it more affordable for patients to get into managed-care plans.

Hopeless about Medicare

Medicare is the biggest problem in healthcare for a psychiatrist we spoke to in Philadelphia. He, too, thinks the political discussion misses the point. “Medicare is actuarially unsustainable,” he argues. “Just on a mathematical basis, it can’t keep going at the [present] rate of growth, and the problem is that there is absolutely nothing which is being put in process now that is addressing this issue at all. I don’t think that anybody - McCain maybe a little bit - is even looking at [it].”

Medicare’s fiscal picture can only improve if the government addresses either cost or access to care, says the psychiatrist. The former would reduce what physicians and hospitals are paid. The latter would reduce the number of people covered, or the number or things for which they are covered, or would increase the amount that beneficiaries pay out of their own pockets.

Dropping reimbursement would be devastating to physicians, especially those in primary care. “I still don’t think anybody has any idea of how fragile the primary-care delivery system is and how close we are to imminent collapse,” says the psychiatrist, who asked his name be withheld because he was speaking without his employer’s authorization. “The marginal revenue per patient is rapidly reaching the marginal cost.”


The psychiatrist’s wife is a primary-care physician who plans to quit soon and probably won’t practice medicine anymore. Though young, she is exhausted by the churn of high volume and low pay. “They are trying to get every last nickel out of it,” says her husband. “Doctors are well-educated enough to know they can do other things. They just can’t survive in this economic model.”

Reducing access through rationing or waiting lists isn’t really an option, either, he feels. “I don’t think we’re anywhere near where people are ready to do that. Basically, patients still believe that after 40 years of largely free healthcare they … should be able to get what they want and pay nothing.”

The only possible solution, he concludes, is for each individual physician to look out for himself within the current environment. Forget about waiting for politicians to fix “the system.” Instead, says this psychiatrist, who also has an MBA from the Wharton School of Business, stay focused on your piece of it, and keep an open mind: “There are different ways to make this succeed. Because so few people are thinking creatively, the people who do think in creative ways have the option to really succeed and succeed big.”

Reinventing the rocket?

When NASA’s scientists want to send a spacecraft farther than is ordinarily possible on one tank of fuel, they don’t waste time redesigning a whole new engine. Instead, they bounce it off the gravitational pull of a nearby planet to “slingshot” the craft into deep space. Great idea, but significant time must pass to reap the benefit. Consider that Galileo took five years to reach Jupiter, even with multiple gravity assists. So it may be with healthcare reform. Some experts say we should keep on with good things that are already afoot, that wholesale reconstruction may in fact hinder as much as help us.

What good things, you ask? The increase in covered preventive care, for one, says Dave Matheson, a senior partner with The Boston Consulting Group. Historically, medical care in the U.S. “has been set up to deal with health when it goes wrong. We do extraordinary work for ‘healthcare train wrecks.’ But now we’re investing up front,” says Matheson, who has been observing American healthcare for 25 years. “A good number of health plans have been putting many more dollars into wellness than they did 10 years ago.”

Some health plans, such as Harvard Pilgrim and BCBS of Massachusetts, to name just a couple, have lately focused heavily on improving their user interfaces. This has prompted “a steady shift in the perception that all a health plan’s interest is in denying - rather than providing - care,” says Matheson. Obviously, many physicians missed that memo. Matheson, though, insists that the trend among insurers and employers is toward greater emphasis on preventive care and it would be a shame for any reform to get in the way of that.

Consumer-directed healthcare is on the rise, as are Internet-based social care support groups (e.g., www.autism-society.org), more reliable medical data, and more transparent healthcare delivery. Many critics insist that major reforms are needed to prompt these developments but Matheson maintains they are already happening without intervention, although not, perhaps, as quickly or as comprehensively as some would like.

Additional time, not new regulations or a whole new system, is needed for these market-based reforms to reach full maturity, says the consultant. Not only will such an overhaul likely fail to be the panacea touted by politicians, it will also need that exact same precious ingredient: time - and lots of it.

“It’s unrealistic to think that next year, or the year after that, we’re going to change everything,” says Joseph Antos, a Wilson H. Taylor Scholar in healthcare and retirement policy at the Washington, D.C.-based American Enterprise Institute for Public Policy Research, a conservative-leaning Washington, D.C. think tank.

Antos likens American healthcare to an adolescent - rip-roaring, full of all the requisite angst, and yearning for “grown-up” independence, but equally rife with insecurities and fear of change. Antos is particularly concerned about healthcare’s “parents,” so to speak: “I’m worried that politics will not allow the healthcare industry to grow up.”

We all know that true maturation includes self-accountability and delayed gratification. Not easy. Will the American public, Antos wonders, be able to deal with this “awkward phase” and see healthcare through its complex metamorphosis?

Antos also questions the wisdom of invoking such drastic proposals as universal health coverage or other extreme ideas. “You’ll hear some politicians say we have ‘the best healthcare in the world.’ No, we don’t,” he cautions. “But in spite of Mike Moore, we also don’t have coverage that’s only as good as Cuba. The views that politicians tend to give on these complicated topics are not so simple.”

Make no mistake. No one is suggesting the U.S. should make like an ostrich, pretending nothing needs fixing. “You won’t find a sensible person that thinks there aren’t real problems,” says Antos.

But despite its problems, healthcare “is a very dynamic sector” of the economy, Antos says. “We should not despair. … Things are changing all the time. All the entities in the health sector are constantly experimenting because they all have a similar interest to do business better. A lot of promising ideas are bubbling up and being tested.”

This article was written by the following staff members: Abigail Beckel is Managing Editor of Physicians Practice. Barbara A. Gabriel is a former Associate Editor of Physicians Practice. Shirley Grace is Associate Editor of Physicians Practice. Laurie Hyland Robertson is Senior Editor of Physicians Practice. Pamela Moore is Editorial Director of Physicians Practice. All authors may be reached via mailto:editor@physicianspractice.com.
This article originally appeared in the July/August 2008 issue of
Physicians Practice.