By David Ignatius
Thursday, August 20, 2009
Reading the transcripts of President Obama's "town hall meetings" this month on heath-care reform is painful. He's preaching the right gospel, but the parishioners are getting restless. The harder he tries to sell his program, the louder and angrier the debate gets -- and the more the general public tunes out the politicians.
It reminds me of the polarizing Iraq debate of several years ago. Forgive the analogy between war and health care, but maybe Obama needs the medical equivalent of a Gen. David Petraeus -- that is, a professional who can break through the political chaff and describe a strategy for reform that can unite the country.
I have a nomination for the medical commander role, and it won't surprise anyone who follows this issue: Dr. Denis Cortese, the chief executive of the Mayo Clinic. He's already doing what the nation needs -- that is, providing high-quality health care at relatively low cost. Every time I listen to Cortese explain what's wrong with the system, I have the same reaction: Let him and other smart health professionals lead us out of the political morass.
Talking to Cortese this week, I heard two themes that cut to the heart of the debate. First, he thinks Obama has made a mistake in moving toward the narrower goal of "health insurance reform" when what the country truly needs is health system reform. Imposing a mandate for universal insurance will only make things worse if we don't change the process so that it becomes more efficient and less costly. The system we have is gradually bankrupting the country; expanding that system without changing the internal dynamics is folly.
Second, Cortese argues that reformers should stop obsessing over whether there's a "public option" in the plan. Yes, we need a yardstick for measuring costs and effectiveness. But we should start by fixing the public options we already have.
Cortese counts six existing public options that should be laboratories for reform: Medicare, with its 45 million patients and a fee-for-service structure that all but guarantees bad medicine; Medicaid, with an additional 34 million beneficiaries; military medicine, through which government doctors deliver state-of-the-art care; the Department of Veterans Affairs, which has improved performance at its hospitals by embracing new technology; the "Tricare" insurance plan for military retirees; and the Federal Employees Health Benefits Program.
Adding a new public option for insurance, as congressional reformers are demanding, would be useful. But it's not necessary now, and it is creating a poisonous debate that's undermining the more important reforms -- which are in the delivery system, not insurance.
If liberals really want to show they are serious, they should begin with our existing single-payer behemoths, Medicare and Medicaid. Cortese argues that the White House should mandate that, within three years, these programs will shift from the current fee-for-service approach to a system that pays for value -- that is, for delivering low-cost, high-quality care. If doctors performed unnecessary tests that ballooned costs, their compensation would be reduced. And doctors would be compensated by regional formulas, to encourage them to work cooperatively in local networks where they could all make more money by practicing better medicine.
What difference would such Medicare reform make? Take a look at estimates prepared by the Dartmouth Institute for Health Policy and Clinical Practice (which developed the national "health atlas" that was the basis for the widely read New Yorker article by Dr. Atul Gawande). At current spending rates, Medicare will run a $660 billion deficit by 2023. But by cutting the annual growth in per-capita spending from the current national average of 3.5 percent to 2.4 percent (the rate in San Francisco, for example), Medicare could save $1.42 trillion and post a big surplus.
This "pay for value" approach would amount to a cultural revolution in American health care. It would take our bloated system and make it cheaper and better. The adjustments wouldn't be easy, and the medical profession would balk unless respected doctors such as Cortese led the way.
Obama has been campaigning furiously in this crazy summer of bogus debates about "death panels," but he's losing traction. Reformers aren't helping by drawing a false line in the sand over a "public option" when we already have one, in Medicare, that provides a laboratory for systemic change. I hope that Obama understands that his health plan is in mortal danger -- and that it's time to call for the doctor.