Health Affairs, 24, no. 6 (2005): 1398 doi: 10.1377/hlthaff.24.6.1398 © 2005 by Project HOPE	New Online   Pay Cuts For Medicare Docs   Access To Care Woes   Public Coverage More Efficient   Empowering Consumers

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Rethinking Reform

PROLOGUE

Rethinking Health System Reform

The papers in this section are intended to stretch the horizons of conventional thinking about reform. First, Victor Fuchs and Ezekiel Emanuel offer an analysis of the causes of the worsening tension between cost and access and a framework for assessing reform options. They identify multiple influences, including global competition, deregulation, and antitrust enforcement, that have combined to squeeze surpluses and cross-subsidies out of traditional employment-based financing, which formerly constituted a kind of undeclared, private social insurance.

Next, Donald Moran, who served in the Office of Management and Budget (OMB) in the Reagan administration, takes a historical tack in his analysis of the system’s problems and likely future direction. The growth of private and public insurance in the post–World War II era has reached its limit, and insurance has now begun to "thin out." Moran predicts more direct service provision to fill the gaps left by this thinning; however, he foresees challenges for the future progress of medical innovation if insurance financing diminishes, and he suggests that market forces could eventually create a tiered environment where generous private coverage will be needed to gain access to high-tech medicine.

Third, Thomas Bodenheimer suggests that from a liberal perspective, health care should be regarded as a human right, not the object of a Hobbesian struggle for individual advantage. The goal of reform should be promotion of equitable access to care, for which New Deal–style social insurance is the appropriate vehicle. Bodenheimer sees some common ground with conservatives in liberals’ acceptance of the value of competition among providers (in the context of social insurance); in a shared belief in the potential of information technology; and in a common tradition of pragmatism.

Finally, Kenneth Thorpe proposes that policymakers shed their fixation with insurance as the cause of health care inflation and focus on the population health trends that are the true drivers of spiraling costs. Tackling population health risk factors such as stress and obesity would do more to control costs than tinkering with benefit design, he argues. The effort should begin with wellness programs, behavioral incentives, school-based programs, and rational assessment of the comparative costs and benefits of available interventions.

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