Health Affairs, 26, no. 6 (2007): 1534-1536 doi: 10.1377/hlthaff.26.6.1534 © 2007 by Project HOPE	New Online   Pay Cuts For Medicare Docs   Access To Care Woes   Public Coverage More Efficient   Empowering Consumers

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Perspectives

PERSPECTIVE

A Graveyard For Grand Theory

Abstract

 
We have failed as a nation to make decent medical care available to all and to control costs. Competing, entrenched interests, more focused on what they have to lose than what they stand to gain, have stymied successive visions of reform. The American public’s aversion to risk has compounded the challenge. There is an urgent need for aspiring health system reformers to chart navigable courses through the cross-currents of interest-group power, anxiety, and ambition that have kept reform from succeeding. Some recent proposals offer reason for hope.

Since the founding of Health Affairs, the political climate has favored market-oriented solutions. The journal has been the premier forum for intelligent discussion of these approaches—and of alternatives that envision a larger government role. Thus, the pages of Health Affairs permit an archeological study of efforts to resolve the conundrums of cost, access, and quality. None of these efforts has come close to working as planned.

Their failure isn’t due to lack of vision or reach: To the contrary, America’s health care commentariat has offered a series of bold models for reform. Health systems planning, already out of fashion when Health Affairs appeared, would have empowered national, state, and local agencies to start and shut down medical facilities and services—a sharp break with hospitals’ and clinics’ long-standing authority to make such decisions on their own. Market advocates’ calls for aggressive antitrust enforcement and an end to legal constraints on competition departed radically from professional ideals, as did management of medical care by health plans. Health care policy’s intellectual leaders have developed carefully thought-out models for single-payer coverage, global budgeting, managed competition, and managed care. Each of these models might have worked, but none ever was given a chance.

The settled expectations of myriad stakeholders stood in the way, as did rival visions of reform. It’s become a cliché to say that health reform fails because those at the table can never agree on the best approach but easily reach consensus on their second choice—the status quo. The loss-aversion that is basic to human psychology has its political counterpart: Doctors, hospitals, health plans, employers—and patients—are reluctant to part with what they’ve come to depend on in exchange for the unproven promise of reform. The "Harry and Louise" ads that doomed the Clinton plan worked by making a connection with the average person’s worries about losing out in the health reform reshuffle. The insurance industry, which sponsored the ads, was itself motivated by the same worry. Even reform strategies that build on existing arrangements—employment-based coverage, Medicaid, and the like—disrupt flows of money and ways of doing things. California Governor Arnold Schwarzenegger’s plan, notable for its ingenious recombination of cash flows from federal, state, and private payers, is facing strong opposition from stakeholders more attuned to expected losses than to likely gains.

Such loss-aversion, not to mention rival stakeholders’ rational self-interests, has torn every health reform strategy asunder. Politics, markets, and the law have provided venues for opposition. Politics destroyed the Clinton plan; consumer backlash, vented through insurance markets, dealt a ruinous blow to tightly managed care. Less well-remembered is the role of legal proceedings in paralyzing health planning. Congress’s partial embrace of health planning in 1974 (in the form of "certificate of need" requirements for new hospital facilities and services) led to frequent wrangling in agencies and courts over rival facilities’ claims of clinical need. Absent clear criteria for need, hearings and appeals often lasted many years, feeding anger and cynicism that made it easy for the Reagan administration to do away with health planning.

A lesson from the past twenty-five years is that the U.S. system won’t allow full-fledged adoption of any one model of reform. Subsets of stakeholders will resist, at both the launch and the implementation stages. Rival paradigms will persist, influencing decisions by the myriad federal, local, and private actors responsible for health system change. The legal and regulatory frameworks that govern medical care will incorporate clashing premises about the roles of professionalism, markets, social equity, and public decision making on questions of distribution and efficiency. Our own contradictory expectations of medicine will amplify this incoherence. We demand all beneficial care without regard for cost, but we don’t want higher premiums, copayments, or taxes. We want our doctors to be free to practice medicine as they think best, but we worry about the rewards they’re offered by drug makers, insurers, and others. And we’re disturbed by social disparities in care, but when our loved ones become ill, we seek the best treatment that money and social position can buy.

Does this mean that pursuit of rational approaches to health care policy is pointless? No, but it is compelling reason to rethink what theorists of health reform should aim to accomplish. Grand theory is dead. What is needed is a reframing of the policy-crafting task, from detailed specification of desired end states into a search for evolutionary pathways toward equity and value. Pathways that avoid immediate, large-scale disruption of settled arrangements are most likely to achieve health reform’s long-term goals. Policies that tear such arrangements asunder are virtually impossible to push forward.

Reform-minded health policy thinkers should thus become opportunists. They should survey the landscape of stakeholders and expectations with an eye toward potential launching points for evolutionary processes—processes that leverage current institutions and incentives. They should keep ultimate goals in mind—especially universal coverage—but they shouldn’t prescribe or predict end states. The newest wave of reform proposals shows promise in this regard. Plans advanced by Democratic presidential candidates Barack Obama and John Edwards leave employment-based coverage intact for the time being, but they create (1) an easy way to purchase private plans individually, and (2) a public alternative to these private plans. This scheme achieves near-universal coverage (through subsidies for the least well-off) without disrupting employees’ expectations or health plans’ near-term business prospects. Its reliance on markets buffers ideological objections. But it leaves room for the individual market to expand and perhaps to supplant employment-based coverage. And it permits the public plan to evolve into a single-payer system by market means. It opens pathways toward these possibilities, but it doesn’t compel them. It puts off these choices: Americans will make them by swarm logic, down the line.

Cost control and quality of care present similar opportunities. Putting medical practice onto more of an evidence-based footing is essential for both, but drug and device makers—and some providers—see this as a threat. Some seemingly rational approaches are thus a dead letter—for example, conditioning approval and coverage for new drugs upon evidence that they work better than older alternatives. But ramping up federal support for comparative efficacy research—say, by committing 1 percent of Medicare spending for this purpose—would greatly expand the evidence base for clinical practice and coverage decision making. This might, over time, push practice patterns toward firmer scientific ground as information intermediaries (such as medical educators and developers of quality-of-care benchmarks) make it embarrassing and costly for providers to disregard the data.

There are many other potential pathways, beyond my scope here. By reconceiving their role as savvy spotters of such possibility, those who strive on these pages to resolve the conundrums of health care policy could nudge us toward solutions that have so far evaded us.

Editor's Notes

 
Gregg Bloche (gbloche{at}brookings.edu) is a professor of law at Georgetown University and a nonresident senior fellow at the Brookings Institution in Washington, D.C. He is also an adjunct professor at the Johns Hopkins Bloomberg School of Public Health in Baltimore, Maryland.

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