Four Questions for Reform
Evaluating health reform proposals
By Stephen A. Gregg
In the near future, we most certainly will be presented with more alternatives for health care
reform than any of us care to imagine. Every candidate for president will have a new plan.
Almost all 50 states are probing the subject in a variety of ways. Unfortunately there is far too
much “clutter” in the debate, leaving us with the need to simplify an otherwise complex subject.
This article equips the “non-expert” with four fundamental questions for critical examination of
Our nation has been grousing about our health care system for decades. Change is in the air. An
upcoming presidential election, highly publicized reforms in Massachusetts, the Healthy
Americans Act sponsored by Oregon’s Sen. Ron Wyden, “Sicko” by Michael Moore, and the
recent passage of SB 329 by the Oregon legislature, suggest something is afoot.
Powerful vested interests shape the landscape, and their interests may not be yours. It is
important that all citizens engage this pending redesign of our health care system with “eyes
wide open,” as health spending accounts for 17 percent of the nation’s economy, about twice the
fraction it was in 1975. Excessive health care spending messes up the national deficit,
international competitiveness, General Motors, the number of teachers in the classroom, and our
ability to pay a mortgage. We may be witnessing a “tipping point” where no one is willing or
able to pay the bill anymore. Those who define the issue as a matter of inadequate allocation of
the expense among the possible sources of funds miss the broader point and are in danger of
occupying an irrelevant position.
One way or another, the economic burdens of health care will migrate to the individual from
open-ended employer or government obligations. The more quickly we can shift from an
apathetic “other people’s money” culture to a “my money” orientation, the sharper our national
support will be for the right solution.
Undoubtedly this change can provide ample room for compassion and community, so let’s not
play to that diversion. If we do nothing about the economic trends of health care, there will be no
surviving sense of compassion or community.
How does the “non-expert” engage this seemingly complex subject? What should be insisted
upon as “dealmakers” or “deal breakers,” forming the basis of evaluating competing reform
proposals? Here are four simple questions which should be asked, whether it’s at your next
neighborhood cocktail party or at the next legislative hearing on Capitol Hill.
Does the proposal tilt too far to the left or right politically?
Free will and choice are regarded as important values within our culture. In many respects health
reform has been frozen by the intractable debate between the impassioned positions of left and
right ideologies. Statistics and endless rationalizations will not change these strongly held
beliefs. If any solution imposes an overly left or right answer, the losing side will successfully
dismantle the solution before or after its implementation. This suggests reform should provide a
broad spectrum of choice matched to diverse individual values. If a significant number of people
want a “government-run” health system, the solution should provide that option. Conversely, if others lean more libertarian, the proposal needs to respect those views. Choice enhances
“alignment” between system and beneficiary — a very powerful characteristic of success. The
focus should be on providing individuals what they want and are willing to pay for. Seek long
term alignment between health plan and member, pushing aside the promotion of the “annual
right” to leap from one health plan to another.
Does the proposal offer strong prospects for universal coverage and controlling costs?
This is the most challenging of the questions as the health care dialogue is full of sophistry,
unintended consequences and outright deception. If we consider it unacceptable that our nation
spends twice as much on health care as other developed nations, then new public funding of the
uninsured should be generated from assessments on existing premium or provider cash flows. It
should be our civic expectation that universal coverage be achieved without the infusion of
“new” money into the system. In addition, forcing individuals or companies to buy a service
(insurance) which has such a dismal track record controlling its costs should be pursued with
more caution than evidenced in current “mandating” debates.
We have had many failed efforts over the past decades aimed at controlling health care costs
(“Comprehensive Health Planning,” “Certificate of Need,” capitation reimbursement, utilization
review, rate setting, gatekeeper concepts, etc.). It is time we respect the elusiveness of this
subject, evaluating the next generation of proposals with a very critical eye, as if we have learned
something from the past. There is little point to comprehensive reform, if the new model is not
economically sustainable. The failure to offer a credible strategy to control costs is the
“universal” weakness of most, if not all, present reform proposals. Some suggest we will control
costs through aggressive prevention programs and large scale improvements to administrative
efficiency. As David Leonardt stated recently in the NY Times, “No one really knows whether
preventative medicine will save money in the long run, let alone free up billions of dollars a year
needed to help pay for universal health insurance.”
Savings in administrative costs may or may not be there, but certainly for the most part these are
one-time cost savings. If the “paper-bag math” does not hold water, we need something better.
Can the “grand design” of the proposal be implemented?
Is this proposal actionable? Is it just more “talk, talk, talk?” Can we see how we transcend from
the present to the future? There is considerable debate within the health policy community as to
whether successful reform can or should be approached comprehensively or incrementally. The
“comprehensive” advocates argue that “incrementalism” fails to provide the required “shock” to
the system and only serves up nominal changes easily sabotaged by status quo interests.
“Comprehensiveness” advocates the politically impossible and uncertain consequences. Both are
worthy arguments. Buckminster Fuller provides some helpful insight to this dilemma: “You
never change things by fighting the existing reality. To change something, build a new model
which makes the existing model obsolete.”
The HMO movement in this country was a real life example of what Fuller was suggesting.
HMOs were conceptualized, and government and employers offered a nurturing and enabling
environment. Regulation insisted that HMOs be offered as an alternative benefit to employees
and even Medicare recipients. People voluntarily elected these alternatives as a superior service to status quo, and the movement was off to the races. Policy did not insist on status quo being
summarily terminated. The new idea had to be better in the eyes of the individual. The shift was
10 percent the first year with manageable increases in market share over several years. We
innovated, evolved, critiqued, and adjusted. This should be the construct of the next generation
of reform as well.
Does the proposal provide a “proof of concept?”
Health care reform is a complex matter. The fourth requirement of the scientific method is
experimentation. We could not fathom the introduction of a promising new drug without
extensive clinical trials. Microsoft would not begin worldwide distribution of its software
without beta testing. Surprisingly, most health reform proposals do not have provisions for any
“proof of concept” in advance of advocating a complete rollout of its untested policy concepts.
How would the Oregon Health Plan have been adjusted if piloted in advance? Did the central
theme of rationing care work? Years later, do we even know? A well constructed experiment
contains stated and predetermined measurements of success, independent and multi-sourced
evaluation, and wide dissemination of the results.
Stephen A. Gregg was the founder and CEO of the Ethix Corporation, a Portland-based national
managed care company. Gregg is co-founder of the Oregon Health Assessment Project (OHAP),
a community-based initiative concerned with the development of an actionable and
comprehensive redesign of Oregon’s health care system.
BrainstormNW - September 2007