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Questioning the Public and the Options: Balancing Big Government & Big Business

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I am sitting on a plane on the way to the TEDMED conference (which I plan to blog about here later in the week), scanning the USA Today, trying not to catch the flu from the woman who is clearly very ill just a row behind me. Two above-the-fold headlines caught my eye: “Pushing Hospitals to Their Limit” and “Reid to Advance Opt-Out ‘Public Option.’” I saw the cable channels on the airport TVs looping feverishly on the same topic…abuzz with Senator Reid’s promise that the Senate version of the healthcare reform bill will contain a “public option” but with an “opt out” mechanism for states. Whatever that means. And then there is the elusive “trigger” option that is getting air time again. Somehow that is supposed to comfort me.


You can almost see relief in the faces of the TV reporters that the public option controversy is back (or that they managed to bring it back) for a few more polarizing news cycles. Polls are apparently showing that the majority of Americans favor a public option. I’ve certainly seen most of my circle of friends and family on Facebook celebrating the idea. But I am confused how everyone can be so confident about a public option. I’m worried that we’re being fed oversimplified, emotional bullet points in lieu of detailed proposals for how exactly this program would work. I’ve been working on these issues for two years now—have read all five of the Congressional bills and dozens of amendments in full—and still feel like I barely comprehend. 


I have avoided talking about insurance reform in this blog for three reasons. First and foremost, I am an not an expert on this complex topic. Second, the healthcare debate has become so bogged down in the public option controversy that I didn’t want to give even more time, energy, and attention to it. Third, this issue is so emotional and extreme for many people that I don’t want anyone to mistakenly assume that my opinions represent any kind of official Intel position. Because they don’t. What I am about to say—as with all things in this blog—are my own opinions. But since I can’t seem to get the world to focus on other important reform issues, I will try to address this big elephant in my little blogosphere.


Don’t get me wrong. I am in favor of everyone having access to quality healthcare—morally, economically, and from the standpoint of American competitiveness—and the idea of a public option is appealing to me. The reason I remain skeptical is because too little has been said about the implementation of a public option. The fact that the term “public option” is almost always in quotes when I read it—or modified with the words ‘so-called’ in front of it—is a red flag suggesting that there is no common or clear definition. Everyone seems to be quoting someone else’s definition. In fact, I’ve been trying to understand well over half a dozen different versions of a “so-called public option” from Congressional members, and there are significant differences among them. So if no one can define the term consistently, how can so many people be “for” it or “against” it, and how can we be in such vehement debate over what is kind of, sort of, notionally, a new and important concept?


We may all be simply investing our best hopes or worst fears into the ambiguity of the “public option” concept—which is fast becoming the new litmus test for belonging or not belonging to a so-called “political party.” People are also using the terms “government paid” and “government run” ambiguously and interchangeably, but those are very different phrases. Would the government both pay for and run some huge new insurance program? Or simply pay for it while some other entity—perhaps even the private market—runs it?  Would we have to create an entire new government department from scratch to run the public option? Or would this be housed in the Department of Health & Human Services, already the largest part of the federal budget? Some lawmakers are now calling the public option “Medicare Part E” for “Medicare for Everyone”—so does this mean Medicare, one of the largest, most painfully slow, un-innovative government bureaucracies in existence, would become much bigger and slower or the prototype for solving all of our healthcare problems? Really?


I know there are lots of plausible answers to the kinds of questions I asked above…but what is the proposed answer actually being voted upon in the end? That’s the version of the public option that I want to evaluate before making up my mind. But getting that level of detail has been difficult because so much of the negotiation in Congress about the public option has been anything but public. Oh, I’ve already complained about too much media attention on the topic, but that’s only been surface level analysis. Our elected leaders have been holding their cards so close to their chests in closed-door committee meetings that many Senators and House members themselves have expressed public frustration that they aren’t being given access to the details of these plans. We need more information on the “so-called public option” to be informed citizens.


It comes down to this for me: we need a hybrid insurance system that maintains fair competition and checks & balances between Big Government and Big Business to pay for—and run—our health plans. I believe that a government-only or a business-only system would hurt us all…that the tension between the two is what can produce a system that can be both universally accessible and continuously innovative.


We already have a Big Government system called Medicare—the largest insurer in the nation—that has its strengths and weaknesses but it is hardly a utopian cure-all for covering the uninsured or bringing down healthcare costs. It’s as easy to drum up anger and horror stories about Medicare as it is about those “big, evil insurance corporations.” Ask a lot of folks who are nearing the magic 65-year-old mark if Medicare is everything they want it to be. You will get an ear full about how complicated and confusing the system is, how it doesn’t cover a lot of the things their private plan did when they were working full time, how they had to give up their doctor of twenty years because he or she didn’t accept Medicare any longer, and how they have been denied services and free choice. As Medicare sets the (slow) pace of innovation and many of the (under) reimbursement policies/amounts for the private insurance marketplace, it needs much reform and rethinking itself before we use it either to run—or as a template for—the public option. But Medicare is also a literal life saver for millions and millions of people—and there are great programs and people in the system who do amazing things in spite of problems and abuses that inevitably occur.


So, too, we already have a Big Business system with the private and employer-driven insurance markets that consist of big and small, for-profit and not-for-profit, organizations that, in their collective, form another huge, confusing, and frustrating bureaucracy for everyone from clinicians to consumers to navigate. There is no doubt the time has come for reform of this system as well. The profit motive—especially with short sighted quarter by quarter thinking instead of long term ROI analysis—means abuses can and do happen. I don’t like big bonuses for insurance company executives, either, and the games that some of them play to deny coverage for pre-existing or emergent conditions are unforgivably horrible. But the private insurance system is also a literal life saver for millions and millions of people—and there are great programs and people in the system who do amazing things in spite of problems and abuses that inevitably occur.


So whatever form an additional “public option” takes, if it ends up happening at all, it should strive to maintain a healthy tension between the stabilizing force of the social safety net that a government run system provides with the innovating force of the services competition that a market-run system provides. I’m looking for a hybrid insurance system that does four things:


1) Covers everyone and every condition

2) Deals with costs by reinventing how care is delivered, delegated, and paid for

3) Drives checks and balances between market power and government power

4) And promotes fair competition and innovation within and between the two


Both systems need adequate oversight/regulation and more focus on prevention. And they both must radically transform where care is delivered (the home whenever possible), who takes responsibility for health (patients themselves in partnership with professional and informal caregivers), how clinicians practice medicine (via coordinated care teams, with a medical home champion overseeing all care with common sense scrutiny), and how clinicians are paid and incentivized (based upon quality outcomes instead of quantity of visits, procedures, or tests given).


So there. I’ve done it. I’ve uttered the “PO” words in this blog. And I’ve come to the conclusion that I can’t come to a conclusion yet. We need more details. We need to be more questioning. We need to strive for balance in all things. And we need to be able to move on beyond the “public option” controversy to start to deal with that other headline making my newspaper today: finding ways to stop pushing hospitals to their limits. Now that’s something I can really hold forth about.  I want to give the public another option: the option of getting health care at home.


Comments are welcome.  please post to: http://blogs.intel.com/healthcare/ 


NOTE:  ERIC DISHMAN'S 'HOME BLOG' PAGE HAS MOVED TO:  blogs.intel.com/healthcare.