The Washington Post
October 24, 2010
The price problem that health-care reform failed to cure
By Alec MacGillis
The health-care law of 2010... sets us on the road to universal health insurance.
But the Democrats' effort to sell the law to the public may be undermined by what even some ardent supporters consider its biggest shortfall. The overhaul left virtually untouched one big element of our health-care dilemma: the price problem. Simply put, Americans pay much more for each bit of care -- tests, procedures, hospital stays, drugs, devices -- than people in other rich nations.
Health-care providers in the United States have tremendous power to set prices. There is no government "single payer" on the other side of the table, and consolidation by hospitals and doctors has left insurers and employers in weak negotiating positions.
"We spend fewer per capita days in the hospital compared with other advanced countries, we see the doctor less frequently, and we swallow fewer pills," said Jon Kingsdale, who oversaw the implementation of Massachusetts's 2006 health-care law. "We just pay a lot more for each of those units than other countries."
The 2010 law does little to address this. Its many cost-control provisions are geared toward reducing the amount of care we consume, not the price we pay. The law encourages doctors and hospitals to join "accountable care organizations" that have financial incentives to limit unnecessary care; it beefs up "comparative effectiveness research" to weed out inefficient treatments; and it will eventually tax the most expensive insurance plans to restrain consumers' superfluous use of health care.
Such measures could reduce redundant tests, emergency room visits and hospital readmissions, which would help control the costs of Medicare, where the government sets rates. But they are less likely to lower prices outside Medicare and stem the growth of private insurance rates.
The main reason for this is politics. Remember how drawn-out the health-care battle was? It started in the spring of 2009 and was waged for a full year. The bill's proponents in the White House and in Congress had some inkling of how tough the fight with the insurance companies would be. Taking on hospitals, doctors, and drug and device manufacturers as well -- the people you'd face in a showdown over prices -- might have been fatal.
So there was no price fight. It is one of those fine political ironies: The law derided as socialism may have had an easier time winning favor from a skeptical public if it was, well, a little more socialist.
Politicians wanted to avoid a confrontation over providers' prices. So a different policy argument took hold: The real reason everything cost so much was the overuse of health care, not the actual prices of treatment.
This argument came primarily from Dartmouth College researchers who had amassed data showing wide disparities in Medicare spending among different regions. Hospitals in the lower-spending areas, mostly in the Upper Midwest and the Northwest, seized on the study to argue that the key to controlling costs was to reward providers like them.
The theory caught fire at the White House. It gave President Obama and his then-budget guru Peter Orszag a way to talk about costs without taking on doctors and hospitals; instead, the White House could simply differentiate between providers that offer "value" and those that don't.
But the Dartmouth rankings, and the concept they supported, did a "disservice" to the debate, said Robert Berenson of the Urban Institute. For one thing, he and others say, the figures overstate regional differences in Medicare spending, which shrink when socioeconomic factors are taken into account. Second, rates of Medicare spending are not necessarily representative of health-care spending for people under 65. Some of the places that do well in the Dartmouth rankings charge high prices for non-Medicare patients -- and were, not surprisingly, among those pushing hardest against a public option.
More broadly, the skeptics argue that merely providing care in smaller quantities will not sufficiently lower costs. They note that Americans already have shorter hospital stays and fewer doctors' visits than people in other advanced countries. What sets us apart is our high prices for these health-care "units" -- a finding trumpeted in a landmark 2003 paper by Princeton's Uwe Reinhardt and others titled "It's the Prices, Stupid." The price problem is only getting worse, researchers and antitrust investigators have found, because of consolidation among providers, and it could be exacerbated by goading them to form even bigger networks.
Comment: Many have commented on the fact that the Patient Protection and Affordable Care Act (PPACA) did little to address one of the most important drivers of the reform process - our unique problem of the outrageous costs of health care. We spend far more per capita on health care than any other nation. This article by Alec MacGillis is singled out as recommended reading on this topic, as he is one of the most credible and well-informed journalists who closely observed the reform process.
The important lesson that MacGillis provides us here is that we do not use more health care than other nations, we simply pay much more for it.
Yet reform was based on the principle that we need to cut back on health care excesses that don't even exist except to a limited extent in some of those regions identified by the Dartmouth researchers as areas of higher utilization. When you consider that we use less care per capita than other nations, it's clear that efforts to ferret out this marginal waste will have very little impact on our total national health expenditures, though eliminating any waste is certainly beneficial.
The real problem is the amount that we pay for health care, yet very little in PPACA will ameliorate that problem. What could provide relief?
Alec MacGillis provides a strong hint: "Health-care providers in the United States have tremendous power to set prices. There is no government 'single payer' on the other side of the table."
As Margaret Flowers and others have been shouting out all along: "We want a seat at the table!"