Once upon a time, there was a great nation that prized, above all, individual liberties. This predilection gave rise to the world’s biggest GDP, the Western genre movie, and what many call the world’s finest array of health care services. For many years, and as part of the benefits package for the world’s most productive labor force, that nation’s employers paid the insurance bills for these services, and all were content until the rate of growth for the costs of health care per capita began to exceed that of the GDP per capita in the late 1990s, 1 and people began to fall out of the ranks of the insured.

That country is, of course, the United States, and this scenario is playing out in a virtual political vacuum. Instead, the private sector is left to struggle to resolve the growing problems created by the above-described dilemma. Hospitals are reeling from subsidizing health care for the uninsured, who are resorting to the nation’s emergency departments for their primary health care. In cities with large uninsured populations like Los Angeles, the problem is no longer confined to the uninsured, as hospitals close and trauma centers are shut down in growing numbers, limiting access to emergency care for all.

Tobacco-settlement lawyer Richard Scruggs is squeezing hospitals from a different flank as he wrests from them agreements to lower the cost of care to the uninsured. And, frankly, there are inherent inequities in a system in which the uninsured must pay at rates that are multiples of those rates negotiated by insurance companies for their beneficiaries. But are the courts the place to resolve the problem? Is not this an issue that deserves a deliberate public health care policy?

This is the defining issue for every health care professional, employee, and consumer in the country because, as described by Reinhardt et al, 1 the factors at play will only deepen the fault lines in our current system over time. Any serious discussion about continuing our current level of coverage as well as extending care must include an accurate projection of its anticipated cost. And in the face of that breathtaking bill, we must inevitably ask the Big Question: Is it time to add cost-effectiveness to our criteria for health care policy? Alan M. Garber’s paper on the subject of considering costs when designing coverage policy 2 lays out the difficulties associated with cost-effectiveness analysis, as well as its value in an environment in which demand exceeds the ability to pay and in which the public is blissfully undereducated regarding the cost of its care.

If we do not address the rising crisis in health care, no one wins: not American workers who must dig deeper to cover higher deductibles; not American business, which is spending more for less care for its workers; and not the government, which faces a declining tax base as more of an employee’s salary is paid in untaxable insurance premiums. What of health care? In some ways, health care has the most difficult job of all. Instead of jockeying for position, the health care professions must put aside petty provincialisms, raise the meaningful questions, and frame the debate.

Cheryl Proval

[email protected]

References:

  1. Reinhardt UE, Hussey PS, Anderson GF. US health care spending in an international context. Health Affairs. 2004;23(3):10-25.
  2. Garber AM. Cost effectiveness and evidence evaluation as criteria for coverage policy. Health Affairs. 10.1377/hlthaff.w4.284. May 19, 2004.