The infuriating reality of healthcare is that it must be run in a systematic way, and that one aspect of that system must be policy (the other 2 are clinical and business). And of course, policy means that politicians ultimately weigh in and “decide” things fundamentally outside their areas of expertise. Not known for consistent fiscal brilliance, their stamp on healthcare often means that much of the downstream effects of legislation consist of crisis management aimed at containing the clinical or economic ruin the legislation overlooked during the planning phase.
Before we go into the latest example of how the new healthcare legislation is spilling over its banks (or causing a run on them?), there is a gem of a quote from the seminal movie A Man for All Seasons about a statesman with an unswerving conscience and a brilliant grasp of natural law, who insisted that his government’s legislation conform to this reality. He was Sir Thomas More, and you guessed it, he was executed for his stance. The issue then was the proposition that a king should run the only church allowed in the country of England. When “asked” to sign the oath of allegiance, Sir Thomas refused. His logic bears repeating at every session of Congress: “Some men think the Earth is round, others think it flat; it is a matter capable of question. But if it is flat, will the King’s command make it round? And if it is round, will the King’s command flatten it? No, I will not sign.”
For policymakers in Congress and the White House responsible for the Health Care and Education Reconciliation Act of 2010 (HCERA), their incentives and areas of knowledge are showing signs of detachment from those of the stakeholders in the rest of the country, whose job it is to carry out the legislation. One wonders if they have really asked themselves whether this legislation is founded on their view of desirability without evidence of its compliance with natural laws of economics and medicine, which owe no allegiance to any officials, elected or appointed—laws that will ultimately supersede any man-made fiat.
The latest round—it is increasingly fitting to evoke boxing imagery when describing interstakeholder dialogue—involves Kathleen Sebelius, Secretary of the US Department of Health and Human Services, warning Karen Ignagni, the health insurance industry’s top lobbyist, that health plans must not raise their premiums to cover increased costs occasioned by the HCERA. Her proclamation gives rise to concern that Ms Sebelius may be dabbling in world-flattening legislative attempts: “We will not stand idly by as insurers blame their premium hikes and increased profits on the requirement that they provide consumers with basic protections.”
I do not know if it is the use of the royal “we” that suggests arrogance, or the more troubling wording throughout the rest of that pithy, dangerous sentence. Instead of a neutral question as to whether insurers are “basing” their premium hikes on the HCERA’s new requirements, she leaps to the pejorative “blame” conclusion. This is not dialogue, but the launching of salvos. And the assumptions build as this revealing sentence continues. These business professionals in a free society are now operating under a “requirement” to provide consumers with “basic protections.” The assumption is that Ms Sebelius knows exactly what constitutes such protections, and that they do not fluctuate but are immutable.
Operating on the notion that they practice their trade in a free society, the insurers are daring to ask why they are so required. They obey economic laws that will stand long after this administration is gone, laws that state that increased benefits may be regarded by some as “basic protections” but are by no means inevitable; they must be paid for. And unlike the federal government, which, if it controlled healthcare, could provide (temporarily) these basic protections by devaluing the dollar and printing spurious money to pay for them, private industry can only pay out benefits based on the monies paid into the system from plan members.
The autocracy of Ms Sebelius’s stance goes deep. There is a “let them [in this case, the insurers] eat cake” attitude inherent in her remarks. Somehow or other, insurers must come up with increased benefits without increasing premiums. And the micromanagement of our healthcare, which is what has alarmed Americans ever since this unpopular, ideologically driven legislation was proposed, is something we are expected to go along with, as if sacrificing fiscal sanity for whatever passes as “basic protections” is not subject to debate.
Healthcare is ruled not by any Congress or administration, Democrat or Republican, but by the “iron triangle” of cost, quality, and access. Warp this triangle out of shape, elongate one of its points, and you do so at the expense of the other two.
This world of healthcare, Ms Sebelius, is not flat; it is not even round; it is triangular. And if you want to avoid ruining a marvelous instrument providing care for so many Americans, listen to the other stakeholders and get in-step with the dance that medicine in the free market created. The rhythm is unforced, and it makes a lot of people happy. It is not that business does not want to dance with the policy sector; it just does not want to dance off the cliff.