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In the midst of a rancorous health care debate, don’t forget these three lessons Minnesota has learned

REUTERS/Jim Bourg
We know change is coming.

We are all exhausted by the back and forth of health care news. It’s hard for even those of us who work in in the field to keep up. Proposals for sweeping change create a gnawing worry about how — or whether — our medical bills will get paid next year, or next month.

Jim Schowalter

It’s easy to lose sight of the big picture, which is very big. Right now, we are in the process of reinventing how we get and pay for care, in Minnesota and nationwide.

We know change is coming. We said it in a State Budget Trends report and pretty much every Task Force of the last decade. Fortunately, working on health care isn’t new for Minnesotans. We’ve tried ideas that worked and others that failed. In the process, we have learned a thing or two about ourselves. These are lessons we can’t ignore.

1. The more of us who have health insurance, the better off we all are.

As a state, we have made immense progress toward making health care available to everyone. The number of Minnesotans without health insurance has dropped by about 200,000 since 2013, saving hospitals more than $50 million in charity care. We’ve brought in about $2 billion of federal health funding, which works directly to keep our friends and neighbors well.

Right now, policymakers are working on a number of urgent problems: how to stabilize the market for individual health insurance, how to ensure that people can get care where they live and how to tame the soaring cost of prescription drugs. These issues are important and need attention. But remember that to get care or prescription drugs, Minnesotans need health insurance. It’s not perfect, but insurance is step one in getting everyone the care they need.

2. Health care is more expensive than Minnesotans can afford.

The debate is so heated because nobody — government, business, household — can really afford to pay more for care. Nine out of ten Minnesotans have health insurance through their employers, or through government programs like Medicare or Medicaid. For years, most of us never thought about how much an X-ray or a course of antibiotics would cost, because we weren’t paying for it — not directly. For many years our employers, government and insurance companies pretty much took care of things for us.

That’s changed and continues to change quickly. We all have been asked to foot the bill for a growing share of our medical bills. We’re paying higher premiums, higher deductibles and higher co-pays.

When one person’s medical bills can increase everyone’s premiums by $5 a month, we can easily see the need to share expensive care broadly. Yet at the same time, lawmakers are hearing proposals that would raise costs. It still has not sunk in that high medical bills were the problem before the ACA, are the problem under the ACA and would still be under the ACA replacement bill just released by the U.S. House of Representatives. Long-term, settling on the financing is just an initial step that gives us all a chance to examine health care expenses and figure out how to lower the bills.

3. Get the incentives right.

Big questions defy easy answers. Even though we’re tempted to look for a silver bullet or a painless solution, no single change will solve our health care problems. None of us are that smart or can think of all the “what if” scenarios that take place in the real world. As a result, we have to focus on setting up the right incentives and let everyone do their job.

This is especially true in health care, where lives are at stake and we want to get the best care. But “best” means balancing many things including our individual preferences along with the science, cost and uncertainty of treatment.  Rather than laying out ambitious ideas and assuming all the complicated moving parts will fall into place — as we did with MNsure systems — it’s vital to plan thoughtfully for the complexities of any change, and to promise only what we’re sure we can deliver.

There is a virtue to thinking big. But in health care, there’s a greater virtue in careful planning. Let’s not subject Minnesotans to the pain of repeating old mistakes.

Jim Schowalter, former commissioner of Minnesota Management and Budget, is president of the Minnesota Council of Health Plans.

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Comments (4)

Lesson 2A

An addendum to Lesson 2 above would be: We cannot afford, individually or as a society, to pay for every potentially-helpful treatment for every individual. There's no free lunch, and just because I don't know how much that x-ray or broken leg or ER visit cost doesn't mean it's without cost. It just means that someone (actually everyone else) has to pick up the slack for what I don't pay.

I would argue, Don Quixote-like, that it's largely because we have a profit-driven health care system, where everyone who provides me with care, medication, or any other health-related service, does so not to make my health better or prolong my active life, though that may be a part of the equation. They provide those services because they're all obliged to make a living from health care, and they have their own families to feed, car payments to make, etc. Every other industrialized nation has a better (i.e., less expensive, more effective) health delivery system than we do, but, Ostrich-like, we will continue to behave, even if we don't really believe it, as if this is the only possible health-care world possible, and/or that what we have is absolutely the best that humans can devise. It's a delusion, but it's OUR delusion…

well said

Part of the self-interest problem are the health insurers, which employ this author. Over many years, the insurance-based mechanism of controlling costs through the use of negotiation with limited provider groups has simply failed to meet its objective. This author represents the failed solution of the past and cannot be trusted to support the necessary reforms that have been well demonstrated throughout the world.

Using principles to make decisions

Thanks for suggesting we need to consider things other than political advantage and self to design health care, as those things will never create a stable high quality system that we can afford.

Trump actually said that everyone needs coverage, but where is the evidence that he believes. Obama was frustrated to cover only half of those with insurance, largely a result of Republicans resisting expanded Medicaid. Republicans are willing to start by allowing 20 million to lose coverage and have done nothing to show they understand that everyone. Their plan actually mainly gives huge tax cuts to very profitable medical device companies and the top 1% of households.

Idea two is that no one can afford healthcare. republicans also deny that idea, thinking that we just need to focus our money on the deserving, Republican voters with private insurance, by taking benefits away from poor Democrats. This is another flaw. It is unaffordable because lots of unnecessary care is provided to great profit and little obvious benefit,

That gets to the idea of rewarding what works. We pay for process not outcomes, That is like running schools to make sure students are always present, even if they aren't learning. Great care that has no positive clinical outcome is a similar thing. What is the benefit of keeping people alive longer who are suffering their way to death? We pay a lot to do that.

Politicians should not be design reform. Those who provide and receive it should. Of course, when the designers don't intimately know their subject, it will be a mess.

What time will the

What time will the Republicans allow for a debate of healthcare changes? What I read is that Mr. Trump wants the whole thing passed by the end of next week at the latest (not thqt he undertands what he's talking about in the first place, sadly).

One of the outrageous ignorances the public has about Obamacare is how much it tries to shift the way healthcare is delivered, including moving from wasteful pay for procedures to a team system where only what's necessary gets done, and done only once! Removing redundancy, removing the perverse incentives providers have to multiply procedures (giving colonoscopies to someone who's already dying of brain cancer, for example), and providing incentives for routine preventive medicine for all that will reduce the need for heroic interventions.

Showalter is right to focus on the cost of health care being the major problem. Of course no one remembers how quickly health care costs were going up before Obamacare!