Health Care Reform? Or Health Insurance Reform?

I had an interesting conversation last night that was quite possibly the best (and quite possibly the only) good argument I've heard against the ACA (the artist previously known as #hcr). The argument was essentially that the law achieves a laudable goal—insuring over 30 million new Americans—but without reforming all of the problems with actual health care. As a result, we'll simply have 16 million people buying into an already expensive and inefficient Medicaid system and another 16 million or so using government subsidies to buy health insurance that is grossly inflated in price. Moreover, there is already a shortage of primary care physicians in this country, so people will not get more preventative care; newly insured people will more likely go to specialists who will simply order needless and expensive tests. Costs will continue to rise, and not much benefit will be gained. Result: While more people will be insured, the ACA has the effect of expanding an already broken system.



In this person's opinion, this article from the New Yorker last year explains the problem. Payment to doctors is based on procedures, not outcomes. As a result, doctors have the incentive to spend money on needless tests, for two reasons. First, when all you have is a hammer, everything looks like a nail. Second, doctors have a cover-your-ass mentality because of evil lawyers (like yours truly). According to that article, about half of all medical procedures seem to provide no health benefit, and—because all procedures have risks—can even be detrimental to health.

Reforming health insurance is important, to be sure, but real health reform requires changing things on the ground. It means incentives to get people to become primary care physicians instead of specialists. It means encouraging the use of evidence-based medicine, instead of a dart-throwing approach. It means encouraging hospitals and community organizations and medical groups to switch to a payment system where doctors are salaried, or where they are paid based on outcomes, not on procedures. Until this happens, expanding health insurance is just expanding a broken system.

This has not changed my view on the ACA; I still think it was a good law to pass, but this is just something to keep in mind, because my generation will still collectively go bankrupt on health care if we don't fix it.

Next up: Tort reform.