Beauty Health for Life

"This message will self-destruct...."

The international arm of the Disease Management Care Blog is working on a presentation for the upcoming Hauptstadtkongreß in Berlin Germany.  Its "Mission Impossible" is to explain the U.S. health care system to a group of German hospital executives in a half hour.

This, in a Nußschale, is what the DMCB intends to say, using approximately eighteen PowerPoint slides:

1. While rising health care costs, as a percentage of U.S. GDP, has always been a problem, rising health care costs as a percentage of U.S. debt is widely viewed as a highly significant threat. We mean it this time.

2. The conservative vs. liberal debate over how to reduce health care costs for the U.S. government is ultimately about transferring its insurance risk.  The conservatives want to transfer risk to patients in the form of vouchers, while the liberals want to transfer risk to providers in the form of bundled payments and gain-sharing.  The liberals, so far, are handily winning the debate.

3. Risk is only half the health orm story.  The other half is quality. There is bipartisan consensus that a) U.S. health care quality could be better, and b) greater quality will mitigate insurance risk, resulting in fewer medical complications, emergency room visits and readmissions.
   
4. There is additional bipartisan consensus that a) insurance risk can be managed and b) quality can be increased when care is provided in large vertically integrated and regional provider systems.

5. If the twin exigencies of risk and quality are not addressed in the next 3-5 years, disappointment could lead to the unraveling of Obamacare and the introduction of a public payer option.

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While the physician Disease Management Care Blog understands the logic behind essential health benefit determinations, believes good health care includes access to reproductive services and also knows that an unintended pregnancy poses special threats to a womans health, it also sympathizes with the U.S. Catholic Bishops stand on birth control pills. 

Such is the luxury of cognitive dissonance.  Yet, the DMCBs real discomfort is over the broader health policy implications of defining BCPs as an essential health benefit that must be covered with only a few exceptions:

1. There are really two ultimate paths to a federal takeover health care.  The first is obvious: formal through the "nationalization" of either the payment or delivery of services. The second is de facto is through the creation of laws, regulations and standards that amount to an expanding domination of the payment or delivery of services. From an end-user perspective, the DMCB thinks there is little difference between the two and believes we are underestimating the ultimate end game for this and multiple other rules and regulations.

2. Decision-making like this can cut both ways.  While womens health advocates can take comfort in the Obama Administrations courage in the face of the Bishops push-back, its possible that future hyper-rational, inflexible, evidence-based, legalistic, uniformist and technocratic decision-making like this will result in endless legalistic, politically charged and awkward decision-making that will always vex some big constituency.  This is the same science used to provoke the controversy over the merits of mammography in women less than age 50 as well as prostate cancer screening in men.  To make the point, the DMCB poses this silly but troubling thought experiment:  since men are just as responsible and should be given every incentive to not cause unwanted pregnancy, should condoms be an essential health benefit?  If persons with cancer run out of treatment options, should a right to control their own bodies and its technical availability make assisted suicide an essential health benefit? 

This time it was the Catholics turn.  The next one could be yours.

3.  Without some sort of accommodation (which may be in the works), the Bishops arent going to back down.  While a majority of their parishioners may believe in and have used birth control, that test fails at two levels: 1) societys institutions are supposed to stand for a higher standard and 2) decades and even centuries of religious interpretation are not up for a vote.  Standing for something is what faith is all about and Church leaders are simply not going to roll over on insurance that covers birth control for their employees and theyre not going to offer access to birth control pills in the course of the provision of health care. Their only choice, other than millions in fines is to exit the health care arena.  David Brooks has an excellent discussion of why thats a problem. 

4.  It is said that the art of politics is the art of the possible: to work out compromise where everyone can walk away a winner.  While coverage of birth control pills is a victory for womens health advocates that a "base" can feel good about, this is also arguably a failure for a President who was committed to bridging differences and creating a health care system that had broad support.

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