Delivery of Care/Opinion

Rationalization and rationing

In search of the missing ingredients in controlling health care costs: regional health planning at the community level

Image by Steve Ruggieri

Health costs, like climate change, threatens to overwhelm our economy, our infrastructure, and our social relationships, until there is a way to address the root causes and to talk about them.

By Peter Simon
Posted 4/1/19
A reader vents his frustration about the inability to address what he sees as the root causes behind the ever-escalating costs of health care in the U.S.
What is the best way to conduct a conversation to talk about the efforts to create a single-payer health plan in the U.S.? Is there a way to stipulate what the facts are, so the arguments do not get lost in divisive tribal politics? Why is there an absence of news coverage about innovations in health in Rhode Island, such as neighborhood health stations and health equity zones? How would the conversation around health change if the sources of dark money were to be removed from electoral politics?
Rhetorical devices aside, such as promising never to talk about the subject again, the reality is that while all health care is personal and complex, the rapid onslaught from the tangible threats of climate change threaten to overwhelm all of us, no matter where you sit on the totem pole of wealth, status and fame. As humans, there is a need to talk with each other, to learn from each other, to share stories and concerns, particularly as the autocrats among us seek to divide us all into cheering sections. Sharing our personal stories is still our most powerful human trait. Can we talk, and listen to each other?

PROVIDENCE – Well, here goes, the last time you will hear anything from me on this subject.

I hear frequently from people I care about, and sometimes even from those who I do not, about their anger and confusion over the financial assault they are feeling from our “health care delivery system.”

I am losing sympathy for all of them. I am sorry to say that my lack of sympathy comes from their unwillingness to think about the root causes of our problems with providing access to quality and affordable medical services to all of us.

One last try. Here is why our costs keep rising despite what our leaders would have you believe about their solutions to this “wicked” problem. There are three forces driving the increasing cost of services:

Our aging population with increasing rates of chronic diseases;

Increasing investment in biomedical interventions that cost a bundle and often yield little to increase our quality of life and longevity by trivial amounts; and

Avarice and hubris. Prices are increased for the same drug or service just to put more money into hands at the top of large institutions in control of access and finance.

Equally bad news
As Walter Mondale once told the American people about his plan to raise taxes, I have equally bad news. Costs will always rise under the forces described above. Yes, we can try to figure out ways to expand access to insure those who remain uninsured and perhaps even make their co-payments and deductibles more affordable, but the only way we will see real changes in the economics of health care is with rationalization of our delivery system’s capacity and rationing of high-cost services.

We knew all this 50 years ago. There actually was legislation created by Congress to address the rising cost of medical care. It was called the “Regional Medical Program,” or RMP, a program of community health planning that included all the medical resources available in a region that might be mobilized to meet a specific medical objective.

The RMP was authorized under the Health, Disease, Cancer and Stroke amendments enacted by Congress in 1965. It died prematurely at the hands of the Nixon administration; Reagan followed up with the elimination of all federal assistance to create comprehensive health planning in the U.S.

Regional planning under the RMP was the target of a powerfully financed communications effort to convince us that government was the problem and not the solution to this or any systemic problem in our country. We are now seeing the same effort to destroy other systems, but I digress.

Health for all?
So, if we want health for all, we need a plan, probably one for each of multiple levels of service: community-based services to acute hospital care. It won’t happen, however, in my lifetime. I know this. I am not happy about it, but I have decided to not let it make me crazy.

I want to apologize to all who have seen my anger and frustration in social situations when I allow myself to be sucked into participating in such discussions.

Next time someone tries to get me to discuss the high cost of care, I am planning on changing the subject; perhaps to the future of our Red Sox, or whether Robert Kraft should be allowed to continue to own the Patriots. I am making a list.

Dr. Peter Simon, a retired pediatrician, is a frequent contributor to ConvergenceRI.


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Ted Almon

Dr. Simon is essentially correct of course, but how is it that the richest country on earth cannot afford to provide the near universal care that all other advanced countries seem to manage, and with results that are superior to ours?

Could it be that we are the only country that insists that providing health care to our people is a business? I suspect that most other countries recognize that providing a service that many citizens cannot afford is a Social Program--not a free enterprise endeavor. The rich must pay for the poor. The healthy will pay for the sick, the young for the old, etc.. How difficult can it be for us to accept this? Our refusal to do so means that financing our system is incredibly fragmented, giving rise to countless pockets of profitability to all sorts of private participants who will fight like hell to preserve their place at the trough. .

Like Dr. Simon, I too am retired after more than 40 years of this same discussion, and I too am tired of it. It won't happen in either of our lifetimes I'm afraid.

Monday, April 1

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