NEJM | Perspective on Physicians and Healthcare Reform

The NEJM recently published a slew of  articles on healthcare reform. Here's two.

From Achieving Health Care Reform — How Physicians Can Help (Fisher ES, Berwick DM, Davis K.)

Two threats in particular put reform at risk: conflicting doctrines (regarding the creation of a new public insurance option and government support for comparative-effectiveness studies) and opposition to change among some current stakeholders. In the face of this uncertainty, physicians have a choice: to wait and see what happens or to lead the change our country needs. We'd prefer the latter.

Physicians should first help to create a shared vision that could overcome doctrinal divides — and bring providers together to create a system better aligned both with public needs and with providers' fundamental interests and values. The starting point is to recognize, as most physicians do, that improving a complex health care system requires action on multiple fronts. In its landmark report Crossing the Quality Chasm, the Institute of Medicine (IOM) described a "chain of effect" that links systems at four different levels as the interrelated determinants of health care quality that must be aligned for reform to yield the desired results.

The first level is aims. For health care reform, we propose that physicians, through their advocacy, help lead the country to embrace the so-called triple aim: better experience of care (safe, effective, patient-centered, timely, efficient, and equitable), better health for the population, and lower total per capita costs.¹

A Win–Win Approach to Financing Health Care Reform (Jonathan Gruber, Ph.D.)

There are a number of possible sources. One is reductions in existing government spending on health care through cost controls. President Barack Obama proposed more than $300 billion of such cost controls in his budget, but it is not clear that either politicians or providers have the appetite to go further. Another is increased taxation of "sin goods" — cigarettes, alcohol, and high-sugar or high-fat foods that cause obesity — whose use raises the cost of health care for all Americans. These taxes make sense, yet it is difficult to raise sufficient revenues from them. The government can also look outside the health care system to increased revenues from taxes on carbon emissions or on other goods and services. But this approach would involve expanding the fight over health care into other realms, compounding the difficulty of passing any legislation.

There is one final potential source: the elimination or limiting of the income-tax exclusion for expenditures on employer-sponsored insurance. Ending the massive tax subsidy for such insurance would result in both the most natural source of financing for health care reform and one of the few that is clearly large enough to finance the necessary subsidies.