How much Change in Health Care?

Obama came to Washington promising change. The notion of change however is always abstract. Now the question arises, how much change do you want in health care?

The Washington Post today has two opinions from two worthwhile writers. The first is Dan Balz, the dean of the press corps. In his article, Balz balances a notion that Obama overstepped his bounds, but also makes note that even if he chose a more modest route, that would not mean success. Delay can kill proposals, and even delaying health reform until after 2010 or until a second term could mean nothing would happen there too. Balz points to the delicate balance of having an ambitious agenda, but also understanding the limits.

Those limits are what come into focus in Ezra Klein's piece in the Outlook section. Here he argues that what Obama is seeking to do is far more limited than a remake of the system. It lies in the tension in the polls. People want health reform, but they want to keep their coverage. In some sense, there is a weird status quo bias that we seem to have. However, as a result, the change that people want, which is more choice, actually does not come. Most people still keep their employer sponsored insurance (ESI), and they cannot change it if they are in a large employer. They are stuck. Such is the schizophrenia of trying to walk the line that Balz points to, which is utterly necessary.

Finally, there is the New York Times "Week in Review" piece by David Leonhardt. Here the crux of his point is that the very people we tend to trust, doctors, are also split on this matter. Here again, radical change would lead toward a panel that would look at comparative effectiveness data and look also at costs when making reimbursement decisions. The so-called IMAC proposal would lead to a better sense of cost control. However, many people are wary of the government entering into the doctor-patient relationship, even if doctors may order procedures, because they may be good for the patient, but these procedures also happen to pay very well. Here too we see something odd going on, doctors are fighting doctors, with the procedure heavy specialties like surgeons or radiology going against the more primary care type doctors like family practitioners or OB-GYNs.

So, where does this leave us. I think what each of these articles reveals is the total schizophrenia in our public opinion when it comes to health reform. We want things to stay the same in some sense but have expansions of coverage. We want to lower the costs, but we also want the way our doctors work to remain in place. It is as if we the public do not have a clear crystalized view of what we want.

It is scary. Indeed, change unlike what Mr. Obama said is something we feel ambivalent about or even dislike. We are creatures of habit. Our minds have evolved to handle certain circumstances and radical change of complex systems that involve many moving parts and long-term probabilistic thinking, which is what is health care (and for that matter a lot of our problems are about). On some hand, I think people logically know that we cannot continue in our system as it is. Yet, never underestimate fear of the unknown.

So, thus lies our schizophrenia. It is in some sense situational. We do not act like rational dispositional actors. Instead the situation around us, and our own internal situations, dictate what is going on.

This is not to say that I am pessimistic about reform. I still think it will come, and I think we will have important but modest change. Unfortunately, if we do not do this, we will have disaster down the road.