The 2024 Republican presidential hopefuls will gather on September 27th at the Ronald Reagan Presidential Library in Simi Valley, California for their second debate. With the Iowa caucuses just four months away, the stakes for this rendezvous will, again, be exceptionally high. But if this forum is a repeat of the first performance in Wisconsin, it will be another missed opportunity for the candidates to address the dire state of U.S. healthcare delivery.
Last month, eight GOP candidates gathered in Milwaukee for their inaugural debate. They fielded questions on a host of pressing domestic and international issues ranging from inflation to taxes & spending, crime & drugs, climate change and the war in Ukraine. One candidate was even asked about the role of the government in leveling with Americans about UFO encounters–leaving him dumbfounded. Unfortunately, amidst this diverse array of topics, not a single healthcare question emerged. In fact, the word “healthcare” wasn’t uttered once during the two-hour examination. In a country where healthcare expenditures account for almost 19% of gross domestic product (GDP), and while our current healthcare delivery system is in a state of critical condition, this omission is deeply troubling.
Today, healthcare spending and health insurance costs continue to skyrocket, and all stakeholders in the healthcare delivery system—providers, payers, drug manufacturers, and consumers—are grappling with the negative impacts of fierce economic, regulatory and competitive pressures. Debate moderators, therefore, cannot afford to let those vying for the nation’s highest office evade this critical issue. This is especially true when what we do know about some of the candidates’ positions indicate that they truly do not understand what it’s going to take to fix a broken system that has been beyond repair for years. And, that goes for candidates on both sides of the aisle.
Most of the major 2024 Republican contenders have thus far advocated for less government intervention and increased transparency, competition and consumer choice. This stance contrasts starkly with President Biden’s ambitious agenda. As I recently discussed, the Democratic frontrunner continues to champion the ill-conceived Affordable Care Act (ACA) as a means to try and lower healthcare costs. He is also leveraging his signature legislative achievement, the Inflation Reduction Act (IRA), to rein in the “greedy” pharmaceutical industry by attempting to lower the high cost of prescription drugs through price negotiation–which was the subject of my last column.
Regardless of one’s political affiliation, one thing is clear: these reform proposals and plans will not bring us any closer to the universal desire for “better health outcomes at lower cost.” As a result, frustrated consumers will continue to bear the brunt of past missteps and an ongoing failure to envision real change.
My journey to complete my last book, “Bringing Value to Healthcare,” and its prequel, “Healthcare at a Turning Point: A Roadmap for Change,” began in the summer leading up to the 2008 presidential election. As I closely observed the candidates’ discussions on healthcare, the increased use of health information technology (HIT) was often offered as one solution to repair a healthcare delivery system that was fragmented, confusing, opaque, expensive, and sometimes outright dangerous. However, this approach completely missed the mark because IT wasn’t the root cause of the system’s problems. A more fundamental issue persisted—a perverse fee-for-service (FFS) payment model.
Under this “test more, treat more” FFS approach, hospitals and other providers adopted a production mentality, which led to overutilization, uncoordinated care, and declining quality. Consumers, who were totally unaware of the costs associated with their care until recently due to price transparency rules, thus began demanding more medical services and drugs, thanks to generous employer-sponsored health plans. Manufacturers capitalized on public ignorance by relying on mass advertising for blockbuster drugs, while neglecting to make a clear case for the true value of medicines and drug innovation. Payers, in turn, contributed to the ethical decline of the entire healthcare sector through their payment practices and business decisions related to providers.
All stakeholders share blame in this chaotic healthcare landscape. At this point, many of these issues are entrenched in a complex system which is why efforts to fix the landscape–whether by trimming around the edges with band-aid fixes as the Centers for Medicare & Medicaid Services (CMS) has done with only modest success, or a full-on heavy-handed regulatory approach, as we’ve seen with ACA and the IRA–has been a 40-year effort in futility.
Today, the tragic consequences are evident everywhere. Our nation is sicker than ever as the chronic disease epidemic continues to spiral out of control. We have shortages of primary care physicians, nurses and other clinicians and even basic drugs and medical supplies. Hospitals and other providers who wrongly assumed that holding on to FFS could weather the Covid-19 tsunami made a disastrous miscalculation. This resulted in more than a million lives needlessly lost, while hospitals financially hemorrhaged–for which they are still paying a heavy price. On the regulation front, The Biden Administration is now targeting short-term health insurance in an effort to save the beleaguered ACA. And, since the IRA’s passage last year, a number of pharmaceutical companies have scaled back their R&D portfolios, which means fewer life-saving drugs coming to market. As this damage unfolds, stories of patient-consumers needlessly suffering and even losing their lives because of an inability to access life-saving cures will become increasingly common.
Before the last presidential election, I wrote about why we cannot fix healthcare by arguing at the margins. What we urgently need is leadership to develop a more strategic and comprehensive approach for healthcare delivery and all of its participants. This means creating a new market-based model built on a foundation of transparency (in cost and quality) and accountability (in tying payment to outcomes across the continuum).
There are no easy answers to get us to a new and necessary destination, but we can better assess the candidates by asking critical questions. Do you have a comprehensive plan to fix a broken healthcare delivery system and if so, what does it entail? How do you intend to address the disconnect between transparency, quality, and cost across the continuum of care? How will you break the cycle of resistance to change by providers and payers? What is your view of the role of the government in healthcare delivery? And, should the government be negotiating drug prices to lower costs? If we don’t ask our candidates these questions–and soon–we risk jeopardizing all that is special about healthcare delivery in the U.S.
President Ronald Reagan once told Congress “health care costs are climbing so fast they may soon threaten the quality of care and access to care which Americans enjoy.” Reagan’s warning back in 1983 is even more pertinent and dire today. It is imperative that this debate prioritizes the topic.
With the U.S. healthcare system buckling under the weight of its own failures, we must demand more and deserve better than discussions about UFOs.
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