In all the conversation surrounding health care reform, we have failed to ask a very simple question: Is increasing access to health insurance the best way to improve access to care? A writer for the Atlantic begs to differ.

In the provocatively titled "How American Health Care Killed My Father," business executive David Goldhill explains that his journey deep into the darkness of health care reform came after his father died of ailments he acquired in the hospital. Goldhill, astonished by some of the hospital practices, began paying very close attention to discussions of medical procedures and errors:

"About a week after my father's death, The New Yorker ran an article by Atul Gawande profiling the efforts of Dr. Peter Pronovost to reduce the incidence of fatal hospital-borne infections. Pronovost's solution? A simple checklist of ICU protocols governing physician hand-washing and other basic sterilization procedures. Hospitals implementing Pronovost's checklist had enjoyed almost instantaneous success, reducing hospital-infection rates by two-thirds within the first three months of its adoption. But many physicians rejected the checklist as an unnecessary and belittling bureaucratic intrusion, and many hospital executives were reluctant to push it on them. The story chronicled Pronovost's travels around the country as he struggled to persuade hospitals to embrace his reform.

It was a heroic story, but to me, it was also deeply unsettling. How was it possible that Pronovost needed to beg hospitals to adopt an essentially cost-free idea that saved so many lives? Here's an industry that loudly protests the high cost of liability insurance and the injustice of our tort system and yet needs extensive lobbying to embrace a simple technique to save up to 100,000 people. "

And what about us-the patients? How does a nation that might close down a business for a single illness from a suspicious hamburger tolerate the carnage inflicted by our hospitals?

After running through a litany of complaints about everything from the nature of a hospital to "the ponzi-scheme financing" that we call insurance, Goldhill ultimately explains that because of a series of oversights and accidents, our current system is FUBAR:

Accidentally, but relentlessly, America has built a health-care system with incentives that inexorably generate terrible and perverse results. Incentives that emphasize health care over any other aspect of health and well-being. That emphasize treatment over prevention. That disguise true costs. That favor complexity, and discourage transparent competition based on price or quality. That result in a generational pyramid scheme rather than sustainable financing. And that-most important-remove consumers from our irreplaceable role as the ultimate ensurer of value.

Instead, Goldhill proposes focusing on the other, related societal issues that may improve heath in a more direct way than providing more access to insurance. He recommends strategies that involved direct government regulation (i.e. setting a fixed price or price range for hospital services, so that when you break your leg, you'll have an idea of what it will cost to fix), being more transparent about procedures and costs (like in the case of Lasik surgery), by shifting the role of "customer" back to patients and not health care companies, and looking at alternative methods of financing care.


His ideas seem interesting - all the way until we got to the part about how to fund this.

How would we pay for most of our health care? The same way we pay for everything else-out of our income and savings. Medicare itself is, in a sense, a form of forced savings, as is commercial insurance. In place of these programs and the premiums we now contribute to them, and along with catastrophic insurance, the government should create a new form of health savings account-a vehicle that has existed, though in imperfect form, since 2003. Every American should be required to maintain an HSA, and contribute a minimum percentage of post-tax income, subject to a floor and a cap in total dollar contributions. The income percentage required should rise over a working life, as wages and wealth typically do.

All noncatastrophic care should eventually be funded out of HSAs. But account-holders should be allowed to withdraw money for any purpose, without penalty, once the funds exceed a ceiling established for each age, and at death any remaining money should be disbursed through inheritance. Our current methods of health-care funding create a "use it or lose it" imperative. This new approach would ensure that families put aside funds for future expenses, but would not force them to spend the funds only on health care.

What about care that falls through the cracks-major expenses (an appendectomy, sports injury, or birth) that might exceed the current balance of someone's HSA but are not catastrophic? These should be funded the same way we pay for most expensive purchases that confer long-term benefits: with credit. Americans should be able to borrow against their future contributions to their HSA to cover major health needs; the government could lend directly, or provide guidelines for private lending. Catastrophic coverage should apply with no deductible for young people, but as people age and save, they should pay a steadily increasing deductible from their HSA, unless the HSA has been exhausted. As a result, much end-of-life care would be paid through savings. [...]

For lower-income Americans who can't fund all of their catastrophic premiums or minimum HSA contributions, the government should fill the gap-in some cases, providing all the funding. You don't think we spend an absurd amount of money on health care? If we abolished Medicaid, we could spend the same money to make a roughly $3,000 HSA contribution and a $2,000 catastrophic-premium payment for 60 million Americans every year. That's a $12,000 annual HSA plus catastrophic coverage for a low-income family of four. Do we really believe most of them wouldn't be better off?

Some experts worry that requiring people to pay directly for routine care would cause some to put off regular checkups. So here's a solution: the government could provide vouchers to all Americans for a free checkup every two years. If everyone participated, the annual cost would be about $30 billion-a small fraction of the government's current spending on care.


While I agree with the idea of paying more up front and out of pocket (many of us without insurance already do this, without the attendant benefits of lowering the price), the idea mandatory HSAs and financing large expenses through credit kind of creeps me out. But I do like the idea of taking a longer view at what health care should be, outside of the bounds of insurance.

How American Health Care Killed My Father [The Atlantic]