Something's gotta give in healthcare. As individuals, we can't just go on saying "yes" to every drug, device, test, or intervention that might work. And as a nation, we can't just allow our health bill to continue to climb, bankrupting sick patients and our economy.
The Obama administration promised healthcare reform and all the interest groups—health professionals, drug and device manufacturers, hospitals, the insurance industry, and patient advocates—are at the table. There is broad agreement that something has to change. And change probably requires saying "no" to some things.
Discussions of reform have begun to encounter resistance: While everyone agrees that limits must be set, each party thinks it's the others who should be reined in.
The public is no different. Rather than thinking that reform means increasing limits, we think of it as increasing opportunities: easier access to affordable healthcare services and doctors we can trust to make good use of the best tests and drugs and devices to keep us free of pain and fully engaged in our lives. Far too few of us realize that less care is often better care and we are thus understandably reluctant to say "no" to recommended tests or procedures of limited value.
Reformers and policy experts interested in reducing costs and improving care have some ideas about what we should say "no" to: treatments that have not been shown to work, doctors who err, and hospitals with poor safety records. "No" to expensive new tests and drugs that are no more effective than older, cheaper ones. "No" to extra tests and services that won't improve our health and the quality of our lives.
But a recent Kaiser Family Foundation poll demonstrates that whether the public will agree to "just say no" depends upon who asks.
It found, for example, that we trust our doctor to tell us what tests and treatments we need, but not our health plan or the government. We don't think there is a significant difference in competence among the doctors who treat us and we are more likely to rely on the experience of friends and family over objective ratings of doctors and hospitals. We're convinced that under-use (caused by penny-pinching health plans) is a bigger problem than the overuse of services. And we believe we are already paying too much for care, which we think is costly due to the excessive profits of insurance and drug companies.
Current reform proposals call for everyone—health plans, drug and device manufacturers, physicians, nurses, hospitals, and yes, the public, sick and well—to recognize and accept new limitations.
And so, alas, healthcare reform is about "no," even for us.
As voters, we will determine the success or defeat of this year's reform efforts. But let's not kid ourselves: Our choice is not between unlimited access to all the healthcare we think we need and draconian government intervention. Rather, we either learn to accept explicit, evidence-based limitations in plans, providers, and treatments, or we continue to accept limitations to care based on de facto rationing of access (growing numbers of uninsured, under-insured, and medically inspired bankruptcy) and treatment (increasingly constrained benefits packages that restrict what treatments they will cover)—accompanied by steadily increasing costs.
We have to say "no" to one of these options. Something's gotta give. Which "no" is it going to be?
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Corrected on : Jessie Gruman is president of the Center for the Advancement of Health.