By Evan Falchuk
So here are some thoughts following my talk last night at the “Israel: A Prescription for Healthcare Reform” event:
1. Yes, we can learn from the health care systems of other countries…but they’re all unique.
Every country’s health care system has developed in the unique circumstances of that country’s economy, culture and history. It’s an obvious, but important, insight, and Israel is no exception.
Israel was founded in 1948, but there were health care organizations in existence there long before that. From the start these organizations were based on the culture of communal self-reliance that characterizes much of Israeli society. From an American perspective, these organizations, called ‘kupot holim’ in Herbrew, look something like an HMO. Today, there are four of these health plans, which provide a basic level of coverage to 100% of the population.
Israeli law requires that all residents join one of these four health plans, which is how they achieve universal coverage. The plans cannot exclude anyone for pre-existing conditions, and are required to provide at a minimum a standardized basket of basic coverage. The plan collect premiums from a combination of the government, employers and the individual insureds, with the extent of individual premium responsibility graduated on the basis of income. Those who earn more, pay more. Many people who can afford it buy supplemental policies on top of these plans.
It seems to function well for Israelis, and includes a greater emphasis on primary care than we see in the United States. From Professor Altman’s description, and that of some of the Israeli audience members, it sounds like it also brings with it limitations on access to specialists, diagnostic testing and medical devices that would be difficult to accept in the United States. And while the system is cheaper as a percentage of GDP than what Americans pay, Israel also struggles with questions of rising health care costs.
2. Regular people are getting very sophisticated about health care reform
The audience of about 100 wasn’t made up of health care wonks, but there were two questions about state versus federal regulation of insurance. If the questions reflect anything about public sentiment, there was a sense of surprise that insurance companies in one state aren’t allowed to sell in another. There was also a question about whether the federal reform will undo the important reforms Massachusetts has done in the last few years. Professor Altman, who spoke on the panel with me, and who has worked on this very issue, seemed to think it was too early to tell. More unintended consequences?
Overall, there was a sense of puzzlement over how our health care system could have ever become so complicated. Professor Altman said it takes him an entire semester to teach the system to his students. I had ten minutes.
3. Health reform in 2009 is about health insurance not health care
There’s little question that some changes to insurance regulation would be helpful. But the soaring rhetoric of reform is terribly disconnected from the reality of the proposals. Maybe this is a good storyline for getting a law passed, but it’s not a recipe for righting what is wrong in our system.
The really important stuff in health care happens where insurance intersects with care, where money mixes with medicine. If the purpose of reform is to save money, we have to change our way of thinking about it. Health care – the relationship between a patient and their doctor – must be at the center of everything we do. But it’s not, and it’s because we keep trying to same old solutions to the same old problems. Medical care too expensive? Pay doctors less. New drugs and technology? Limit their use. No one likes this approach – least of all patients and their doctors. And what’s worse, it doesn’t work.
So, yes, the focus on health insurance reform will lead to many changes, and more complexity. And some day, years from now, someone will be explaining the American system to an audience, and people will wonder, how did anyone ever create a system such as this?
