As the health reform debate moves to the final round, it's important to remain focused on the goal. There are numerous other issues seeking to divert our attention from the key goals of the effort. There were two:

1. Healthcare for the uninsured.

2. Reduce expenditures for healthcare in the U.S.

Clarifications:
1. Many decry the fact that there are uninsured people in this country. In our culture, healthcare equates to health insurance, so those without insurance have trouble getting care. With all that we have, surely we could provide healthcare/health insurance for everyone. So for a variety of reasons, one goal of health reform is healthcare (insurance) for everyone.

2. For a perspective on the expenditure problem, reference Peter Orzag's work, particularly his writing about Medicare. Given the current trajectory, Medicare will consume all of the discretionary spending of the federal government in the foreseeable future. Not good, so this is a worthy goal.

Unfortunately, there are many distractions on the way to reform. Some are peripheral issues that are indeed important but not related to the key goals, above. Some are created by opponents of any reform who seek to delay the process by offering distractions that divert attention from the key goals. Here is a partial list:

1. Abortion. Sorry, this was never on the agenda. It's a legal part of healthcare and doesn't consume large amounts of money. Forget it.

2. "Lies." Sorry, the current legislative proposals do contain wording to prevent reform money from being used to provide healthcare for illegals. Reasonable people might argue that there are no provisions for enforcement, but reasonable people don't shout insults in a public meeting. Besides, the rules for enforcement are typically written by the Secretary of the relevant bureau (in this case, HHS) after the legislation has passed. And that usually after a period for public comment. Besides, there are some compelling arguments that illegals should have healthcare. These are the folks who wash dishes in the restaurant where you ate last nite or drove the taxi you took from the airport. Don't you want to know if they have Tb?

3. Technology. viewed by some as a key to paying for reform. Buzzer! Last time I looked, IT cost money. Big money. Many advantages to electronic records, but if it were truly cost effective, everyone would be doing it already. Lots of clever and convenient tricks, but saving money is not one of them. My history with IT goes back to mainframes and Hollerith cards, and I love it. Don't oversell it.

4. Insurance. A complex issue here. Insurance reform will be part of any solution, but it is NOT the problem. Yes, insurance executives do some pretty egregious things (I hear they can't shave in front of a mirror), but insurance, per se, tends to mimic costs of healthcare. And that's the problem. Healthcare costs too much. Bring down the cost of individual healthcare services, and you should see the costs of insurance fall, particularly if we allow competition across state lines.

5. Prevention. Nice idea. I'm all for it, but it doesn't save money. Some still think it might in the long run. Maybe. One current idea is targeted surveillance--only do the tests in high-risk groups. Anyone for genetic testing here? With a family history of colon cancer, you may rate a colonoscopy. Otherwise, fecal occult blood will do. Yes, we'll miss a few, but that's statistics for you. From a population health standpoint, it doesn't pay to test everyone. However, if you have enough money, you may want a colonoscopy every 10 years and be willing to pay for it yourself.

6. Bundled care. Your views on the package deal approach depend on where you where you sit. Those in closed panel HMO's (like Mayo or Kaiser) love the idea. They are better able to take advantage of it, since they own the whole production line. Otherwise, it's a hard sell. Will it save money? Not clear. Mayo and Kaiser will try to make sure that doesn't happen. Possibly a partial solution in some local areas, but not an easy fix for the system.

7. Disparities. The idea here is to take the Dartmouth atlas and make every community look like the low cost areas they have identified. What they don't say is that the unit cost of healthcare services doesn't vary that much. Some areas just provide more care than others. Gawande's article drew attention to McAllen, TX as a high cost area, and yes, the cost per resident is very high. But the utilization is also very high. The unit cost is reasonable; they just do a lot more healthcare in McAllen, TX. Reducing the amount of healthcare provided would certainly reduce the total expenditures. That's what rationing is all about. This is what HMO's did in their early years. Certificate of Need laws were based on this philosophy--rationing resources. They didn't work and have been abandoned in most places. CON laws are anti-competitive and thus subject to graft and corruption. Some countries limit the number of providers. A U.S. physician can't just move to another country and set up practice. We might try closing a few medical schools or limiting the number of residency slots in surgical specialties. Those would be popular ideas.

8. Disease management. Another in the list of promising ideas that sounds as if it should work. I was sold. The thought is to teach patients how to manage their own chronic disease (diabetes, asthma) and do this with low cost providers. The needs for expensive healthcare services would thus be minimized and costs would go down. But they didn't. Maybe we're just doing it wrong. At any rate, it's not a magic bullet.

There are others, and I may revise this posting from time to time.

Looks like nothing works! What can we do! Well, if I were King, . . . . no, you wouldn't like it. No one would. That's what makes reform difficult.