The Five Big Health-Care Dilemmas

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It might make sense for Congress to turn over that power to an independent agency, something along the lines of the Federal Health Board proposed by former Senate majority leader Tom Daschle, who had been Obama's choice for Health and Human Services Secretary until he withdrew his nomination amid a controversy over unpaid taxes. Conservatives charge that this would put Washington in the middle of decisions that are best left to doctors and patients. But would Americans really find a faraway government bureaucrat any more objectionable in that role than a faceless private insurance company that makes those decisions now? Either way, Congress is going to want to have a say in shaping the benefits package. What still needs to be resolved is how much congressional involvement it makes sense to have.

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5. How will we bring down costs?
The problem with American health care, those who have studied the system will tell you, is not that we get too little care but that we use too much. By some estimates, as much as 30 cents of every health-care dollar is spent on medical treatment that is unnecessary, ineffective, duplicative or even harmful. Changing all that is going to require revamping health care from top to bottom, starting with the way health-care providers are reimbursed. While the current system pays them for the amount of care they provide, real reform would put more emphasis on the quality of that care and the outcomes it achieves.

If there is an ideal out there, Baucus says, it can be seen in the kind of medicine already being practiced by Kaiser Permanente, the Mayo Clinic, Intermountain Healthcare and Geisinger Health System, which manage to hold down costs and get better results. Their operations have fostered closer teamwork among care providers. Also important will be electronic record-keeping that saves time and avoids errors, and comparative-effectiveness research that gives doctors and patients a better sense of which treatments work best. And a reformed health-care system would put more emphasis on preventive care and managing such chronic conditions as asthma, heart disease and diabetes that now account for 75 cents out of every medical dollar spent. All these things would force a cultural and economic revolution on the health industry — and the patients who depend on it.

Can this country really afford to reform health care? What everyone seems to have concluded in the past five years is that we can't afford not to. When Washington punts on health care, it only becomes more difficult to fix the system the next time it tries. "The reason why we're going to pass it," Baucus says, "is we're not going to have this opportunity again."

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