As health-policy wonks, we're as excited as kids on Christmas that comprehensive health reform is back on the national agenda. Our experience tells us that reform proposals are often replete with "silver bullets" -- quick and easy ways to fix our complex and increasingly costly system. The Clinton's 1993 Health Security Act "solved" the cost issues with a national board enforcing global budgets, moving money around like puppets on a string. Such concepts were rejected not by interest groups, but by many of us who knew they wouldn't work.
The Star Tribune's Dec. 15 editorial "Could U.S. board curtail health costs?" offers up the 2008 silver bullet -- an "independent Federal Health Board" with sweeping powers to overhaul Medicare, Medicaid and possibly the private health care delivery system, too. The board could make an "end run" around Congress to make "unpopular" decisions to rein in costs. Since Congress has "had its chance," we should turn over regulatory and administrative control to an unrepresentative body.
It's an old canard that the devil is in the details. But it is true, which is why few details exist around any of the proposals for independent health boards. Here are some red flags:
•"Independent" is another word for unaccountable. Yes, the board may be insulated from greedy special interests, but it would also be insulated from us. We are both the beneficiaries of public programs and its financiers through our payroll and income tax contributions. We the people have a serious stake in access and affordability, which we ought not delegate to an unaccountable board.
•"Independent" isn't better. Proponents of an independent board often cite the Federal Reserve or the SEC as models. The current financial meltdown has taught us that they are not truly independent from politics, nor do they guarantee adequate oversight, and they may not work in the public interest.
•We already have a model that will work. Public servants in agencies within the federal Department of Health and Human Services have all the expertise necessary to develop new payment models and provide incentives for cost-effective care. They have lacked resources and direction. They have most importantly lacked leadership -- of the kind that former Sen. Tom Daschle, the HHS secretary-designee, will provide. And leadership that President-elect Barack Obama has already demonstrated.
Today's elected officials seem too eager to dodge responsibility for decisions that are difficult and have significant consequences. The public knows that we are all paying too much, that we are settling for a system that too often tolerates poor quality and medical errors, and that we have an insurance system that doesn't protect us. We should empower our elected representatives to make the decisions that need to be made, not make an "end run" around them.
What are alternatives to a centralized, top-down approach? To get real change, you need to find real savings. The best way to do that is by having professionals who run the system find them and apply them -- and by lining up the financial incentives to reward these people for success. Minnesota's Mayo Clinic and Health Partners are already nearly there. There is no evidence that an American health care system will respond to decisions by an unrepresentative body in Washington that has all the answers. The true challenge of health reform is for government to call out the best in health organizations and professionals from the bottom up. That's change we can believe in.
Dave Durenberger, a U.S. senator from 1978 to 1995, is a senior fellow at the University of St. Thomas' Opus College of Business. Susan Bartlett Foote is a professor of health policy and management at the University of Minnesota's School of Public Health.