Health care reform as it is currently imagined does little to address the most pressing concerns of the industry, said political commentator Reihan Salam.
In a talk entitled “My Vision for the U.S. Healthcare System in Twenty Years,” Salam detailed his interpretation of the current state of American health care and how it can become a more robust and productive industry. Salam, a senior fellow at the conservative think tank R Street Institute who writes for Reuters and a variety of online publications, spoke Tuesday morning at the Sanford School of Public Policy. Salam spoke broadly about the healthcare sector within the larger American economy and his suggestions for the industry, including some discussion of the current insurance debate.
“My fear,” he said, “is that a lot of the things we’re seeing right now [in health care reform] are things that are going to give more access to a health care system that actually doesn’t work very well.”
The pressing issue of health care right now is that providing health care coverage to more people under the existing system will be expensive, he said. Salam thinks it is too expensive, and the Affordable Care Act will make it more expensive than it needs to be.
Salam insisted that the Affordable Care Act—with its mix of Medicare, Medicaid, employer-based health care and subsidized plans—is actually a similar model to what people on the right are talking about. The crucial element he believes is missing is the same nimbleness he used to characterize the rest of his ideal health care system.
“If you regulate [insurance] less stringently,” he said, “you won’t prevent new plans from meeting the needs of people who are more low-cost.
Salam presented a vision of a health care system that does not require so much subsidization as the current system or the Affordable Care Act, which he said is difficult to do effectively. Instead, the ideal American health sector would become more “nimble” through innovations that would make health care more accessible and tailor regulation more appropriately.
One improvement would be to rearrange the proportion of medical tasks that are assigned only to physicians by making aspects of health care easier and cheaper for other medical professionals to carry out.
“Only physicians can do a whole host of things because they’re so complicated that ordinary people couldn’t possibly understand them,” Salam said. “With empowering innovations, you could have physicians’ assistants or even ordinary individuals do some of the same things.”
This could include not only complex medical tasks but also the more time-intensive, relationship-building aspects of medicine. Turning such responsibilities over to professionals who do need as much education as physicians would allow physicians themselves to become more specialized, which Salam posited would be a constructive change to our health care system.
Allowing medical professionals to specialize would hopefully have a ripple effect of efficiency across the healthcare system, Salam said. He pointed to Medicaid as a program that does a particularly poor job with primary care and suggested it would benefit from “splitting it up.” Ultimately, Salam said, this increase in productivity would free up capital that could go toward improving medical technologies and knowledge and allow the entire industry to be more innovative.
“My fantasy is that we can come up with something that does all of those discrete jobs that make up the medical system better,” Salam said.
Pressed for a definition of “better,” Salam paused, but offered the idea of “a better mix of cost and quality over time.”
In order for this reorganization of tasks to take place, regulation of health care would have to undergo significant changes. Salam was clear that regulation is important and necessary, especially when determining who is qualified to make diagnoses. But in the final stages of medicine, when, for example, the main issue is ensuring that patients are taking their medication, Salam believes that the American healthcare system over-regulates by requiring too many qualifications to carry out less complicated tasks.
“It’s not about getting rid of regulation,” Salam said, “but thinking about which of the areas we want regulation.”
Salam respects that the health care sector is one that inspires a unique anxiety. But the bottom line, he said, is that Americans approach the industry without the nuance it deserves.
“We’re assuming there’s some top-down way to figure out what the business model should look like, that efficiency is an outcome. What I argue is that we can think about efficiency being a dynamic process,” Salam said.
Don Taylor, associate professor of public policy, who invited Salam to speak, said he tries to give students a balanced intellectual picture of health care issues.
“I’ve tried to invite people [to speak] who have different perspectives than me,” Taylor said. “What we want for the Duke campus is for it to be a place for the exchange of ideas.”
Taylor hopes the talk contributed to a spirit of action on campus.
“The thing about this issue is,” Taylor said, “the country can’t afford for you to wait until you’re in your 40s to engage. You have to take your training and your energy to go toward the problem and help fix it.”
Salam agreed with the need for proactive change.
“We have this huge anxiety about the jobs we have right now and preserving them,” he said. “But when I think about my ideal health system, I think about a health system in which you incentivize new business models. We want the creation of simpler, cheaper products that are a lot more accessible to more people and allow us to treat new ailments in cheaper, better ways.”
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