I told you so . . .

As I wrote in this space when Massachusetts first passed its landmark health care reform law, there wasn't enough money to pay for the promised universal coverage, and unless some serious structural reforms to contain costs were implemented, we were headed for a massive crackup. Nah nah nah nah nah. Yes, we managed to get about 97% of the people enrolled in some form of health care insurance, but the cost kept going up relentlessly -- by 8% a year. Now we're dumping legal immigrants from coverage, and the powers that be knew they had to do something drastic if there were to be any hope of maintaining something close to universal access.

What do politicians do when they've painted themselves into a corner? Appoint a commission, of course. This one has come up with what is, in essence, the only possible answer, not only for Massachusetts but for all of us: one way or another, set a global budget and allocate resources within that budget. Since they aren't proposing a single payer system (which would be by far the easiest and most elegant path toward that end, of course), they're proposing a structural reform that keeps the patchwork of competing private insurance plans.

Basically, providers would form alliances that include the range of health care services, then contract with payers to cover your body for a fixed fee. As Globe reporter Liz Kowalczyk writes, "Patients could find it harder to get procedures they want but are of questionable benefit if doctors are operating within a budget." Well obviously, and of course that's precisely the horrific, fascistic, communistic outcome the Republicans are screaming will happen to us if we allow the secretly Muslim terrorist sympathizing non-U.S. citizen president to engage in Comparative Effectiveness Research and a publicly sponsored insurance plan. Of course this commission isn't talking about doing either of those things but they're proposing the freedom destroying practice of rationing anyway.

The obvious question is, why would you want to undergo a procedure of questionable benefit? Personally, I'd rather keep all my parts intact unless I know damn well I have a good reason not to. But that's just me. The larger question is whether this can ever happen politically. So far, the doctors and hospitals here in the People's Republic of Taxachusetts say they will consider it, but they are warning that they don't want to, you know, lose any income as a result. People unclear on the concept. Right now, doctors and hospitals get paid to do stuff to you, so naturally, they do as much stuff as possible and make as much money as possible. The whole idea behind the proposed reform is to gradually squeeze money out of the system, causing them to do less stuff. There will either have to be fewer doctors, or each one of them will have to make less money. QED. And a good thing too. Oh yeah. Less drugs. Less hospital days. Less of a lot of stuff.

This is pretty similar to the managed care experiments of the 90s which the public just would not accept. But it can be done in a way which meets less resistance, I think. Managed care was largely managed by insurance companies that had reviewers who had no contact with patients make often arbitrary or clearly wrong decisions about denying care. Doctors need to be free to work with their patients in making decisions, but they need to have a different consciousness about it, and better information, and different incentives. That's what we're talking about here.

It is a long long way from here to there, and a lot of new infrastructure and resources will have to be put in place as well as a radical change in the culture. But maybe, just maybe, it can work.