Atul Gawande- Remembering What We're Fighting About

When you are in the middle of a fight, very seldom to you ever stop, assess, and confirm that you remember why you are fighting in the first place. Most of the time we just keep on fighting.

That’s what we’re doing with health care. Even though legislation has been passed to change the way things work, we’re just continuing to fight because many adamantly disagree with the approach that is being used to make the changes and most don’t really understand what is going on. If you didn’t understand the health care system before- you really don’t understand it now. If we don’t change, it is very likely the end-result will cost a lot more and create more damage before we are through. The health care debate has become a part of a much deeper discussion our country is having with itself and still hasn’t quite figured out the right answer.

Atul Gawande’s June 1, 2009 New Yorker article had quite an influence on getting us where we are today. (It’s a good article- You can link to it Here) Sometimes it’s important to step back and reflect on why this fight started in the first place.

The health care system Gawande describes is influenced by many different incentives both internally created and externally driven. The influence of the incentives and the personal make-up of the health care stakeholders determine the type of health care system that is developed in a local community. The health care system then determines the economics (how much it costs and how it is delivered). Gawande believed the health and age of a population have little to do with significant variations in the cost of health care we are experiencing today; it’s the system used to deliver health care that really matters.

Yes, critics have challenged some of the facts but the challenges don’t erase the picture of health care the article constructs. The challenges don't negate the reality.

Even as we continue to fight about it, we should also take some time to step back and reflect on the health care system described by Gawande almost 3 years ago. We need to take a moment and remember what we’re fighting for- and hope we are making some progress to come to a solution as we fight.

At this point, the progress seems questionable.

Iowa Caucuses- Health Care IS an Economic and Debt Issue

The Iowa caucuses are over and it’s on to New Hampshire. To nobody’s surprise, it was a close contest, a lot of money was spent, and a lot of negative advertising was used in the strategies. Republicans still aren’t united behind any single contestant- but the field will narrow over the next few weeks.

Iowa gave us the first look at the results of the Citizens United decision made by the Supreme Court last year. There is going to be even more money spent, with candidates hiding behind the covers of the “super PACs” created on their behalf. Free speech? We’ll see.

Iowan’s are a rational bunch. They look at things from a different perspective than those in Washington D.C., New York, California or the other highly populated areas. They care about community, about agriculture, and about things that are relevant to themselves. They don’t usually like the negativity associated with politics- but the Iowa caucuses proved the negative ads work. We’ll see a lot more of them.

Interestingly, Iowa Republican’s participating in the caucuses listed the economy and the debt as their primary issues of concern. Health care and abortion listed in the distance.

The Iowa caucuses proved that we continue to keep health care as a separate and distinct political issue even though fixing our health care mess is directly related to both the economy and the debt. A Pew Research Foundation study in April, 2011 determined the unfunded liabilities associated with pensions and health care for state governments increased 26% (to $1.6 trillion) in one year alone. Health care IS an economic and debt issue.

Iowa has always been the starting point of the presidential election process and used to either gather momentum or begin the elimination of candidates. Iowa also provides lessons as to what works and what doesn’t work in the campaign process.

The Iowa caucuses taught us: The Republicans are still not sure who to get behind to run against Obama in 2012, Super PAC negativity works (unfortunately)- and we’ll see a lot more, "retail/door-to-door" politics is still effective, and we still don’t believe reforming health care has much to do with jobs, the economy, or our debt.

We’ll see what we learn in New Hamphshire.

2011 Government Financial Report- Unacceptable

Right before Christmas (December 23) the Government Accountability Office (GAO) released its “2011 Financial Report of the United States Government.” The GAO works for Congress and operates as a bi-partisan watchdog to monitor how taxpayer dollars are being spent.

The press release associated with the release of the report stated, “The U.S. Government Accountability Office (GAO) cannot render an opinion on the 2011 consolidated financial statements of the federal government, because of widespread material internal control weaknesses, significant uncertainties, and other limitations.

Specifically, the press release cited; 1. Serious financial management problems at the Department of Defense (DOD) that make its financial statements unauditable, 2. The federal government’s inability to adequately account for and reconcile intragovernmental activity and balances between federal agencies, and 3. The federal government’s ineffective process for preparing the consolidated financial statements.

The report identified a material weakness of $115.3 billion in improper payments, information security issues across government, and tax collection activities.

I’ve posted the study in the Library of our site. It discusses some of the basic numbers ($1.3 trillion deficit compared to $2.1` trillion in 2010; 1.9 million new jobs compared to 350,000 in 2010) and an overview of some of the actions taken to try to get the country on the right track. You can look at the numbers and decide how well they are working for yourself. The numbers indicate some progress was made- just not nearly enough.

From a health care perspective- the report makes two significant points- Medicare, Medicaid, and Social Security are big parts of the problem (representing 45% of all spending), and the Medicare Trust Fund will run out of funding in 2024- five years earlier than was projected in 2010.

While many are calling for “cuts” that usually impact the “boots on the ground” citizen, this report shows we would likely find huge opportunities to reduce spending simply by putting accountable accounting systems in place to track where money is going and how well it is being invested.

In a nutshell, the accounting controls and books used to measure how well we’re doing financially as a country are a mess. In all honesty, we probably don’t have a real clue how big our debt really is- and its inexcusable. The financial managers associated with such a report in the private market would likely be fired.

We should expect no less from those responsible for the allocation of our taxpayer dollars- including the Congress (both Republican and Democrat alike). They need to be held accountable for the results of their efforts. This effort is unacceptable.