William Cayley: Focus on investing in health, not on cost containment

No one wants a bankrupt healthcare system, but we need to care for those who are sick or in need

bill_cayley_2It was announced last week that the Trump administration will end cost sharing reduction (CSR) payments to health insurance companies—the latest in an increasingly long line of efforts to repeal, replace, reform, or otherwise revise the Affordable Care Act (ACA). The ACA has been criticised for burdening both physicians and patients with increased regulation and paperwork, yet it’s been clearly documented that it has also led to a reduction in the number of uninsured individuals in the US.

While the ACA is far from perfect, efforts to change it based purely on cost considerations are misguided. It is often claimed that the United States has the “best” healthcare system in the world. That assertion can clearly be challenged by looking at various outcomes, but if by the “best” one means the capacity to deliver advanced care or to deal with complicated medical conditions with “state of the art” or “high tech” medical approaches, then the claim has merit. In the US, we have the ability to provide a level of technically advanced medical care that is not available in much of the rest of the world.

The percentage of our gross domestic product (GDP) spent on healthcare is not inherently a problem—the problem is that we spend that amount relatively ineffectively. It is vitally important for clinical and health systems research to explore how we can provide quality care in simpler or less expensive ways. Yet it is also important for us to recognise as a society that caring for our neighbours is going to cost us money: we cannot care for those in need without footing the bill for the cost.

While legislators and politicians may fight over political agendas and budgetary priorities, it is imperative that those of us who care for patients strive to keep the focus on our patients. No one wants a healthcare system that goes bankrupt, but neither should anyone want a system that balances its budget on the backs of those in need. It costs to provide medical care, and it may cost more to provide state of the art care for those who are sick or disadvantaged.

We need to change the conversation from one about cost reduction or cost containment to a conversation about values, priorities, and effective, efficient provision of care. If the health of our society is of value, we need to be willing to invest in that health—and we need to be sure that we are investing well.

William E Cayley Jr is a clinical professor at the University of Wisconsin, Department of Family Medicine and Community Health.

Competing interests: I declare that I have read and understood BMJ policy on declaration of interests and I have no relevant interests to declare.

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