It's The Money That Matters

Let's face it: when it comes to reining in the cost trends for Medicare and Medicaid, it's going to be either 1) really painful or 2)  really experimental.  That's how the Disease Management Care Blog summarizes Meredith Rosenthal's New England Journal review of the "hard" versus "hopeful" ideologies underlying the Republican Ryan versus the Democratic White House approaches to deficit reduction. 

An easy-to-read table that compares the two can be found here. Dr. Rosenthal points out that hard evidence that Republican "premium support payments" will control costs is weak and that, under such a system, consumers may not always make wise choices.  Alternatively, it's also questionable whether the Feds are really up to the task of implementing the Dems' complicated reforms in an unwieldy health care system. 

The biggest commonality in both approaches is that it's the most vulnerable patients who are at highest risk.  Under the Ryan Plan, patients with the greatest needs may be stymied by increased out of pocket expenses.  Under the White House Plan, unintended consequences of global or performance-based payments could result in provider "gaming" or denials of care reminiscent of old fashioned capitation.

It's depressing to read that while both the White House and the Ryan Plans have downsides, the one thing that they don't have is overlap.  It's hard to see how an Independent Payment Advisory Board (Dems) could be reconciled with greater consumer choice (Republican), or how commercial competition for enrollees (Republican) could be combined with a regulated insurance benefit (Dems).  The good news is that the two options make some credible approaches to cost control.  The bad news is that there doesn't appear to be much room for compromise.

When the DMCB is confronted by difficult choices, its angst is eased by breaking out into song.  Given the fraying of our social contract, maybe that message from the 80's - that it's really money that matters - has greater wisdom than US taxpayers generally appreciate.  That or big hair......