Tough choices, small steps control health care costs

This column will find the connection between twisted panties, getting old, table saws, explosives, seat belts, beasts and health care costs. That might seem an impossible task, but not to worry; it is the work of columnists to take the threads of seemingly disparate ideas and weave them into the whole cloth of a reasoned commentary.

Gov. John Baldacci recently proposed a law that would allow police to stop and ticket Mainers for not wearing seat belts, explaining that Maine could no longer afford the millions of dollars in health costs from unnecessary injuries to unbelted car crash victims. (Current law allows ticketing for lack of a seat belt only after the driver is stopped for another offense.) His proposal for a so-called primary enforcement seat belt law is bound to get a lot of panties in a twist in this state, because many of its citizens think seat belts should be a matter of individual choice.

Increases in health care costs are a lot like the process of becoming, as they say in Maine, “an old faahht,” which is to say inevitable no matter what we do. The big question is whether those costs will go up much faster than our incomes increase (the current answer is yes). The big questions about aging are whether we will age well or poorly, and whether we will die prematurely from some preventable cause. If we all sit on our centers of gravity and do nothing, we are going to age and die prematurely, and health care costs are going to increase much faster than we can afford.

Action to control health care cost increases is the alternative, of course, but what action? Ideally we would make huge strides quickly, throwing health care costs onto the social table saw like a sheet of 4×8 plywood and just whacking out about 20 percent in a whir of RPMs and a blur of sawdust. That is not going to happen, however, because the health care system is too complex, the cutback choices are too difficult, and there are no big, easy answers.

Another appealing idea would be to blow up the current systems of health care delivery and payment and start all over – like one of those big, old buildings taken down by explosives on its own footprint by a demolition firm. Yah, baby! We could then have a single-payer, universal insurance, national health care, and all would be well. But that is not going to happen either, because those are not easy answers either, the health insurance companies and other constituencies are too powerful to push out, and the free market philosophy is too entrenched in our national psyche.

We are then left with partial solutions to rising health care costs, solutions that are more akin to the work of hand planes than table saws, of chisels rather than chain saws. We are left with the need to chip ceaselessly away at health care cost increases by taking millions of small, individual and collective steps that shave down the rate of health care cost increases to something bearable. That’s what the governor’s primary seat belt proposal is – another chip off the block, another shave of the plane. If we want the affordable health care we do not have now there must be many more such efforts where that came from. Many will be similar to the primary seat belt bill; difficult choices, limitations on individual and institutional freedoms, often irritating and sometimes downright painful, but all necessary if we are to control health care costs.

Every one of us will have to suffer in order for all of us to gain. Doctors will have to give up the freedom to still practice largely without regard to cost. Hospitals need to give up the freedom of every hospital to add health care services without regard to adding costs, and the freedom from responsibility for leadership of initiatives to control hospital costs and improve hospital care. Those of us with health insurance (Medicaid, Medicare, employer-based, etc.) need to give up the freedom we have from a real sense responsibility for the health care costs we generate, a freedom derived from the fact that most of our costs are paid by our insurance.

We need to be asking if we really need that test, that pill, that procedure, and what more we could be doing to prevent our illnesses, even when we are not paying for much of those services. We all need to give up the freedom to eat what we want and not exercise adequately, because in doing so we are piling pounds on our hips and health care costs on our society.

There is no magic bullet to shoot the beast of rapidly rising health care costs in America, because the beast is us; we feed it with our voracious appetites for too much food and too much health care, too much personal freedom, our free market approach and much more. The beast can only be tamed by taking the many small, painful steps necessary to control us, and by giving up some of the freedom to drive our lives and lifestyles without the seat belt of individual and collective responsibility.

The governor of Maine is telling us, as leaders should, that we have tough choices to make and must make them, and that a primary seat belt law is one of the many tough choices we have to make if we want our health care costs brought under control. He is right. If, as you buckle up, you are tempted to curse your seat belt and the governor for a tighter seat belt law, take the shoulder strap and pull it tightly across your mouth. Then hold it there until you remember that it is time for all of us to whine less and do more to control our individual health care costs.

Erik Steele, D.O., a physician in Bangor, is chief medical officer of Eastern Maine Healthcare Systems and is on the staff of several hospital emergency rooms in the region.