Journal of Community Health Vol. 3, No. 3, Spring 1978
EDITORIAL
AD HOC,
POST
HOC,
IN HOCK
Self-declared health policy historians, or retrospective commentators on the national health scene, are fond of reminding us about the cyclical nature of concern about health care financing. The cries of alarm heard today are but a reecho of similar plaints raised generations ago. Perhaps at last the time has come to move from bemoaning to enacting. If we are to see the coming of national health insurance (NHI) at last, however, it behooves us at least to think carefully about what we want and about how we want to get it. We have been talking and planning for a long time; what do we know? As the moment of NHI's relaity becomes imminent, one can sense a lessening enthusiasm for it among both its proponents and opponents. Both are fearful of the cost and the complexity such a program would entail. This apprehension has led to much discussion about the strategy of using incremental approaches---most notably, a program for catastrophic insurance coverage. Nor is the cyclical phenomenon limited to NHI. We have a history of dealing with major issues in an ad hoc way, only to realize the full implications of such decisions post hoc; often we are in hock as a result. T h e ad hoc mentality may make an option look attractive because of its short-run implication; this may also lead us into temptation by enticing us to overlook the serious long-term disadvantages of the option. A case in point is the currently touted proposal for putting a reluctant toe in the N H I ocean by means of a gradual program that would begin with protection only against catastrophic costs. This type of program has great political appeal: It is dramatic. It provides a sense of security against major financial jeopardy, especially to the middle class. And, perhaps most important, this insurance benefit can be achieved for what appears to be a relatively low expenditure. However, appearances can be deceptive, especially in the long run. A brief recollection of our recent experience with the Medicare program should provide cause for pause. T h e expansion of benefits to include the treatment of chronic renal disease produced a spate of activity to offer these services. The insurance coverage for this particular service led to markedly increased provision and utilization of the covered service. This predicament can be readily extrapolated to the issue of catastrophic coverage. One needs little imagination to picture the flurry of activity that is likely to follow close upon the passage of such a program. Just as dialysis centers 0094-5145,e78/1300-0193500,95 © 1978 Human Sciences Press 193
194
JOURNAL OF COMMUNITY HEALTH
sprang up on the heels of the expanded Medicare program, so too will burn centers, trauma centers, rehabilitation centers, and the other high-technology projects that deal with catastrophic illness. It is because these kinds of programs are heavily dependent upon technology that they are expensive. And it is precisely against this expense that catastrophic insurance is designed to protect us. Special coverage for this segment of the health care industry can thus be expected to foster further growth of expensive treatments, With no commensurate reductions elsewhere. As a result, the overall cost of care must rise. Not only will costs rise in the short run; they could easily spawn a generalized inflation across the whole industry. In the incremental approach, as insurance coverage is broadened to include other services, the new, highly developed area of complex technology could become the yardstick that is used by other newly covered services. Each area covered will be understandably anxious to achieve the same level of development and each will feel entitled to do so by the precedent established in the early phases of the plan. After all, who can refuse life-saving, or even life-promoting, care? Thus what began as an anti-inflationary, cautious approach to a politically and organizationally overwhelming program may well turn out to be more inflationary and more overwhelming in the long run. What is the alternative? We suggest that, however frightening, implementation of N H I should be approached as a total package--or at least as close to total as we are capable of envisioning. This is the only way that we will be in a position to appreciate the full magnitude of our actions. We cannot plan efficiently unless we anticipate the full impact of the program. Only in this way can we search actively for all the balances that must be achieved as we try to establish the kind of system that will be able to deal with the program in toto. It is almost tautologic to say that this will require an enormous amount of planning, but at some point we must plunge in. To do it incrementally may be not only inflationary but improvisatory. On the other hand, another ad hoc approach might well be welcomed by researchers, who could then perform a bevy of post hoc studies. Robert L. Kane, M.D.
EDITORIAL
AD HOC,
POST
HOC,
IN HOCK
Self-declared health policy historians, or retrospective commentators on the national health scene, are fond of reminding us about the cyclical nature of concern about health care financing. The cries of alarm heard today are but a reecho of similar plaints raised generations ago. Perhaps at last the time has come to move from bemoaning to enacting. If we are to see the coming of national health insurance (NHI) at last, however, it behooves us at least to think carefully about what we want and about how we want to get it. We have been talking and planning for a long time; what do we know? As the moment of NHI's relaity becomes imminent, one can sense a lessening enthusiasm for it among both its proponents and opponents. Both are fearful of the cost and the complexity such a program would entail. This apprehension has led to much discussion about the strategy of using incremental approaches---most notably, a program for catastrophic insurance coverage. Nor is the cyclical phenomenon limited to NHI. We have a history of dealing with major issues in an ad hoc way, only to realize the full implications of such decisions post hoc; often we are in hock as a result. T h e ad hoc mentality may make an option look attractive because of its short-run implication; this may also lead us into temptation by enticing us to overlook the serious long-term disadvantages of the option. A case in point is the currently touted proposal for putting a reluctant toe in the N H I ocean by means of a gradual program that would begin with protection only against catastrophic costs. This type of program has great political appeal: It is dramatic. It provides a sense of security against major financial jeopardy, especially to the middle class. And, perhaps most important, this insurance benefit can be achieved for what appears to be a relatively low expenditure. However, appearances can be deceptive, especially in the long run. A brief recollection of our recent experience with the Medicare program should provide cause for pause. T h e expansion of benefits to include the treatment of chronic renal disease produced a spate of activity to offer these services. The insurance coverage for this particular service led to markedly increased provision and utilization of the covered service. This predicament can be readily extrapolated to the issue of catastrophic coverage. One needs little imagination to picture the flurry of activity that is likely to follow close upon the passage of such a program. Just as dialysis centers 0094-5145,e78/1300-0193500,95 © 1978 Human Sciences Press 193
194
JOURNAL OF COMMUNITY HEALTH
sprang up on the heels of the expanded Medicare program, so too will burn centers, trauma centers, rehabilitation centers, and the other high-technology projects that deal with catastrophic illness. It is because these kinds of programs are heavily dependent upon technology that they are expensive. And it is precisely against this expense that catastrophic insurance is designed to protect us. Special coverage for this segment of the health care industry can thus be expected to foster further growth of expensive treatments, With no commensurate reductions elsewhere. As a result, the overall cost of care must rise. Not only will costs rise in the short run; they could easily spawn a generalized inflation across the whole industry. In the incremental approach, as insurance coverage is broadened to include other services, the new, highly developed area of complex technology could become the yardstick that is used by other newly covered services. Each area covered will be understandably anxious to achieve the same level of development and each will feel entitled to do so by the precedent established in the early phases of the plan. After all, who can refuse life-saving, or even life-promoting, care? Thus what began as an anti-inflationary, cautious approach to a politically and organizationally overwhelming program may well turn out to be more inflationary and more overwhelming in the long run. What is the alternative? We suggest that, however frightening, implementation of N H I should be approached as a total package--or at least as close to total as we are capable of envisioning. This is the only way that we will be in a position to appreciate the full magnitude of our actions. We cannot plan efficiently unless we anticipate the full impact of the program. Only in this way can we search actively for all the balances that must be achieved as we try to establish the kind of system that will be able to deal with the program in toto. It is almost tautologic to say that this will require an enormous amount of planning, but at some point we must plunge in. To do it incrementally may be not only inflationary but improvisatory. On the other hand, another ad hoc approach might well be welcomed by researchers, who could then perform a bevy of post hoc studies. Robert L. Kane, M.D.
