I am always amused at our collective ability to avoid addressing the fundamental issues that confront us in health care. They are foundational issues whose resolutions are seminal to the architecture of any future health care financing model, yet are absent in the national debate because they are uncomfortable to consider.

Of those primal questions, few are more contentious than the simple query: is health care is a commodity, or something else entirely?

If it's a commodity, capitalistic market forces should determine the cost of care, rationing of care should be based on ability to afford it, regulation should encourage quality and price competition, with the goal of improving value and reducing cost a metric the purchaser determines. Safety net programs should be implemented to cover those not able to afford basic care while tort remedy for perceived wrongs available and encouraged. Physician and hospital fees, as well as outcomes, should be publically available for comparative review. Physician ownership of hospitals, imaging centers and other healthcare facilities should not only be allowed, but encouraged and our disconnected insurance payment system altered: the patient is responsible for the bill and the insurance reimburses the patient per their contractual policy.

If it's an entitlement provided to all citizens, a base level of outcomes-based care should be provided with attendant cost-saving simplification and reduction in administrative fees. Rationing of care should be based on the cost to the system and outcomes achieved, not financial capacity of the individual and tort reform to protect providers ironclad. A global national health care budget should be developed and adhered to no matter the individual impact. Hospitals should be viewed as cost centers, regional budgets used to address disparity and public health education expanded to reduce over utilization.

The problem is no one will agree fully with either position as these are adaptive problems that do not lend themselves to faux technical solutions. These are difficult, nuanced, culturally-charged Gordian knots that require painful frankness and a different type of leadership, one in which the future of the nation is placed ahead of the individual, each of us willing to "lose" something so that all of us may "win."

But address it we must, if meaningful, sustainable progress is to be achieved.

What is your answer?

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