Fixing health care on the back of a napkin. (4 napkins actually)

The health care debate is quickly becoming an epic American tragedy. As a concept, the original idea was marvelous: "Affordable, quality health care for every American". That is a wish every American can understand.

The reality was never going to be as clean and easy as the speech made it sound. Health care in America is a business. There are lots of people who make lots of money preventing people from getting sick, helping people who are sick, and insuring people for when we do get sick. When there are lots of people making money at anything, they're never going to agree on everything. Even those three simple terms -- "affordable", "quality" and "every" -- are inherently at conflict. But we all got the concept.

It's not working out the way anyone conceived. Where our leaders are taking us is not marvelous. Unless the White House moves quickly and boldly in the next two weeks, the most likely outcome of next month's congressional debates will be a health care system that costs individuals more than ever and ends up putting more money into the hands of the very people that created the mess in the first place.

There are probably about a hundred people in this country who really understand how health care works. I'm guessing that right now half of them are trying to change the system and half of them are trying to keep it the same. Let's see if we can't get more of us to understand the basics so we can decide for ourselves which is the better direction.

In the next four posts, I'm going to do my best to explain what's going on in the way I know best: with simple pictures drawn on a napkin.

Actually, it's going to take four napkins. My colleague Tony Jones and I have been through piles of research and enough whiteboard markers to get an elephant stoned. I think we've come up with a clear and simple view of the essentials of the health care debate.

Without further ado, here's the first napkin. Let me know if it makes sense. (Or not.)
(Click here to view all slides as a PDF.)

 
This is the overall title page for all four napkins.

This napkin introduces the business of health care.

The equation is simple: I get sick, my doctor fixes me, my doctor gets paid.

Lately though, the "payer" (my insurance provider) has come between me and my doctor, telling both of us which treatments are okay and which are not. In fact, my insurance carrier has become the party that "rations" my health care.

The reason that's happened is because health care is really TWO businesses: one makes money fixing me, the other makes money providing payment.

I'm stuck in the middle. Both sides are interested in my health and my money. (Usually one more than the other.)

When I'm healthy, the insurance side loves me. I pay my premiums and they get to keep the money!

When I'm sick, the "provider" side (doctors, hospitals, pharmaceutical companies, etc.) love me. They get to provide their products and services and they get paid. (Partially by me and partially by my insurance carrier.)

Both businesses want my money. They hate each other.

Since I'm the only one putting money into the system (either via taxes, premiums, or cash payments), health care is a zero-sum game: there's only so much money to go around. When one business is getting it, the other is not. Both sides like to get as much from me as they can, to the exclusion of the other.

As the two sides fight to squeeze more blood from the stone that is me, I get... well, squeezed. This is bankrupting me and in more and more cases (can you say "Detroit"?) my employer. (More on that when we get to napkin 4.)

It's gotten so bad that the White House has determined that it needs to step in.

As it surveyed the damage, the White House determined that most of the things that need to change immediately fall on the "insurance" side of the equation. (Universal coverage, no restrictions, lower premiums, insurance exchanges, etc.)

 
Next up: what "health care reform" is really about. (It isn't health care.)

Comments

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Great that you're doing this. Much needed with all the shouting. Should you need support about the the position of insurers, here's a Bill Moyers PBS interview with former CIGNA exec Wendell Potter

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Hey the cartoons are good. Nice to see the post

[Alex Janson]

I have lived in seven countries and as I see the USA was the last country where there was more freedom than anywhere else. This is coming to an end. First the right-wing used 9-11 as an excuse to decrease freedom, and now the left-wing led by Obama wants to take away any remaining advantage in the USA. The left-wing always wants to increase government intervention and the only business is healthcare where there was until lately more freedom in the USA than elsewhere. A great recession is coming in the next years caused by the “baby-boom demographic wave” and by the out of control federal debt. This will wipe out the healthcare program. The more the federal government is increasing spending, the deeper the recession will be. There is nothing to be gained from increased spending. Any tinkering with healthcare should be based on present (before the Obama bill) level of spending.

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Had to drop by and leave a comment on the sketches you have up there, they are honestly hilarious!

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Thanks for the review. I think a fundamental problem with insurers is that most of them are public companies, therefore responsible to their investors and motivated to constantly increase profits.

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[public lice]

This is one that I will share to many, thank you for the great post

[Ron Stone]

I like your napkin explainations of this healthcare equation. Maybe the healthcare (and other) bills in congress should be limited to a few napkins for all to see instead of hundreds and thousands of pages of hidden costs and agendas.

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Tough times for now regarding our health care policy but what can we do? We don't have the power and all we have to do is to follow. We are just ordinary people and hoping for a better future for our children's health care system.I hope our president will realize what do we really need and not what their pockets want.

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Fixing health care is important for everybody and I want to write an article about my opinion.

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[Tracy D.]

Great job, keep it up. Of course this is an oversimplification, but we have to simplify the conversation so voices which are not usual heard can join in. The fact that only "100 people understand it" is why you have to keep doing what you are doing.

[Ingrid]

To all the people screaming "Oversimplification!" I have to say, STFU because people like me who understand NOTHING might actually start to understand a little bit from such simplification. Then, I can find out more later, at least I get some basics down this way! It's like explaining an atom to a high-school student. At first you tell them there are three parts... which isn't true, but it helps them grasp the concept before introducing them to orbitals and quarks and things. OK? Oversimplification is fine - and I'm not an idiot, I know it is a simplification, but this is absolutely VALUABLE for getting me started in my understanding. OK? Thankyou.

[James]

Doctors are not 'in it for the money'.

Too often they practice defensive medicine-- ordering tests of marginal value solely to prevent a lawsuit against them.

And the other thing lacking from this over-simplified fantasy is the Medicare/Medicaid debacle. These failed government programs pay 30 cents on the dollar of the actual incurred cost of care. Guess who pays the rest?

The problem with government-run anything is that it has a bottomless pit of money (when the money runs out they just print more!). The net result is that the (bad) government money drives out the (good) private money. In such an environment competition is impossible.

Look up Gresham's Law. Educate yourself.

And stop posting this propagandistic nonsense.

[Leah]

I agree with William and others - there are those whose goals/interests run deeper and broader than pure profit but who have been forced into squashing those interests. Many doctors DO want to provide actual care.

Also, you've left out other parts of the equation, in terms of why costs are the way they are. I appreciate the attempt but agree that the simplification is maybe a little too simplified.

[William]

What about primary care doctors who's mission is to keep us well?

[Eli]

I like the thought - but this concept might be better-suited to things upon which there is broad agreement (i.e. electric motors, photosynthesis, etc.) There are obviously many interpretations of this issue. It can be quite misleading to create a metaphor which there is an internal logic, but which misrepresents the truth. The viewer, after being forced to digest this logic, is then trapped by it's circularity.