I ran across an article talking about the financing of healthcare in the United States by a consultant who has been working inside the system for decades. His piece does a decent job of explaining the single hardest policy issue in healthcare reform: How it all gets paid for.
You can find it at We All Want Healthcare To Cost Much Less — But We Are Asking The Wrong Question. The subtitle says it all:
Imagine this: Healthcare — the whole system — for half as much. Better, more effective. No rationing. Everybody in.
I don’t agree with everything in the article, but he makes a good case for saying that any failure to frame payment the right way dooms the whole system to waste and the exclusion of people with disabilities and chronic medical issues.
P.S.: There is another problem with developing and using payment systems in health care reform. The complexity of all the payment systems, especially the complexity of anticipating the unintended consequences of a payment arrangement that seems to work well is akin to the unanticipated consequences of the use of derivatives in global finance. The design seemed fine, the results, not so much.
Payment system design is so complex that designers drop consideration of whether the payment system will impact the quality of the services and supports individuals receive. It is implicitly or explicitly assumed that the two subsystems can be designed and implemented more or less separately from one another. Integration is valued, but not designed.