One of the many lessons from history, both good and bad, is that major societal reforms rarely work as planned. Linear cause-and-effect logic (reform X will realize benefit Y) often fails to hold because of the labyrinthine political and socio-economic convolutions that any reform negotiates as it moves from policy idea to implemented improvement. This is especially true in healthcare where system-wide interventions can have profound and unanticipated consequences.
The major thrust of the government’s new proposals for health reform is to change patient behaviors that will improve outcomes and performance in the healthcare system. In the first place, they will move the NHS back towards health prevention – tackling things like obesity and smoking that are known to cause long term ill health. They will also provide more personal service, making it possible for people to see doctors at times that suit them rather than only during working hours and they will offer more regular health checks.
However, we must be realistic and acknowledge that these and other changes are unlikely to substantially reduce the number of Americans without insurance or to significantly reduce the size of public and private healthcare expenditures in the near term. This is because the primary barriers to access stressed in most reform proposals are financial. Nonetheless, all healthcare reforms should be grounded in the understanding that the problem of poor access is more than just a matter of money. For example, the various policies that restrict access to certain generally covered services – from drug formularies that limit access to many drugs to staffing criteria that constrain the number and types of practitioners available to deliver mental health services – should be studied with a view to identifying the extent to which they do or do not impede access to effective medical care.