How Screwed Up Does Health Care Need to Get Before We'll Fix It?

“We need to be screwed!”

Not altogether surprising words to spill out of a college student’s mouth. But this particular student was not talking about sex. She was discussing the U.S. health-care system – more specifically what she thought it would take for our two political parties to come together to find a reasonable way to control our nation’s health-care costs.

It was the last day of the semester, the last class discussion in my Intro to the U.S. Health-care System course at Duke University. We had spent a lot of time over the semester discussing the runaway cost of American healthcare. We had explored the many failed attempts, by both the government and private industry, to rein in these costs—Medicare’s DRG program for example; the rise of managed care in the 80’s and 90’s too. We had read about the many U.S. presidents who had tried and failed to reform the system—from Nixon through Clinton. And of course, we had explored Obamacare in detail, and we had concluded (as have most experts) that even if the law withstands all challenges, even if it slowly unfolds as scheduled over the next few years, the law will still have little impact on health-care costs. The Obama reforms are much better at assuring people’s access to health insurance than they are at controlling the cost of that insurance, a fact that once again reveals its similarities to the “Romneycare plan” in Massachusetts, which has helped 98% of that state’s citizens obtain health insurance, but at a staggering cost which the state is now trying to cope with.

In short, we had come to a consensus that health reform would need to be an ongoing process, and that someone, somehow, needed to make the kind of changes that would “bend the cost curve,” as health policy wonks are want to say.

But how will we do that? Perhaps if one party controls the House, sixty Senate seats and the presidency, we can pass additional legislation. But even in that case, that party would need to take on powerful interest groups. Controlling health-care costs, after all, means reducing the incomes of doctors, hospitals, pharmaceutical companies, device manufacturers and the like. It also means overcoming accusations of “health-care rationing” from one’s political opponents.

How could any political party overcome that aggregation of forces? That was when my student threw out the idea of us needing to be “screwed.” “When everyone agrees our system is unworkable, that it is broken, then maybe we’ll be forced to work together,” she said.

This provocative comment generated lively debate. (Okay, almost every topic we discussed that semester generated lively debate; Duke students aren’t famous for their reticence.)

“Screwed ain’t going to be enough,” one student exclaimed. He went on to add something to the effect of “We’re already screwed. And yet we still can’t balance our budgets, and still haven’t found a way to keep people from being one major illness away from bankruptcy.” Several more minutes of back and forth debate ensued. The topic: whether the U.S. health-care system was already screwed or was on the verge of being screwed.

And then another consensus formed: people agreed that we were already in deep trouble and that our political parties still hadn’t found a way to work together, nor had special interest groups ceased their lobbying for their interests over the good of the public. The room became downcast.

Then another student came to the rescue, with, I guess you could say, a glimmer of hope: “We will fix the problem, we will. We just need to be super screwed!”

And that, my friends, is not only a promising title for my next book, but is also the way our semester ended. With the awful hope that our health-care system would become just enough worse to force us to fix it, hopefully before the damage to our nation becomes irreversible.

Shortly afterwards, my fifty or so students filed out of the classroom. Once again, their post-adolescent minds could return to the kind of, um, screwing that qualifies as super.

Peter Ubel is a professor of business administration, medicine and public policy.  This commentary was originally published at on August 15.