Gov. Arnold Schwarzenegger wants to expand access to healthcare for all Californians. Various other state legislators have announced the same goal. Meanwhile, President Bush says that he wants to cut $40 billion out of Medicare and Medicaid over the next five years.

Our politicians are obviously going in different directions, and yet they are free to do so because no one is measuring the healthcare needs of the population, no one has identified what services will and won't be provided and no one has estimated what the services actually cost.

This divorce from the realities of need and cost allows our politicians (and our insurance companies) to operate in a world of conjecture when dealing with the life-and-death issues of healthcare. They have picked numbers out of the air and offered them to us in the form of public policies and programs. We have no objective information upon which to accept or reject those numbers. We can do better--and we should do better.

We can measure and predict healthcare need. Using established actuarial methods, we can determine how many people will be born in a given time interval. We can predict how many people will have auto accidents, heart attacks, strokes and influenza. We can predict how many will need appendectomies and knee replacements and how many will develop high blood pressure and diabetes. With decent accuracy, we can estimate the population's future disease burden.

If we know the disease burden and we specify what diagnostics, treatments and services ought to be covered, we can determine the total amount of medical services our people need and from how many practitioners of various types. We can also determine how many clinics, offices, hospitals, trauma centers and public health personnel we need. That's a far cry from where we are today, with hospitals and ERs closing despite increasing demand. All over Southern California, patients wait for hours and days for hospital beds to "open up."

If we know the disease burden of our population and we specify what a basic healthcare plan should cover, we can predict our healthcare costs. We can judge whether the insurance premium we are paying is rational or excessive. We can determine whether taking $40 billion out of Medicare and Medicaid is prudent or irresponsible. We can measure whether the governor's proposal is realistic or unsustainable. We can gauge whether private insurers are subsidizing Medicare and Medicaid, as some contend, or if the reverse is true.

To put the healthcare debate on a solid footing, we need objective information and a trustworthy system to evaluate it. We can get the information on the disease burden relatively easily. We already have most of it; all that remains is to collect it systematically.

Deciding what should and shouldn't be included in a basic healthcare benefit package will generate controversy, but it's already been done before. Kaiser has a basic package that is time tested. The California Medical Association developed a similar package in 1992. Developing a basic package will not prevent people who want more generous benefits from buying  them, but it will put a "floor" under the general population and set a benchmark.

The collection of costs will be the most ticklish job. Inevitably, some will want to dictate what they think the costs ought to be, but doing so will make reimbursement inadequate to meet true cost, driving providers out of California. Conversely, if we actually measure what the costs are, our system will be grounded in reality, and thus sustainable.

Government is too big a player in healthcare to be the guardian of need and cost information. A private foundation or endowment should be set up as an independent entity to gather and analyze the data. RAND Corp. or Stanford Research Institute might be good candidates for that task. Once established and tested, the independent entity could be publicly funded.
When we realistically predict needs and costs, we can plan infrastructure and human resources, instead of allowing people to suffer under a supply-demand mismatch.

The system above yields valuable information regardless of whether the payment comes from a government program, insurance policy or health savings account. It will keep government and private insurers honest and help people with HSAs determine if they have adequate resources.

If we do nothing, we will continue to have a healthcare system that bears no relation to our needs-and often fails to meet them. We will live in a society that uses predicted need to plan freeways, commercial parking and utilities, but doesn't use the same principles to provide a system upon which our lives depend. We will continue to treat many people at the wrong end of their disease process, treating strokes rather than hypertension, diabetes rather than obesity. We can do better. Our profession can do better.

Brian Johnston, MD, an emergency physician at White Memorial Hospital in Los Angeles, is a trustee of the California Medical Association and a past president of the Los Angeles County Medical Association. He can be reached at drbrianjohnston@earthlink.net.