Fifth in a series: Introduction, Issue 1 (Housing), Issue 2 (Security), Issue 3 (Education)..., Issue 4 (Ethics)
Well... what can I say. I have struggled mightily with a way into this post.
As with so many things, I am not exactly an expert on the health care debate. What I am is an interested listener, one who's managed to get a lot of exposure to different aspects of the issues around health care. My Mom, as a teacher in the health professions, gave me a lot of good background as I was growing up. Dr. T - who recently started coming around as a reader - has been... many things... to me, but one of them has been, as an HMO executive, a knowledgeable expert on these things as well. In addition, I've worked with pharmaceutical companies professionally, with additional, frequent contacts with medical professionals around the country.
I lay this groundwork because more than other issues, I would urge everyone to keep an open mind on health care, and do your own investigating. There's a lot of good stuff out there [try here (for current health care debates), here (for guides to other countries), or here... for starters].
Like many folks, my first real exposure to issues around health care came during the Clinton Administration, and a proposal to create "Universal Health Care". Developed by a commission headed by Hillary Clinton, the plan was an ambitious, complex, plan to bring all Americans into a system of universal coverage and care. It was heavily criticized by many folks, and opposed most deeply by the insurance industry. "Hillary Care" as it became known, went down in flames, tarnished the President and the then First Lady, and resulted in a long term decision that health care was "too hot" for Washington.
Since 1994, things have managed to only get worse. More people are uninsured. Health care costs have risen steadily. The passage of Medicare Part D - the "drug plan" for seniors - has caused greater bureaucratic headaches and confusion for seniors. And pharmaceutical companies continue to benefit from sky high drug prices in the US.
In order to understand where we are, you have to understand where we've been - our current system, or really systems, of care developed after World War II. Then, an influx of postwar workers into the economy and changes in government regulations served to encourage companies to make health insurance a part of employee benefit packages. With most male adults in the workforce, the vast majority of folks were covered, and retirees were provided for in these ambitious plans (along with their pensions). Gradually, though, the system began to slip. Medicare was created to cover elderly people who'd fallen through the cracks. Medicaid was developed to cover welfare recipients and people in poverty. And then, in the seventies, as the economy worsened, health care costs began to spiral and businesses found insurance costs rising.
By almost any measure, the United States lags other nations in health care for its citizens. Our infant mortality rate is higher, our costs per patient are double that of other developed countries, and more of our population lacks insurance, hospitals, doctors... in other words, adequate care. The debate on this issue has been almost nonexistent - Republicans suggest small-bore free market solutions (tort reforms for malpractice, "health savings" accounts etc) that have little impact on the larger issues, while progressive activists debate pie-in-the-sky solutions. Businesses are exiting their longstanding commitments to insuring their workers (and their retirees), and state governments are facing enormous challenges covering poor people (especially children) in Medicaid.
There is considerable focus now on health insurance. The theory goes that health care costs will be reduced when more people - ideally everyone - is covered, preferably under a system of "single payer" (probably the government, covering all costs). This coverage would probably be somewhat "bare bones," possibly with high deductibles, and would probably allow for a system of add-on policies offered by insurers. Risk - that is, the possibility of having to pay high costs for the very sick - would be spread out more widely than now, benefitting all, and making it easier to control hospital and drug costs.
Sounds lovely, yes? Well, there are enormous hurdles to enacting anything. And they have to do with issues people either don't know, or ignore, to make their points:
- Although people focus on the 47 million uninsured, the first thing is that most Americans are insured, even today.
- Medicare is popular - though highly bureaucratic and somewhat confusing - and changing it in adverse ways will mobilize seniors
- The Veterans Administration operates a system of healthcare separate from all other providers. After years of problems, the VA system has become a model of successful government operation of health care; however the system probably cannot survive massive expansion (i.e. be used as a vehicle for universal coverage), and would be difficult or impossible to dismantle
- Insurers are deeply opposed to universal coverage, and have a great deal of money to spend to block it
But the big problem is that most people do not understand the health care systems. In particular, young, healthy, white collar workers with insurance still heavily subsidized by their employers are likely to be unaware of many of the issues or how they will be affected by them (and they are likely to be swayed by scare tactics from their insurers). Many concerned people understand only small parts of the whole picture, and have already been swayed by rhetoric and advertising. Our health care system, while the most expensive, is also the one most likely to have the most advanced, cutting edge treatments. Unfortunately, most people cannot have them, and under any "reform" system, some people will lose their ability to access some types of "heroic" care.
I would sum up the problem with solving the health care system in one word: hospitals. Most "solutions" to the health care issue involve hospital access - improving it, changing the use of emergency care, implementing new types of care, etc. But no one - almost no one - asks a basic question - "Are hospitals the best method for delivering care?" The answer, for much primary, preventive care, is actually no. Yet doctors continue to be trained (as viewers of a popular doctor show know) in the hospital system, learning outmoded models of care delivery that may never apply to their practices. Dismantling hospitals - especially in older cities which still suffer on gluts of unused hospital beds - is highly unpopular. Changing doctor training and methods of payment is even less.
I'd love to tell you that I have a solution to all of this, but that's not my point on this issue. Indeed, the worst thing in this debate, is the notion of "one size fits all" solutions that neglect to address a wide array of dilemmas - things like the concentration of hospitals in Boston and New York, the lack of hospitals in rural areas, the lack of doctors to provide general care in poorer neighborhoods, the concentrations of specialized physicians (the real Nip/Tuck) in profitable areas and practices. My point is that this issue is becoming too big, and too messed up, to ignore. People - you, my small band of readers - need to get more informed on what's at stake and where the issues lie.
Mitt Romney and Arnold Schwarzenegger are showing that even if the national party doesn't get it, even Republicans are realizing that healthcare will be a major issue in the new century. And yet so few people understand what these changes might mean, or what issues still exist, that we are likely to institute bad solutions to misunderstood problems that will wreak more havoc than they solve. Health insurance is not, and should not be confused with, actually delivering health care to the population - a basic need, if not right, that's really the focus in all of this. As the year progresses, I'll try to illuminate the issues under debate. Draw your own conclusions.
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