Monday, September 14, 2009

What Health Care "System?"

In the screaming match that passes for today's health care reform debate, fear and sanctimony are running the show, while rationality, data and decorum have left the building. Why does everyone seem hellbent on blaming everyone else for bad faith? Because we are ALL victims of a situation beyond anyone's control - and victims tend not to be rational, nor data-driven, nor decorous.

So let's see if we can agree on one simple fact: there is no US health care “system.” What we call our “system” is, in daily practice, a sprawling hodgepodge of historic accidents (e.g., job-based insurance); ideological conflict (e.g. government/corporations good/evil or vice versa); and competing economic schemes with enormous amounts of cash in play. Health care in America combines the tortured, politicized complexity of the U.S. tax code with a conundra of intractable political, cultural, and religious disagreements about personal rights and responsibilities.

This may not be news to us health care lifers, even if it is to the idealists in the Obama Administration or the opportunists on Wall Street, but every time policymakers, corporate health benefits purchasers, insurance companies, or entrepreneurs try to fix something in our health care system, they run smack into its central reality: the primary producers and consumers of medical care are uniquely, stubbornly self-serving as they chew through vast sums of other people’s money. Doctors and hospitals are driven by irresolvable conflicts between personal gain and ethical responsibilities; patients are driven by the acrimony and anguish that accompany life-and-death medical decisions; consumers, paying for the most part with everybody’s money but their own, demand that the system serve them with the immediacy and flexibility of other industries; and health insurers are trapped in the middle, trying to keep everybody happy. A group of highly imaginative, energetic people armed with the world’s largest Mark-n-Wipe board could not purposefully design a more complex, dysfunctional system if they tried. The result is a $2 trillion-per-year fiasco in slow motion, a bloody mess narrated with moral shrillness and played out one competing anecdote after another. Death panels? Puh-leeze. Read the actual bill, and you'll be forced to admit that what's really driving the hysteria is fear - of government, of death, of the loss of control - not anything written by anyone in Washington.

So where do we go from here? Quite simply: somewhere else. Now. Another decade of the status quo, and we will have squandered both the political moment for real change ushered in with the election of President Obama, and we will confront the inevitable collapse of our non-system, one that finally fails not just the un-insured and under-insured, but one that fails all of us, including those screaming loudest to protect the status quo. How else to explain why (1) most Americans think the health care "system" is a mess while (2) most Americans are scared to death of changing it. This paradox is rooted in the fact that our health care "system" is a disaster, while at the same time, our medical industrial complex still produces, year after year, the world's greatest medical miracles. If you don't think so, ask anyone old enough to remember the AIDS quilt, or what a breast cancer diagnosis used to mean, or how we used to treat chronic schizophrenia.

That's the $2 trillion question: how can we save American medicine while junking American health care? Maybe if we only stop screaming long enough to have a real discussion about it...


  1. So, you are saying that we are really arguing about "the myth of a U.S. healthcare system?" And that a real system simply does not exist? Or in other words, it is an oxymoron?

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