Healthcare Reform: Complicated? Or Not…

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When people talk about healthcare reform, what starts as a policy question often deteriorates into a Tower-of-Babel cacophony of confusion. Everyone’s talking about something different. And, frankly, it’s hard to know how to make things better when no one knows where they’re headed. So do I know where we should be going with healthcare in this country? Well, sort of.

I spent a year in Scotland when I was young(er). I also worked in a hospital/clinic in West Africa. I did a rotation at the Hospital for Children in Great Ormond Street, London. My husband grew up in Britain and my mother-in-law, brother-in-law and sister-in-law all live there. So what do these experiences have to do with the fact that you can’t get a new patient appointment with your private-insurance-assigned doctor in less than eight months?

See, the weird thing is, healthcare reform is, in many ways, not that complicated. Here’s why. At some point, in this country, we decided that everyone should have a place at a public school – that the benefits, to us all, were worth our shared (to varying amounts) resources to provide it. We also decided that if you called the fire department, no one would decide if you qualify – they just come. We even have, nationwide, a free “universal” system of lawyers – called public defenders. And, furthermore, if someone broke into your house with a gun and you called 911, we, as a nation, have decided that it would be wrong to ask what your “crime-coverage” was, or whether or not your “crime-premiums” were paid up before the police came to help.

Now granted, for every community across America, the quality of those services can vary. Tremendously. For lots of us, what you get is somewhat dependent on how much energy and resources you put into it. If everyone – particularly the wealthy – pulls out, the system deteriorates to the point of collapse. If everyone participates and contributes, you get economies of scale and great service overall. If having a superb public school is your (generally wealthy) community’s top priority, you’ll have great schools (and usually a conspicuous absence of private schools). If you want an ethical police department, you’ll stay on top of it, and react with appropriate horror and oversight when the system fails.

But within these wide variations, and the exceptions to the rule, the bottom line is, there’s someone who’ll come out when you call 911 without caring if you can pay – except when it comes to healthcare.

In every other “developed” country in the world, healthcare as a service was created at about the same time as fire, police and schools. It was included in the evolution toward providing basic, vital services. People who live in a country with a nationwide heathcare system are somewhat shocked when they finally understand that we truly, actually, don’t have one here. “But what do people do?” is the circular, never-ending, horrified question that gets asked over and over.

Which means that healthcare reform is both more, and LESS complicated that it appears. If we think of healthcare as the same as fire, police, and schools, then it gives us a very clear framework for imagining what it looks like in other countries. Sure, you want a private school, or a private detective, go ahead. But underneath it all, there’s a basic structure that exists for everyone. Is that public system flawed? Yes. Is it better than nothing? Undeniably, yes.

How we get there with healthcare is another story. Raise your hand if you know how we managed the nationwide development of universal, “socialized” police. Or fire. Or schools.

Anyone?

Right now, that’s information we could use – even if it is dated. But even without it, there are some undeniable truths. Rapid-response pilot projects are crucial learning tools. Our other services have already taught us that, for any nationwide system, we must define basic minimum standards – that everyone adheres to. These standards might be laughably obvious for some areas, and a struggle to achieve for others. More than likely, healthcare provision in this country, eventually, will be somewhat like our experience with our other, existing services – regional differences, varying tax bases, widely varying salaries for those involved. But such a system would come with some tremendous benefits – not just for the people it serves, but for many practitioners. Right now, a private-practice primary care physician in my wealthy Bay area suburb makes almost exactly half what a San Francisco fire chief makes, and a third less than our local elementary school principal (who leaves at 3:30 and has winter break plus summers off) – and the doctor’s got minimal-to-no vacation time, and almost twice the weekly work-hours (ah, so now we understand the eight-month new-patient-appointment delay…).

Should doctors be able to make a “profit”? Well, should police? Or firefighters? If you think of healthcare reform as a rallying cry to Unify 911 Services, fire-police-AND-health, the whole issue suddenly gets much clearer…at least in my mind.

Are you ready to start a rallying cry of your own? Do you have a different vision in mind? Weigh in by using the comments section below.

JT Russell

January 19, 2009 at 11:37 pm · Reply

There was a time when, if you wanted to become a physician, the bankrolling required more than the velleity of simply making the making the choice and the financing appears.
Then in the 1950’s and 1960’s the (then) HEW came up with what seemed a simple solution to the health care conundrum: financial aid to medical schools. They planned to flood the market with new MD’s and so cause increased competition to lower the cost factor attributable to doctors’ incomes.
In the mid 1970’s I was a dinner guest of a brilliant couple of Washington health apparatchiks. He was (among other things) guiding the nascent EPSDT program. And she (the sister of one of the Brookings Institution’s leading economists) was eventually to become the Director of the National Center for Health Statistics. In short, not only were they broadly wired into the beltway health establishment, they had their hands on the steering wheel.
Another guest that evening was the wife of a health economist who had recently been jilted by her co-researcher husband. And she was getting back at him by blabbing about the results of their latest findings, before they had been published: financial support of medical education was having the opposite effect on health costs than they had anticipated!
Although the money given to Medical Schools had worked to increase the supply of physicians, there hadn’t been the expected depressive influence on doc’s incomes. They had found that wherever there were new MD graduates, they would produce medical care and make a handsome income while doing it. The equation was more docs=more procedures and higher medical costs—not lower fees.
By producing more Docs, Washington had increased the supply of costly medical care providers who continued to command a great return on the investment the government had made in their education.
There was amused consternation around the dinner table. Medical Economics had not responded to the “Law” of supply and demand. “Well, maybe we’ll do better with this new entity, The HMO.”