Healthcare Reform
Blog topic: Healthcare Reform or Social Reform?
Here is ObamaCare again for a potentially last shot at glory, as President and Democrats struggle to pass legislation, any legislation!
If these efforts fail, ObamaCare, like previously ClintonCare, will be seen as one of history's major legislative failures. Both would, however, differ significantly since the Clintons, for over a decade and a half, succeeded in simply removing the topic from further national consideration. Obama, no Clinton, faces different circumstances: Should Congress, indeed, defeat ObamaCare, health care reform, this time, will remain on the national agenda since the public strongly supports individual components of reform, if implemented incrementally.
A potentially toxic political atmosphere would then be the consequence for an administration already perceived as driven by ideology rather than practicability, and tone deaf to public concerns, since the Republican concept of incremental change would become the obvious next legislative option. Even forced passage of highly unpopular ObamaCare now appears, therefore, to President and Democrats the lesser evil, whatever the short-term political consequences.
What currently defines Democrats and Republicans in their respective proposals for health care reform is well known. Both parties, in skirmishes over coverage and costs, so far, however, overlooked, that in the mind of the public success of reform will be defined by quality of medical care patients in the end can expect to receive. Talking points around health care coverage for all, program costs and long-term budgetary consequences have dominated the discourse but neither party so far understands that the public's primary concerns involve none of the above: Most people really only care about easy and affordable access to, what they subjectively perceive, as good quality medical care. Subjectivities in these concerns are then where most difficulties in reforming U.S. health care arise.
What defines good health care is even within the medical profession controversial. As physicians and scientists we, mostly through outcome comparisons, attempt to define quality of medical care objectively. Because medical care is highly multifactorial in nature, even statistically sophisticated outcome comparisons not always allow for accurate quality assessments. The public defines good health care in much simpler ways: as long as personal needs are met, health care is perceived as good.
Personal needs between individuals however differ. People have different expectation at different ages, in different socioeconomic and ethnic groups or based on varying cultural backgrounds. These then, in turn, lead to discrepancies in expectations and, consequently, to varying opinions as to where health care reform should take us.
Looking in this way at the current national health care debate, it becomes apparent that the primary issues of debate should not be insurance coverage and costs of treatments but the social reengineering of how we provide health care. Only social solutions to health care management, and not so much health care itself, will, ultimately, improve patient satisfaction, better what organized medicine perceives as quality of care and, finally, lower national health care expenditures.
Take, for example, the woman who for all of her life has been receiving primary health care in emergency rooms. Unless taught otherwise, she will, likely, continue, even if government-supported insurance suddenly offers free and easy access to primary care elsewhere. ObamaCare will neither improve her medical care, nor, as suggested by Democrats, save costs by preventing expensive utilization of emergency rooms, unless, of course, she, first, and before implementation of reforms, is successfully reeducated.
Or consider all those who, despite obvious risk factors, fail to screen for colon cancer via colonoscopies, and end up diagnosed with incurable malignant disease. Will proposed health care reforms, without prior educational efforts, direct such individuals towards more timely screening procedures? Unlikely! They, too, therefore, only unlikely will get better health care under ObamaCare, and neither will national health care costs benefit from early diagnoses.
A new Chinese emigrant, reasonably, may choose a small, poorer quality, local hospital with Mandarin or Cantonese speaking staff over a medically much more sophisticated facility where he would find himself culturally isolated. His first generation offspring, culturally integrated, may already make very different choices. Or consider how government and insurance industry have addressed higher risks of very young and old drivers by establishing special educational and teaching frameworks for both age groups. Why should health care not be approached in similar ways?
These greatly varying examples demonstrate that social circumstance should occupy the very core of the national health care debate. Because such approaches are not pursued, wide pars exist in all socioeconomic strata between organized medicine and public in defining good quality of care.
The recently prominently reported story of a Canadian politician serves as an example: Though Canada in many international rankings places higher than the U.S. in quality of national health care, he chose to receive medical care in the U.S. Canada neither offers the world-leading excellence of prominent U.S. medical centers nor the immediate access to and convenience of U.S. medicine. Canadian medicine is, therefore, undoubtedly more even but also more mediocre in contrast to, for example, New York City where, within blocks of each other, patients can receive some of the world's best and clearly inferior quality of care. This obviously socially privileged Canadian politician, nevertheless, chose U.S. health care over care in his own country.
Choices like this can in a free market-based health care system not be legislated. How and where we choose to receive health care is largely based on social rather than medical circumstances. It is difficult to understand how this important point remains so totally ignored in the national health care debate.
Reform of U.S. health care without prior well thought out socioeconomic interventions is, therefore, destined to fail medically and economically. Such reforms would only mimic the Canadian and other similar systems in dragging down excellence to lower common denominators of medical practice, and do so without significant economic cost savings. This argument, of course, favors incremental changes, as proposed by Republicans, because only segmental, step-wise reforms allow for timely socioeconomic interventions in preparation.
How this is done best does not depend on insurance companies or the question whether public options should be offered or not. It starts, from the ground up, with the question, what is it that we are trying to achieve? Reforming the national health care system smartly involves basic building blocks: successful maintenance of health (i.e., prevention), timely diagnoses of diseases and, ultimately, application of most effective therapies when diseases strike. Affecting each of these components in different socioeconomic spheres effectively should represent the ultimate goal of health care reform.
Government is, not well suited to manage improvements in quality of care. The world's leading medical institutions did not achieve preeminence because of government guidance. Government, therefore, should be restricted to defining outcome goals but should leave medical professionals to decide how to satisfy those. Better medical care is costly; but, paradoxically, poor medical care is even costlier by leading to more hospitalizations, more absenteeism from work and, ultimately, to more government support, whether patients carry health care insurance or not. A permanently disabled individual, independent of insurance status, always becomes a cost center for society. Nothing will, therefore, save more in overall health care costs over the long run than improving quality of care.
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