It’s been a strange old week for me in healthcare. Half was spent working with new Health 2.0 technology companies who are trying change every conceivable aspect of the patient and physician relationship. The rest was spent hanging out with a bunch of right wing lunatics. In the background the major healthcare policy stories of the last few weeks have been Sen. Hillary Clinton’s announcement – at last! – of her plan for universal coverage, and President George Bush’s vetoing of the children’s health insurance program.
So, I guess it’s my job to try to make sense of all of this. And, well, I can. But not in ways you may like.
The politics of the moment is very strange indeed.
On the one hand, a deeply unpopular president has gone against moderate members of his own party by vetoing a bill to help “the children” by expanding government-backed health care for young Americans. If there is a more powerful sound bite for Democratic candidates during the next year, I haven’t seen it. Nor have you.
On the other hand, the Democrat presidential candidates have come up with a series of proposals that the Republicans have already dismissed as socialized or, worse, French. This despite the fact that the French health care system is commonly known as one of the best in the world and is actually one that Americans would rather like.
Meanwhile, inside the beltway and on WMUR, the only TV station that matters in Manchester, N.H., a myriad of interest groups are now focusing on the uninsured. The American Cancer Society is spending all of its publicity budget for the next year on the uninsured, while Physicians for a National Health Program (an advocate of the single-payer system) is attacking Democratic candidates because they all leave a role for private insurance companies in their policy proposals. The American Medical Association (AMA) is plastering the Washington DC Metro subway with exhortations to listen to the voice for the uninsured, hoping, I guess, that you’ll conveniently forget the AMA’s role in stopping any sort of national universal insurance program for the past century or so.
What this all comes down to is an open, raging and actually somewhat interesting philosophical battle about how best to provide insurance coverage. Which is how I found myself on a stage – with someone calling himself an “Objectivist” in that fine Ayn Rand tradition – speaking to an audience of knee-jerk libertarians. The Objectivist wasn’t very objective, but boy did he object to virtually everything done on behalf of the community. Why? In his philosophy anything done on behalf the community is, by definition, something done to somebody against their will. I have met plenty of people who want to abolish Medicare and Medicaid, without providing any substitute (and they are mostly young and rich). But this is the first time I’ve met someone wanting to abolish the publicly-funded fire department in favor of a garden hose brigade. My pleas that he support his contention that the private sector works better in healthcare than the public sector with actual data were roundly ignored so, faced with this sort of audience, I couldn’t help but feel some sympathy for the struggle any politician will have to get some level of common understanding of the real health care problems confronting America.
It’s quite possible to have a rational conversation with a libertarian and eventually convince them that a free market in health insurance is not the same as a free market in home insurance. After all, the health insurance seller is – through medical records and queries about your health, habits and well-being – able to see which house is already a simmering fire before they write an insurance contract. Yes – that’s what health insurance underwriting actually does–what do you think those “family history” questions are all about?. But if that objectivist doesn’t care that the sick person with the (figurative) house on fire is going to suffer, or agree that that somehow society should help them out, it’s pretty hard to understand how you come up with a solution that will keep them happy.
Which gives Democrats a two-faced dilemma if they really want to change the current system. First, can they get enough Americans with a shared general understanding of the problems facing the entire healthcare system so they can actually win an election on the issue? Democrats main chance of taking back the White House and keeping the Congress rests on people’s belief that they are better for domestic policy, particularly healthcare. Which is why the Republicans are playing to the gallery and decrying all things French (except wine, cheese, and in the case of Mrs. Rudolph Giuliani, handbags).
Assuming the Democrats get over that hurdle, then they actually have to try to get something passed. Now it gets really tricky.
I’ve said repeatedly on this site that I think things aren’t bad enough yet for enough Americans to clamor for a change in the health care system. Although most American have horrible health insurance, the majority of them don’t know it. And they have no idea that the medical care they are receiving is massively suboptimal. Getting that particular message across is very difficult. Who wants to hear that their doctor is a dope? Or that, by extension, they’re dope for having a bad doctor? No one. So Hillary Clinton, Sen. Barack Obama’s and to a lesser extent former Sen. John Edwards’ proposals all stress that they’re not trying to change employer-based health insurance, which most Americans have and, it seems, tolerate. Instead, the politicians say they are merely trying to add a little wraparound for those people for whom employer-based health insurance is not available.
When you burrow into the details of the proposals – and you can be assured that the lobbyists for the healthcare industry will – it becomes clear that at some stage employers and insurance companies, not to mention the Medicare program, will have to start acting very differently. No rational end payer – put in the situation of not be able to easily get out of covering people who are sick and therefore expensive – is going to just let the healthcare system continue on in cruise control as it is done for the past 50 years or so. The folks who pay the bills are going to demand changes. And changes aren’t going to be much loved by the folks who have been running health care for the past half-century. That means that despite their high-fallootin’ rhetoric about the uninsured, the AMA (not to mention the drug companies, hospitals and everyone else with a nose in the trough) is going to find itself in stark opposition to much of what health care reform will mean.
The question then is pretty basic: Is the disgust of the American public with the healthcare system enough to overcome the healthcare industry’s inertia? My guess is that much more pain and education is required. The group that I spoke with last week had no comprehension of the concept of spreading risk and cost for health care across the community or society. Worse, the discussion was also hijacked by several outright loonies who thought that all problems in American health care were due to illegal immigrants – as if there’s a rash of elderly cancer patients swimming across the Rio Grande. There’s lots of fear-mongering – on the left and the right – and gets in the way of genuine efforts for change.
Perhaps what’s needed is a real down-and-dirty political operative like Otto von Bismarck, President Lyndon Johnson or even – God help us – Dick Cheney who knows how to focus attention on selling healthcare reform the way they sold the idea of invading other countries: As some kind of patriotic duty. If you question that you’re some kind of traitor.
Failing that, I can see Sen. Hillary Rodham Clinton spending two presidential terms trying – really trying – to have a sensible conversation about healthcare reform with an objectivist who wants to abolish the fire department so we can all put out mountain fires with our garden hoses.