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The Connection is an open conversation, a group blog, and a nonpartisan effort to spark a rich discourse on fundamental values in health reform. Anyone can submit a post, and a selection of posts will appear here, on the Health Affairs blog, and in an upcoming volume.
10.6.09
| From New Health Dialogue
Liberty. Justice, Responsibility, Solidarity.
These are some of the American Values highlighted in the Hastings Center’s report on “Connecting American Values with Health Reform.”
Watching health reform unfold here in Washington, however, that “Connection” is painfully elusive. The debate is not a careful calibration of competing rights, values and obligations. It’s a political moshpit. Instead of values, we have vitriol.
Outside of Washington, even extremely astute people ask me why we can’t fix a health care system that is inefficient, inequitable and downright inexplicable.
I patiently explain that this fight is not purely about policy (or values). Health policy becomes a gritty proxy for politics.
Values, or at least ideology – particularly about the size and reach of government – play a role in politics. But an awful lot of what passes for policy debate is trench warfare before the next election. Look at the list of amendments proposed for any of the major bills – and ask yourself how many are meant to improve the health and well-being of the American people and the American economy, and how many are meant to score points, woo donors, placate interest groups and create a C-Span moment.(Both parties do this, particularly while in the minority; theatrics is the next best thing to votes.)
Still, for those who believe (as President Obama tells us) in a moral imperative to cover the uninsured and create an economically sustainable health system, it is tempting to indulge in a little values-imbued wishful thinking.
What would the health reform debate look like if, as Thomas Murray wrote in the introduction to the Hastings essays, values were the “beating heart of health reform?” What if the health care debate truly was aimed at realizing our national vision of “liberty and justice for all”? What would it look like if we dropped that vitriol, and returned to values? If, as Dr. Murray wrote, we centered on this simple core idea:
Everyone should be responsible for participating in whatever way is appropriate. When anyone needs health care that is reasonably effective and not financially ruinous, the care will be there for them.
To have such a conversation, the first requirement would be honesty. I’m not sure if it’s Jeffersonian, Hamiltonian or Jacksonian but I certainly like to think of honesty as an American value.
If we were honest, we’d still have genuine and perhaps unbridgeable differences about the public plan, or the level of subsidies or the practicality of certain models of care.
But we wouldn’t be screaming about death panels, abortion mandates, illegal immigrants, taxpayer funded sex change operations and a government takeover of health care.
If we were honest, we would reach beyond bipartisan platitudes about a broken system and acknowledge that there is no such thing as the status quo in health care. Our system gets a bit more broken each day, and all sectors of society bear the cost in incalculable (and inequitable) ways..
If we were honest, we would stop talking about “consumer” and “providers” buying and selling goods and services in a rational market. We’d talk about patients and families and doctors and nurses, and understand that health care is not a “commodity” in the usual sense of the word.
Above all, we’d stop talking about how health reform is going to bring a scary heartless bureaucratically-induced rationing – and recognize that we are already rationing. Only we ration irrationally, in unkind, unfair and unscientific ways. Our surest path to deeper and coarser rationing – the Medicare equivalent of slash and burn – is to do nothing.
That brings me to two of the final “Connecting Values” essays – Quality and Efficiency. Both are concrete and pragmatic, less abstract than liberty or justice. But in health reform, they may be our salvation. We don’t, after all, have a Congressional Justice and Fairness Office “scoring” health legislation. We have a Congressional Budget Office – and budgets may reflect our national values and priorites more than our shouted political discourse.
So rather than having two stark choices (taxing more or cutting benefits – aka rationing) we have a third path, that budgetary nirvana of delivery system reform, realigned payment incentives and comparative effectiveness research. New ways of delivering care, including a renewed emphasis on treating the frail and the chronically ill in the community instead of in the ER and ICU. New models of shared-decision making, and more and better palliative care, both of which may change how patients and families weigh when to reach for the brass rings of modern medical technology, when to give chicken soup and Tylenol a try, when the time has come to seek a gentle end.
Maybe in 10 or 15 years from now, we’ll be back to shouting. Maybe these new models – accountable care organizations and multi-specialty physician group practices and advanced medical homes and concurrent care – will turn out to be one more set of next best things that weren’t so good after all. Maybe we are fooling ourselves when we listen to the quality and efficiency gurus who say we can have higher quality for lower cost. But I don’t think so. I’ve spend enough time talking to patients and clinicians at the forefront of change – from Annapolis to Akron to Anchorage — to believe that there is a better way. A way that will bring us quality and efficiency as well as justice and responsibility and compassion. If we can stop shouting long enough to get there.
value: Efficiency, Honesty, Pragmatism, Quality
Christopher George
10.6.09
Honesty would be helpful and American, as you point out. Wasn’t it Sam Clemens, hiding behind his dishonest pseudonom, Mark Twain, who said, “Always be good, it will gratify some and astonish the rest.”
The biggest problem is the complete lack of consensus about what our healthcare system should look like.
Honestly, we can’t afford to go on the way we are going. The current legislation is no more reform than the stimulus package is a job creator. Honestly, we do need death panels. Perhaps a more appealing name could be found, but obviously we need to stop doing most all of the end of life care.
Honestly, why don’t we concentrate on the obvious things that everyone can agree on. Everyone but everyone in healtheconomics thinks that the dysfunctional link between employment and coverage is crazy. So, why are we strengthening, not dismantling that link?
Honestly, if costs are the problem, why isn’t cost control the centerpiece of reform? If there is so much waste, why don’t we wring that out before we expand the system? Why don’t we find a state healthcare system that is actually working, to use as a model before we impose this inchoate miss-mash on the whole nation, as a bakery would make a small batch before a full production run.
Honestly, abortion is a relatively inexpensive procedure, which deeply and irrevocably divides the nation. It is not as though poor women were going backrupt financing abortions. Were I running reform, I would exclude it from the debate and exclude it from coverage. Private charities could provide payment for the indigent; the vast majority of abortions could be paid by the patients. Why pick a fight over a tiny part of the problem?
The honest answer is that for some reformers getting the idealogical part of reform is more important than the practical part.
Ed
10.6.09
I guess we should have tried to reform politics before we tried to reform healthcare.
A broken system trying to fix a broken system is what it looks like we have now.
Ann Malone RN
defendhealth.org
10.7.09
Yes!!! Thank you for this statement:
“If we were honest, we would stop talking about “consumer” and “providers” buying and selling goods and services in a rational market. We’d talk about patients and families and doctors and nurses, and understand that health care is not a “commodity” in the usual sense of the word.”
I agree.
Now would someone please try and convince Families USA and their affiliates such as Community Catalyst and “Health Care For All Massachusetts” (HCFA MA) to stop using “Healthcare Consumer” in just about every other sentence, and stop them from pursuing reforms that enshrine the consumer paradigm, such as the failing individual mandate law in Massachusetts.
It is beyond words discouraging that HCFA MA, in my home state, takes huge sums of money every year from the health insurance industry (BCBS MA leads the pack in “grantmaking”) and other corporate entities.
These medical-industrial-complex entities, composed of insurers, drug co’s, device makers, some medical specialties, etc etc, are businesses that profit quite handsomely off of health care being treated like a commodity to be bought and sold in the marketplace. All the while thousands of people are bankrupted from high health costs and inadequate insurance policies, thousands die prematurely each year after living sicker lives, and thousands more experience untold suffering.
The urgency of health reform is real. But what do we do with the knowledge that, as Ed puts it “A broken system trying to fix a broken system is what it looks like we have now.”
Tweets that mention Honest Debate – and Pragmatic Solutions : Values & Health Reform Connection -- Topsy.com
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10.7.09
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Evan Falchuk
seefirstblog.com
10.7.09
Joanne,
Nice, thoughtful post.
I think all the shouting is because reform has turned into a political issue.
It’s almost as if the substance is secondary. I mean, are people really this upset about changes to insurance regulation?
There’s a real danger for doctors if they wade deeply into these political waters. Doctors must preserve their role as independent, trusted sources of information about how medical care really ought to work.
As it is today they risk tarnishing that image by getting drawn into the politics.
More here: http://bit.ly/4fmbVk
Thanks again,
Evan Falchuk
Ann Malone RN
defendhealth.org
10.7.09
Evan F – Reform didn’t “turn into” a political issue, it IS a political issue! By definition, health system reform involves politics. The busy intersection of Health Policy, Politics, and Advocacy is where reform does–or does not–take place.
Your comment gives the impression that you are very far removed from the harsh and cruel realities of America’s health care crisis. I’ve been a nurse for 15 years and have borne witness to an immense amount of preventable suffering and angst that huge numbers of people–patients and their families–are being subjected to needlessly, due to our profit-crazed broken healthcare system.
Truly reforming the system requires that we go far beyond instituting “changes to insurance regulation”. Please try to understand the depth and scope of what really is a national disaster (the U.S. health care system) to better understand the passion that many Americans bring to the health reform issue. Efforts to put a human face on this big but very personal issue is done well at this site http://guaranteedhealthcare.org/blog/colette-washington-cna-nnoc/2008/10/09/andrea-bates-indianapolis-in-10102008
Regarding “tarnishing that image by getting drawn into the politics” of reform, I would argue that doctors and nurses have a professional AND an ethical/moral obligation to participate in the political reform process. We are duty-bound to make every effort to benefit our patients and our communities. To not do so is abandonment of the patient.
Joanne Kenen
newhealthdialogue.org
11.25.09
My apologies for taking so long to respond — the health reform debate has changed since these comments were posted, but I’ll offer my belated response anyway.
Christopher – I do think the House and Senate bills are reform. Not perfect reform by any means. But they will cover more than 30 million people who currently go without health insurance. They regulate insurers, and give people new protections. If you look at the actual bills – not just the headlines — they do a lot more for delivery system reform and restraining costs than you might believe. (Ron Brownstein has a good piece on this at the Atlantic.com) Is there more to be done? Yes of course. But this is more than an “incremental” start. It’s a very major piece of social legislation — and remember Social Security and Medicare and Medicaid and other big initiatives at their creation aren’t what they are today. (http://www.newamerica.net/blog/new-health-dialogue/2009/health-reform-closer-goal-line-and-its-historic-goal-line-15383). We changed them and improved them. Even if we passed our perfect vision of health reform, we’d be revisiting it. Health policy and health care are by definition dynamic, not static. Treatments change, demographics change, public health priorities and challenges change etc. As far as your point about following a state model — no state has done this, and no state can tackle costs/delivery system as effectively as the federal government can (through Medicare and Medicaid and other federal health programs). The closest is Massachusetts — and the House and Senate bills do resemble the Massachusetts model, broadly speaking. Exchanges, subsidies, individual mandate etc. (Ann’s comments made clear that she is no fan of the Massachusetts model, but 97 percent coverage is way better than any other state. And they are now tackling phase two, cost and delivery system)
Ed — Yes it’s a broken system! We keep fixing parts of it, and it keeps breaking in new ways! If we wait for a perfect political system before we tackle health reform, we’re going to be waiting a long time. And we’ve already waited a century.
Evan – I agree. Health care is politics, or a proxy for politics. That’s what I wrote in my post. Some of that is legitimate and sincere disagreement about the size and role of government. Some of it is part of our perpetual campaign cycle.