Click here for a full text transcript of the conversation.

Host Ira Flatow said in his introduction:

“Lost in the fray [of acronyms and actuarial tables] is the whole reason to have the health care debate in the first place…we’re going to try to reel it back in to talk about our values. What role do they play in shaping health care policy?”

Flatow noted that in its recent collection of essays, Connecting American Values with Health Reform, “The Hastings Center has tried to bring values back into the discussion.”

Len Nichols, health policy director at the New America Foundation, also participated in the show. Nichols, a health economist who wrote an essay on stewardship for the Hastings Center collection, said that passage of the final health care reform legislation is contingent on leadership that promotes shared values. “It is sometimes true is that those values seem to differ among political antagonists….but when you probe deeply and get in a dialogue you find out the values are actually shared,” Nichols said. “I believe most people share them and therefore we will end up with a bill that moves our country forward.”

Single Payer

Single-payer advocates in the U.S., such as Physicians for a National Health Plan, to take just one example, argue that present health reform efforts ought not even to be considered “reform.” Steffie Woolhandler of PNHP, for example, testified at a hearing at the President’s Council on Bioethics in 2008 that most of the health reform proposals being floated during the 2008 elections constituted “placebo” reform. For PNHP, the issue is that we’ve got nearly 50 million Americans who are uninsured, and who disproportionately suffer and die because they’re uninsured, in this country. Yet others get far more care than they need, and in fact more care than can do them any good. Coverage is not stable for most Americans. Private individuals and companies profit off the illness of others. As a result, we spend far more on health care than any other developed nation, yet fail to profit from it sufficiently, and in fact do much worse in many basic measures of public health than most other wealthy nations. Dr. Woolhandler believes that all necessary and effective health care should be free for everyone who needs it, and that it should be paid for via a nonprofit, national health plan.

Single-payer health care can look different depending on its foundational principles and how it’s instantiated. PNHP, for example, advocates universal access to comprehensive, publicly funded health care, free of additional charge to the public, provided by one’s own choice of providers, with policies set through democratic means. Many of its goals are similar to the goals of Canada’s Medicare program, which are public administration, comprehensiveness, universality, portability, and accessibility. PNHP, focusing on its American audience, pays particular attention to emphasizing free choice of private providers – a feature which, in this land that otherwise emphasizes choice, most insured Americans don’t currently enjoy through their coverage.

Incongruous Values

If you believe that everyone ought to have access to health care, that everyone will benefit by having universal access, and that we have a duty to ensure such access by stewarding dollars in the most effective and efficient means possible, then single payer looks like a pretty reasonable way to go. Indeed, it – or, perhaps, another form of universal coverage, such as one that uses a heavily-regulated system of nonprofit insurers who set provider payment rates through all-payer negotiation and who accordingly also do not restrict their beneficiaries’ choices of providers – would be just about the only reasonable way to go. As Joseph White and others have detailed, we have little evidence that the private market has improved health care costs and delivery in this country in recent decades.

But, if you do not assume everyone has an equal right to health care, regardless of ability to pay, and if you give less priority to the role of social solidarity, and perhaps also regard health care primarily as a consumer good, then single payer can start to look rather problematic. This is where we find ourselves in this country, where a distinct subsection of the population believes that justice, or at least distributive justice, in the case of health care among other items, entails allowing each person to keep the fruits of his or her own labor and accomplishments, without redistribution of the wealth.

In the United States, the values that we tend to prize are not ones that would at first glance favor a single-payer, Canadian-style system, but rather something far more like what we’re presently seeing going through Congress – an at-times incongruous amalgam of conflicting values and ends. Distributive justice in health care in the United States is a curious notion. On the one hand, most would agree in principle that health care should be equally available to all, and that we should strive to make it so. We do provide a substantial amount of care through public means or charity, and most of our coverage is tax-subsidized or -advantaged. Yet few of us have guaranteed coverage, and if we go without, the public often considers this to be our own fault. The substantial role of the government in the provision, financing and regulation of coverage tends to be obscure to most casual observers. Additionally, most of us obtain our health insurance through work, which appeals to our notion, whether real or fictional, of equality of opportunity and meritocracy in action. According to these notions, those of us who have coverage through employment do so by dint of hard work, intelligence, perseverance or other traits, and many of those who lack it do so because of a failure of effort, will, or other issue.

This becomes clearer through an examination of polls asking the public about health coverage. A recent Gallup poll, for example, found that 61% of Americans believed that individuals, rather than the government, should be primarily responsible for ensuring that they and their families have health coverage. And while a plurality or majority of Americans, when polled, support national, tax-financed health insurance, the number drops substantially – to about 40% – when asked whether their support would continue if this entailed that all Americans would get their coverage from a single government plan.

These incongruous values and beliefs pose a problem in implementing any health coverage system with a relatively homogeneous set of underlying values. We can’t simply decide that a given form of coverage is abstractly best suited to accomplish certain policy and ethical goals, and then implement it accordingly. Rather, like Daniel Callahan noted in a somewhat different context, we need also to look to the structure and values of the society in which we’re proposing that such a change come about. What we presently do, and what we ultimately decide to do with respect to health reform, as the late Senator Kennedy observed, says much about us as a society. We can continue on our present path, or we can choose to more clearly opt for one set of values over another.

Values in Major Current Coverage Reform Proposals

Current health reform efforts in Congress – or at least the ones getting all the publicity – prioritize many if not most of the same goals we presently further through our health coverage system. We all know what’s going on in Congress right now. All the health coverage reform bills under serious consideration now in Congress build and expand on our present, fragmented, and largely private but substantially publicly funded health coverage system. They would require everyone to obtain coverage, largely through the private market, give subsidies to lower- and middle-income Americans, and expand Medicaid. While a public plan option for Americans who don’t have coverage through work appeared dead as of August, chances are looking slightly – _slightly_ – better for its passage, though it’s still likely that it won’t make it in any final bill that might be enacted.

Under any of these proposals, justice in both of the senses I outlined earlier will continue to be only partially served: while more people will have access to coverage, in part through redistribution of the wealth, many others will not due to inadequate subsidies in a market that will continue to be private and for-profit. Social responsibility will exist via copious tax subsidies and public program expansions, but the labyrinthine nature of the system will continue to obscure the effect this could otherwise have on fostering solidarity, instead allowing many to continue to believe, whether correctly or incorrectly, that coverage is provided for the most part via one’s own efforts and financing. Lastly, the treatment of health care as a commodity from which to profit will continue with little if any abatement.

So to what extent, if at all, could a pragmatic single-payer advocate support the major features of the primary congressional bills under consideration, as making sufficient improvement, however flawed, to the present system while also laying at least some groundwork, if not a foundation, on which to ultimately achieve their goals?

Obama and the Democrats who wrote the major House and Senate bills deliberately chose to keep the current system more-or-less intact. They feared that, if they attempted wholesale change, Americans who presently have coverage – the majority – would oppose them and kill reform altogether. It was a pragmatic move, as many have observed. But almost no matter how one defines what it means to have an adequately functioning health coverage system, the one thing nearly everyone, on any side of the political spectrum, can agree on is that our present system isn’t working. If the reform fails to make certain key changes or additions to the system, particularly regarding benefit plan and capital investment regulation, provider payment reform, and security and affordability of coverage, then a tremendous opportunity will have been lost.

All the major bills under consideration include a mandate that individuals obtain health insurance, or else pay a penalty. Additionally, all of them except the Senate Finance bill also contain some form of mandate that employers provide coverage for their employees. While the House bill penalties have some teeth, the Senate penalties for failing to obtain coverage for oneself or provide coverage for one’s employees are minimal in comparison to the price of insurance. In exchange, they require insurers to guarantee issue and renewability, to institute modified community rating, and to set minimum benefit standards for the individual and small group markets. They also provide subsidies for people buying coverage on the nongroup market to ensure that coverage costs for them don’t exceed a certain percentage of their gross income, say between 2 and 12%, depending on the bill.

Now, these mandates could be quite reasonable if, for example, health insurance plans were tightly regulated in the benefits they offered, if plans jointly negotiated provider payments, and if prices were kept within the legitimate means of all Americans, whether through subsidies or otherwise. After all, in the absence of universal, government-provided coverage, we would need some way of ensuring that everyone obtains coverage, thereby spreading the risk most broadly and, ideally, helping to avoid financial disaster for those who incur substantial medical costs. But the proposed subsidies are pretty meager for middle-income Americans. The expectations regarding the maximum appropriate percentage of income for individuals to pay for health coverage are not reasonable, and they don’t include all out-of-pocket expenses. Administration of the credits will not be simple, and will require Americans seeking them to also seek and undergo eligibility determinations. All-payer negotiations aren’t under consideration. And the ability of risk-spreading mechanisms to accomplish what they’d need to do is questionable at best. If you advocate universal, single-payer health coverage, and believe that, as a pragmatic minimum, coverage must be genuinely affordable, cover most reasonable and necessary medical expenses without substantial out-of-pocket expense, and must provide relatively uniform and stable access for everyone, then these provisions simply don’t do the job.

The Medicaid expansion poses other issues. On the one hand, the proposed expansion eliminates eligibility categories and protects the lowest-income Americans from the heavy out-of-pocket expenses they’d otherwise incur if they were instead forced into the private market for coverage. Both make sense, and deserve support, particularly from supporters of universal coverage of nearly any form. However, nothing will be done to ensure adequate provider payment. Given that the Medicaid expansions will ultimately cost states substantially more money, because the population covered will expand dramatically in most states, this practically guarantees that providers will continue to be poorly reimbursed in relation to other plans, and hence likely reduce access for Medicaid beneficiaries. The disparate access it will likely engender would be difficult for even the most pragmatic and compromising single payer advocate to swallow.

Then there’s the public plan. Not only did the Senate Finance committee not include a public plan option in their bill, but the White House went to some lengths over the summer to indicate that, while it supports a public plan option, it doesn’t consider it to be an essential part of any legislation that might ultimately pass. If you’re a single-payer advocate, then a robust public plan option, one with cost controls and that’s available to a wide range of Americans, is essential. If the public option were successful in providing decent, stable and affordable coverage, it could provide a basis on which ultimately to expand. This, of course, is precisely what single-payer opponents fear, and why they’ve vociferously blocked such an option. Then again, this is what was originally said about Medicare, and it’s been nearly 45 years now without such a transformation. Nevertheless, a public option won’t likely make it into any bill that’s ultimately passed, even if only Democrats are on board, except perhaps in a very attenuated form.

So where does this leave our pragmatic single-payer advocate? Community and solidarity are little to be found in any of the bills under consideration. While they do reform some particularly ugly features of our present health coverage system – and this is a good thing – they largely retain the fragmentary nature of our system, and give Americans little reason to feel jointly invested in it. While they improve the ability of many, particularly lower-income, Americans to obtain coverage, they hardly guarantee health security. People can still lose their coverage in any number of ways, and they can still go broke paying for medical care. Perhaps a very, very pragmatic advocate of universal, single-payer coverage could hold his or her nose and support at least the Senate HELP bill or two of the three House bills. But these bills run far astray from the principles such an advocate holds dear.

The president emeritus of the Hastings Center opens his insightful essay with the observation that the American people’s faith in medical progress is boundless. In this short comment, I want to expand on his thoughts by reexamining the cardinal tenets of that faith, since they embody a set of values that distract us from building a society that promotes good health, an infinitely more difficult task than building a better sick care system.

What are the core values driving our belief in high-tech medicine? At their root, they are the values of good old-fashioned American individualism. This is the land of opportunity, where everyone has the God-given right to thrive and prosper. It’s also the land of the second chance, a place for the self-made and remade man — like President Ronald Reagan or Don Draper of the award-winning new drama “Mad Men.”

Death in this value system is not the end of a journey, but a rotten break. It’s the end of our chance to make a mark in the world, thus a fate to be avoided at all cost. Ray Kurzweil, the nonpareil Baby Boomer inventor, is the faith’s high priest, gobbling dozens of pills and supplements daily in his quest to remain on his “Fantastic Voyage: Live Long Enough to Live Forever,” to use the title of his 2005 book.

These values have been written into the laws that govern the delivery of health care, especially Medicare. That universal, single-payer system was designed to provide health care for our oldest and therefore most vulnerable citizens. But in setting up that system, Congress said the government (i.e., all of us) would pay for any medical intervention deemed “reasonable and necessary” to return a person to health, and it could never consider cost when making those determinations. How deeply ingrained are those values? So deeply ingrained that it was child’s play this past summer for right wing demagogues to stir up passionate outrage over nonexistent efforts to “pull the plug on grandma.”

The public religiously believes there will be a technological fix for the hundreds of diseases that may hit us as our bodies degenerate, and tithes accordingly. Any effort to limit prices for what must be paid for new technologies is met with cries from industry that it will stifle innovation. The taxpayers provide the seed corn for new technology by investing nearly $30 billion a year in basic research through the National Institutes of Health and other government health-related programs (this year supplemented with $10 billion in stimulus act funds).

But that’s just the start of the process. Those researchers are encouraged to patent their findings and start companies to bring their inventions to market, a reflection of another core American value — entrepreneurialism. The government refuses to limit prices so these companies will have “incentives” to leap the regulatory barriers to entry. And even when it invests in comparative effectiveness research to determine if these new inventions are any better than older interventions, the government will insist that those findings cannot be used to determine payment policy.

Where has this lead us? We have new anti-cancer drugs that cost $50,000 to $100,000 a year despite extending life a matter of weeks or months. We are helping pay to develop cameras-in-a-pill that can scope out our innards, the latest twist in imaging technology. We will collectively pay additional billions for a pill that can be taken once a day instead of twice a day. As I write, a hospital in suburban Chicago is building a $130 million cyclotron to deliver proton beam therapy to prostate cancer patients in the name of sparing them the life-altering side effects of incontinence and impotence that affects some patients given traditional interventions like surgery or radiation. Does it work any better? No one knows. Did these men need these interventions in the first place? For many, the answer is no. Will anyone tell them the alternatives, or challenge the erection of this new altar to high-tech medicine? Alas, the answer is no.

The results are as described by Callahan and others: half of the annual increase in the cost of our increasingly unaffordable health care system can be attributed to the proliferation of newer and always more expensive forms of care. What gets lost in that lament is that the return on this investment is on a downward spiral. Our life expectancy not only lags behind other advanced industrial countries, but every year it grows a little more slowly.

Why has our technological faith failed us? The answer is simple. Increased longevity has nothing to do with extending the natural human lifespan. Societies increase longevity by eliminating premature mortality. Technology is one means to that end, but it is probably the least efficient  method. It’s definitely the most expensive.

The dramatic increases in longevity we saw in the early 20th century was largely the result of better sanitation that reduced infectious disease deaths. The gains of the postwar era were largely the result of better housing, better heating, less burdensome work, and more leisure — each a product of an increasingly wealthier society. In more recent years, cleaner air, less smoking, and better diets have played a bigger role than medical interventions in extending life.

That’s not to say that medical technology hasn’t helped. It can and does save lives. It can even perform miracles in some cases. But the truth is that investment in technology will never bring the U.S. up to the longevity standards of other advanced industrial countries. Why? Because our misplaced faith has distracted us from tackling the real and enduring determinants of ill-health in our society– poverty, income inequality, social insecurity, and status anxiety, the hallmarks of our increasingly dysfunctional social order. There’s a vast literature on the social determinants of health. Alas, it has gone unnoticed and unremarked in the current health care reform debate.

Rebuild our health care delivery and health insurance systems? It’s a necessary, even laudable goal. But it’s not sufficient if we want to improve our population’s health. Until our values allow us to put that goal to front and center, we’ll be forever doomed to disappointment from the poor returns from our massive investment in high-tech medicine.

It is a business truism that if you can’t measure it, you can’t manage it.  Our healthcare system is incredibly adept at measuring revenue, procedures performed, and patients moved out the door.  In our current system, physicians and facilities get tangible rewards for managing these measures efficiently.  However, research such as the Dartmouth Atlas illustrates that more of these things—payments, procedures, and patient throughput—aren’t yielding better health outcomes.

We need to focus on measuring quality and holding providers accountable for it.  We need to redefine efficiency as using our resources to get the best health outcomes.

As the largest payer in healthcare, the Centers for Medicare and Medicaid Services (CMS) has made substantial progress toward building accountability into the system.  Nearly all hospitals that provide services to Medicare patients report on quality measures such as steps to avoid infection, mortality rates for certain surgeries, and quality of patient experience.   However, there is still a long way to go towards accountability throughout healthcare. When CMS gave physicians an opportunity to report their use of good practices in caring for Medicare patients and offered a financial incentive for that reporting, the initial response rate was below twenty percent.  That level of accountability is not enough.

Health care reform must support the efforts underway at CMS and among private payers to measure the use of good practices, the rates of positive health outcomes such as diabetes or blood pressure under control, and the level of patient satisfaction with communication and controlling pain.  We must achieve a high level of measurement so that physicians and providers can manage their quality and be held accountable for it.  Only then can we get to the point where doing health care well is as rewarding as simply doing a lot of it.

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.