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.”

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.

This essay appears in the Hastings Center’s Connecting American Values with Health Reform Collection, available here.

A movement has emerged within health care over the past several decades that sees quality as the combined and unceasing efforts of everyone involved in health care—professionals, patients and their families, researchers, payers, planners, and educators—to make the changes that will lead to better outcomes, better system performance, and better professional development; in other words, better health, better care, and better learning. This sweeping view recognizes that the pursuit of quality and safety is a dynamic process, not a static and narrowly focused endpoint. People associated with the quality movement accept this pursuit as both a moral responsibility and a serious applied science. They also believe unequivocally that everyone in health care has two jobs when they go to work every day: to provide care, and to make it better—a view that is entirely congruent with the idea that “unceasing movement toward new levels of performance” lies at the very heart of professionalism.

A movement has emerged within health care over the past several decades that sees quality as the combined and unceasing efforts of everyone involved in health care—professionals, patients and their families, researchers, payers, planners, and educators—to make the changes that will lead to better outcomes, better system performance, and better professional development; in other words, better health, better care, and better learning. This sweeping view recognizes that the pursuit of quality and safety is a dynamic process, not a static and narrowly focused endpoint. People associated with the quality movement accept this pursuit as both a moral responsibility and a serious applied science. They also believe unequivocally that everyone in health care has two jobs when they go to work every day: to provide care, and to make it better—a view that is entirely congruent with the idea that “unceasing movement toward new levels of performance” lies at the very heart of professionalism.

Several centuries ago, the widespread adoption of commercial values arguably paved the way for the flowering of science. This essay explores the seemingly unlikely proposition that commercial values have also served as the principal catalyst for the quality movement in medicine when they have come up against the decidedly noncommercial values that medicine has held sacrosanct. Improving the quality of health care is likely to be crucial in the success of health care reform, in part because, like science, improvements in quality can bring benefits that serve as a powerful counterweight to the potentially corrosive effects of commerce on professional and social relationships.

Guardians and Gifts, Science and Commerce

Medicine has historically shunned commerce. Until quite recently, for example, it was not acceptable for doctors and hospitals to advertise. The admonition to “shun trading” is a key element in what the scholar and social critic Jane Jacobs has called the “guardian moral syndrome”—a code of tightly linked moral values that governs one of the two systems of human survival, “taking” (the other being “trading”). In public life, the guardian moral syndrome, which includes the exertion of prowess, adherence to tradition, and the dispersing of largess, is expressed most clearly in government, but also in the military and religion—all of which support themselves through the taking of taxes, tithes, and territory.

Since healers were initially members of a priesthood, it should not be surprising that from its beginnings, health care was essentially a creature of the guardian moral syndrome. Of course, like everyone else, healers need to put bread on the table. But since they neither taxed nor tithed, they were forced to engage in trading. Until about fifty years ago, however, they did so on a limited scale; to a substantial degree, they relied instead on nonfinancial rewards from the “gift relationships” inherent in medical practice. That is, they relied on deferred and uncertain (but ultimately increased) rewards offered in response to their gifts of care and healing. Rather than devoting themselves to the immediate, calculated exchange that defines commerce (such as contracts, investment, capital, and interest), healers felt themselves to be rewarded through their high social status, enormous respect, and great professional autonomy.

The underlying moral values of health care in the West changed at a glacial pace, if at all, until about the beginning of the nineteenth century. That was a time of enormous social and intellectual change: the latter stages of the Enlightenment, the beginning of the end of slavery, the spread of democracy and republicanism, the emergence of the industrial revolution, and the rapid evolution of science. Jacobs argues that a major— and perhaps the major—force that drove most of these social changes was the progressive shift from the small-scale exchange of goods and services (much of it in gift relationship mode) into full-blown commercial enterprises.

Commerce depended for its success on the assertion of its own moral “syndrome,” which consisted exactly of the moral values that science needed in order to flourish. In commerce, as in science, the questioning of dogma—dissent—became a virtue rather than a heresy. Likewise, meticulous observation, insatiable curiosity, and innovation were prized qualities rather than distractions; the generation of new knowledge was recognized as a productive investment, rather than a threat; and honesty and transparency became the bedrock of marketplace conduct, for the very concept of money rests entirely on trust.

Medicine Becomes a Commodity

The scientific awakening slowly made its way into medicine during the nineteenth century, leading to many new, more rational, and improved ways to care for patients, including anesthesia, antisepsis, and x-ray imaging. But until about the time of World War II, the guardian moral syndrome continued to dominate health care’s social values, and explicit concern for quality and safety remained strangely muted.

Two events that emerged in the 1940s were instrumental in prompting medicine to take quality and safety seriously: the discovery of antibiotics, with their seemingly miraculous power to cure humanity’s traditional scourge, infectious disease, and the evolution of improved study designs and statistical methods, which made possible the subsequent development of quantitative clinical research. The arrival of potent pharmaceuticals, plus better ways of documenting their effectiveness (not to mention better surgical techniques), led to a sweeping epiphany: what doctors do actually “works”! Equally important, most of these dazzling new interventions could be separated from the “learned intermediaries”— namely, doctors—who delivered them, which made it easier to give them commercial value and to buy and sell them in the marketplace.

And to be sure, during the past thirty years, health care has become at least as much a business as a profession: patients are now considered “customers,” doctors and hospitals advertise product lines, and medical insurance companies consider money spent on clinical care to be the “loss ratio.” The preoccupation with quality and safety in health care has emerged exactly in parallel with this surge in medical commercialism. The commercial values of comfort, industriousness, thrift, and efficiency have been instrumental in industry’s development of an entire science of improvement and safety that is now slowly working its way into health care. And although it would be hard to prove conclusively that the two are related, the striking resemblance between these commercial values and the Institute of Medicine’s rules for achieving quality—which include transparency and the free flow of information, continuous decreases in waste, and customization based on patients’ needs and values—argues strongly for a causal connection.

The Value of Quality

Both commercial and guardian enterprises are essential in well-functioning societies: when either has pushed the other aside, the result has generally been disastrous. Consider, for example, the devastation that has resulted from total government control of economies such as in the Soviet Union and, more recently, Zimbabwe; or, conversely, the chaos and destruction that has occurred when radical free-market policy has replaced most major governmental functions, as in the recent history of Indonesia, Chile, Argentina, and South Africa, among other places. Further, the two moral syndromes must be held together in tension: they cannot be blended together into some entirely new enterprise, nor can they be rigidly separated. The only viable option then is for the two enterprises to develop a symbiotic relationship that leaves intact the values characteristic of each, but at the same time fosters close, respectful interaction between them. This is what happens, for example, when government legislates a goal, such as increased automotive fuel efficiency, but leaves it up to industry to figure out how to accomplish that goal, whether by improving engines, or making vehicles lighter, or developing some other, entirely new strategy.

As things stand now, a complex and often contradictory mix of guardian and commercial moral values is roiling the health care system. For example, the moral obligation felt by providers to do everything possible to meet every patient’s medical needs can be seen as a form of guardian “largess” that supports— and is supported by—commercial interest in financial gain, but at the same time conflicts with the commercial values of thrift and efficiency. And the fragmenting effects of commerce on social relationships can result in distressing “buyer beware” scenarios. Take, for example, the recently proposed system of consumer-driven care, in which trust in physicians, based on unverifiable assertions about the cost and quality of individual physicians’ services, could be converted from a purely instrumental good into a commodity that would be bought and sold; a marketplace for such behavior could end up pitting physicians and patients against one another as suppliers and customers.

Policy Implications

For it to be successful, health care reform will need to manage extremely effectively the tension between guardian and commercial values that currently pushes and pulls medicine in wildly different directions. If it fails to do so, we are likely to face increases in the fragmenting effects of commerce, including increases in the damaging effects of conflicts of interest, particularly in clinical research; worsening of the destructive drive for “hamster wheel” productivity in clinical practice; and further distortion of undergraduate, graduate, and continuing medical education under pressures of money and time—while at the same time we could fail to overcome guardian legacies such as inefficiency, uncontrolled largess, and difficulty in responding to patients’ values and preferences.

But if we’re clever and tough enough to build in “moral syndrome-friendly” interaction throughout a reformed health system, there’s no telling how much better off patients, providers, and everyone else might be. In fact, the many existing examples of syndrome-friendly interactions that support both better clinical outcomes and increased efficiency already give some cause for optimism. Thus, pay-for-performance, although hardly a panacea, honors the principle of making better clinical “widgets,” rather than just more clinical “widgets.” Pragmatic clinical trials are beginning to provide valuable information on the comparative effectiveness of new and existing interventions, strengthening further the marriage between effectiveness and efficiency. And exploration of the business case for quality suggests that better care can save “dark green dollars”—real, bankable savings, that is, not just the “light green dollars” of potential, on-paper savings.

Finally, consider patient-centered care, a concept that found little support in medicine over the centuries, but that is now emerging as a core precept in medical quality improvement. It seems right that the long-standing and widely honored commercial adage “The customer is always right” is creeping into patient care. Who would have guessed?

Frank Davidoff, MD, MACP, is editor emeritus of Annals of Internal Medicine, and executive editor of the Institute for Healthcare Improvement.

This is the introductory essay in the Hastings Center’s Connecting American Values with Health Reform Collection, available here.

The atmosphere was tense. Representatives of the insurance industry were huddled in one corner.  The other members of the Task Force on Genetic Information and Insurance, mostly academics and consumer representatives, were bunched across the room. As chair of the task force, I was in the middle, trying to make sense of the disagreement, which was growing more intense by the minute.

Our mandate was to provide recommendations about what health insurers should and should not do with genetic information. This was the early 1990s; there wasn’t much information available about an individual’s genes, but the avalanche of genetic information was gathering strength. The first few pebbles had arrived recently, and ever larger ones, such as the tests for genes linked to breast and ovarian cancer, would appear soon. We had time—not a lot, but some—to plan for how private health insurers would deal with information about our genetic risks for diseases, from the rare and inexorable progression of Huntington’s disease to far more common ones such as Parkinson’s, diabetes, and heart disease. Health insurers were accustomed to shaping policies according to the risks people presented. If someone with cancer was like a house afire, someone with a genetic risk of cancer was a house with a smoldering pile of rags in the corner.

The standoff in that room, though, was puzzling. We asked the insurers if they believed that everyone should have access to insurance whatever their risks: Yes, they agreed, everyone should have access to insurance. So, they were in favor of universal access, right? No, they adamantly insisted, universal access would be the death of the  industry. Finally, we understood what frightened them: to insurers, universal access meant that people could sail along without any insurance coverage until the day they became ill, when they could march into the insurer’s offices and demand to be covered.

That’s not what we had in mind, we explained. Everyone should have to pay their fair share and, when they needed care, their health insurance would be there to cover the cost. We described it as universal participation.  Fine, said the insurers, we can agree with that.

Among the lessons I learned from chairing the task force (including: Don’t fly from England to San Francisco and expect to control a contentious meeting), one stands out for this collection of provocative essays: understanding what’s at stake in a public policy debate is as vital as it can be elusive.

Connecting American Values with Health Reform is our effort to identify what is at stake amidst the swirling confusion of proposals for delivery systems, financing, cost control, and other details necessary for any practical reform. These details, though, are instruments carrying with them the impedimenta of history, habit, and interests.  To see things afresh, it helps to return to foundational questions: What do we want health reform to accomplish? What values should our institutions and practices be built upon, embody, and achieve?

The language of values has another virtue: Unlike health policy mavens, most Americans are baffled by the alphabet soup of program acronyms, economic models, and the difference between cost-benefit and cost-effectiveness analyses. Heck, most of us can’t explain the difference between Medicare and Medicaid. But we all understand what values are, and we can defend our preferences among them. Which leads to another reason The Hastings Center undertook this project.

Values can be wielded like cudgels to batter your opponents. That, unfortunately, has been all too common in recent political discourse. But values worth taking seriously — including all the values addressed in this collection of essays – are far more subtle, multifaceted, and interesting ideas that can cross political boundaries. Liberty, Bruce Jennings reminds us in an echo of Isaiah Berlin’s classic formulation, includes both freedom from and freedom to — and each of those meanings of liberty deserves attention in health reform. Liberty can mean the freedom from the imposition of a particular health plan and physicians; but it also demands a health care system that does not deny a would-be entrepreneur the freedom to pursue her vision, a freedom not available to the parent of a child with diabetes, for whom health insurance would be unaffordable outside the protective umbrella of a large group policy.

We chose the authors of these essays to represent a broad spectrum of beliefs. We assigned each of them a particular value to address, but we did not tell them what to say about it, other than to display the complexity residing within each value and spell out the policy implications of taking that value seriously for American health reform.

In reading these essays, I found moments of great illumination and insight along with occasional areas of disagreement; familiar ideas displayed in new and revealing aspects; new arguments, distinctions, and concepts. I was provoked, enlightened, and occasionally surprised. I hope that other readers will have a similar experience.

Most of all, I came away convinced that values are the beating heart of health reform, that these authors have begun a marvelous conversation about those values, and that the implications for American health reform are concrete and vitally important. A handful of ideas stand out.

First, simplistic understandings of values are deceptive and harmful to private insight and public discourse. Liberty, properly understood, is not the opposite of equality; justice, not the opposite of liberty; and responsibility, both personal and social, is crucial to the full realization of liberty and justice. Efficiency, an instrumental value rather than an end in itself, is intimately related to quality, solidarity, stewardship, and justice.  Core American values, rather than existing in ineluctable tension with one another, form a sturdy, mutually reinforcing foundation for health reform.

Second, when we acknowledge, as we must, that our goal is health, we are obliged to think much more broadly than our patchwork system of health care. Healthy children, healthy adults, and healthy communities are the outcome of many factors—from decent housing and safe areas for play and exercise to good jobs and schools.  Health care, crucial for episodes of acute illness and for the care of chronic diseases, is a significant but not dominant determinant of a community’s health. As responsible stewards of community resources, we should invest our finite public funds according to where they will do the most good. At times the best investment for health may be in education, job creation, or environmental protections, not in health care.

Third, the practice of individual underwriting in health insurance—making it harder to get the sicker you are — should be given a prompt funeral and buried with a stake through its heart. A concept such as actuarial fairness — which makes good moral sense in commercial insurance where risks are voluntary and the losses measured in money — has no place in deciding who gets access to the health care they need.

Fourth, efficiency and communal responsibility are essential if we are to have an affordable, effective, and sustainable health care system. This will require, at a minimum, systematically studying and improving the quality
and effectiveness of what we do in the name of health care. It will also require restructuring incentives so that providers are rewarded for results rather than for the numbers of procedures or tests they perform. There is good evidence that such changes would also lead to a higher quality of care.

Finally, the concept the task force developed more than fifteen years ago—universal participation—may be one whose time has finally come. The core idea is simple enough: 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. I was delighted to find the concept, if not the term, endorsed so often in these essays.

Whatever combination of private and public programs we choose, it’s a good time to connect American values with American health reform.

Thomas H. Murray is the President of the Hastings Center.