Many journalists have called and asked me what I have learned from watching the much heralded Health Care Summit at Blair House.
Actually quite a bit, as the discourse there crystallized so clearly the ideological division that makes coherent and comprehensive health reform so difficult in this country, if not impossible.
In thinking about this question, I make a distinction between the policy-making elite and the “American people” — the plebs — for whom, allegedly, the elite makes policy. My counter-question then is: Are either the elite or the plebs actually ready for health reform at this time? I think not.
Let me focus on the policy-making elite first.
The view from the left. In the ideal world envisaged by the policy-making elite left of center of the ideological spectrum, the individual’s health care experience is independent of that individual’s socio-economic class, and the individual’s financial contribution to pay for health care is based on that individual’s ability to pay and completely divorced from that individual’s health status. Access to needed and locally available health care is viewed as an individual’s inherent right. This dream makes the financing of health care in the country a collective responsibility in which relatively healthier and/or wealthier people subsidize the health care used by relatively sicker and/or poorer members of society. Rationing health care by income class has no place in this picture. Heavy government involvement to enforce the implied redistribution of income does.
The view from the right. By contrast, the policy-making elite right of center of the ideological spectrum dreams of a world in which the individual’s use of health care is, in the first place, his or her own financial responsibility, although some collectively financed subsidies should be granted low-income families to help them afford at least a bare-bones, minimal package of health-care services. In this view, it is not only acceptable but entirely proper that sicker individuals should be charged higher health insurance premiums than are charged healthier individuals. Furthermore, rationing a good part of health care by income class – especially primary and secondary care — is countenanced with equanimity, because health care is viewed as basically not different from other basic commodities, such as food, housing and clothing, whose quantity and quality also is rationed by income class. Access to needed health care is decidedly not viewed as an individual’s right. It is, at most, a privilege bestowed on the less fortunate by the more fortunate. Government’s role in health care in this vision is to be kept to a minimum.
When I say “rationing by income class” I mean the following. Textbooks in economics explain that the role of prices in an economy is to ration scarce resources among unlimited wants. If prices and high cost sharing by patients are used as instruments of cost control in health care, they will ration low-income families much more out of health care than they will high-income families – hence rationing by income class.
Because these different visions of the ideal health system are driven strictly by ideology, one cannot judge one wrong and the other one correct, or even inferior or superior. They must both be respected, even if not shared, by all. And they cannot be resolved through health-services research, which can at most move closer to the facts the folklore on which ideology so often is defended.
A Uniquely American Ideological Impasse
Most industrialized countries in the world have closed this ideological gap long ago. They now slouch heavily toward the more egalitarian view espoused by left-of-center Americans.
Not so in the United States. And as long as I have lived in this country, I have seen efforts at health reform tumble into this ideological gulf, which has only grown wide over time. Health reform is likely to tumble into this ideological abyss in the future, until one or the other ideology clearly triumphs in the political arena, which would then make the imposition of one vision on the plebs possible. So far the center of the ideological spectrum has not been able to evolve an amalgamated vision that could carry the day on Capitol Hill.
Thus, short of a cram down of some reform by one or the other side in the ideological fray – e.g., through deft parliamentary maneuvers — reform of our health-care sector will not be possible in this country, and the sector will continue to both save Americans physiologically and devastate them financially for years to come. We may just have to get used to it.
In a recent address to the AcademyHealth conference on health policy, and on a blog post in The New York Times, I have suggested that one practical way to fathom the width and depth of this gulf might have been for the President to ask the Republican participants in the Summit to complete the following table after, of course, having the President entering the Democrats’ numbers first. (We can in fact find them in the 11-page description of the President’s ideas on health reform):
In the meantime, as the policy-making elite stews in its stalemate, the American plebs dreams of a political Messiah willing to build for them a health system that:
- Lets only patients and their own physicians determine how to respond clinically to a given medical condition, never an insurance clerk or, even worse, government bureaucrats.
- Limits their families’ out-of-pocket payments for health care to make it “affordable.”
- Keeps insurance premiums and taxes for health care low.
- Does not ever ration health care, because that is un-American and practiced only by un-American alien nations with inferior health systems.
- Does not allow public or private insurers to let “costs” or “cost-effectiveness” ever enter coverage decisions, because that would implicitly put a price on human life which, in America, unlike elsewhere in the world, is priceless.
- Does not mandate individuals to purchase health insurance, if they do not wish to do so, if for no other reason than that this would be unconstitutional and, therefore, un-American.
- On the other hand, grants every American the moral right – backed up by a government mandate called EMTALA– to receive critically needed and possibly high cost health care from hospitals and their affiliated doctors, even if they are uninsured and could not possibly pay for that expensive care with their own resources.
- Controls Medicare spending, which is widely thought to be completely out of control, as long as it does not reduce payments to hospitals or to doctors or to producers of medical technology, or to any other provider of health care.
- Provides universal health insurance coverage to all Americans, provided it does not mean raising taxes or cutting Medicare spending or raising premiums on healthy Americans.
- Keeps government out of health care but somehow makes sure that insurance companies do not exploit patients through incomprehensible fine print, no one engages in price gouging – e.g., charge $10 for an aspirin — and no one in health care earns excessive profits (or any at all).
One must wonder why America’s policy-making elite has found it so hard to satisfy these simple wishes of the American plebs. And as the American people anxiously wait for that Messiah, I wish them luck. In the meantime, we shall muddle through as usual.