For all the talk of health care this time around, the New England Journal of Medicine is warning us that American health care isn't in crisis in any way that would translate into substantive reform.
The argument responds to the three biggest reasons health care reformers want change - the number of uninsured is too high, the cost of health care is too high, and there really isn't a system. But none of these things necessarily translate into instability, crisis or reform.
On the first, the article responds:
That Americans who lack coverage can "still get care," as President Bush recently declared, drains moral urgency from the health care reform enterprise.
This self-congratulatory proposition is half true: many of the uninsured can make an appointment or drop in for care at a safety-net venue. Should they become seriously ill, however, and need referrals to specialists, inpatient care, high-tech procedures, or a regimen of prescription drugs, access becomes unpredictable and spotty, an ugly exercise in rationing. Yet this reality seems to sit too many layers down for the American public to appreciate it. Hence the reception to (for example) the Clinton health care reform plan of 1993–1994: why let the government muck up the system for 100% of the population merely to bring it to the 15% who can get health care without it? The problem is not so much deficiencies in the U.S. value system as it is a myopic reading of facts that keeps important values out of political play. The social mythology surrounding the safety net lends the system an eerie stability — which does not augur well for reforms requiring redistribution of resources from the haves to the have-nots.
In other words, any amount of help to people who don't have health care, no matter how bad it is, means that people think that the system is working, or, more precisely, that people in a position of power think that the system is working well enough so that there's no moral obligation for them to change things.
In response to high health care costs:
U.S. health care costs have been in "crisis" for roughly 40 years, and they remain high for several reasons, including administrative overhead, high payments to providers, and the practice of defensive medicine. The key variable, however, seems to be a heavy reliance on specialized services and technology. Managed care was supposed to contain these "excesses," but its unhappy fate shows that the country's medical "style" is less a problem to be solved than an entrenched American cultural construct.
To be sure, this configuration is not inviolate: advocates for public health, prevention, and primary care decry the system's inverted priorities; some argue that public policies should more accurately reflect the influence of social determinants on health outcomes; chroniclers of transformation and reorganization highlight the impact of managed care. None of these critics have much dented the medical–cultural nexus, however, and the less rapidly rising health costs of the 1990s triggered a strong backlash against managed care. Nothing in today's strategic portfolio holds much promise of disrupting these formidable medical–cultural continuities, so reformers cannot plausibly promise substantial new efficiencies and savings.
I can sense the hopelessness here, that health care costs have been high for a long time and that never translated into reform so why should it now, but I think the lack of employers willing to meet their burden in this system of providing health care to their employees now changes things around a bit. Sure, the costs are the same, but with people being more intimately connected with those costs, they might be more willing to push for reform.
In response to the patchwork/non-system argument:
Reform is indeed on the agenda of all the major relevant groups, but the crucial question is how much political capital they are prepared to spend to make it happen. Despite deep differences in the interests of its members, the axis of opposition that has throttled reform in the past — business, insurance, and providers — still concurs on three points: that reform should not make big government much bigger; that the costs of reform ought not to fall on them; and that other items on their agendas take precedence. Lacking a plausible strategy for defeating these interests, reformers may have to work around them. Doing so may admit major expansions of Medicaid and SCHIP but will not turn the patchwork into a true system.
Ugh. Depressing, but probably true. There are a lot of powerful interests working against substantive health care reform, and we should have the sense to realize what we're working up against here. It's not just a mentality, it's actual power.
Just because the system's bad doesn't mean that it's unstable.
This article put a lot of the rhetoric in this presidential campaign in perspective - maybe health care shouldn't be a top issue because it's not going to change as a result of this election. I don't know, but something tells me that falling off the band-wagon and not pushing for change isn't going to help anything.