Wednesday, October 13, 2010

Health Reform Elephant

I sometimes think of health reform as an elephant , sometimes as a group of elephants.

Elephants are big. They are the largest land mammal on the planet. In Angola in 1956, a male weighed in at a record 12 tons. The health system is big. It costs $2.5 trillion a year and employs 14 million Americans. Health care is easily the largest elephant in the U.S. economy.

Elephants are so big nobody can miss them. Everybody is aware of them, especially when they roam outside their native habitat. An elephant that escapes from the circus is called a rogue elephant. Many consider the health system a rogue elephant , because it threatens to ravage the economy.

But because the health system is so important – everybody during their lifetime needs the system, we have tended not to talk openly about it until now. The system is even sacred to some, i.e. everybody likes their doctor, their hospital, their Medicare, and their health plan. But the system is so obvious, so taken for granted, and so personal that it is uncomfortable to discuss.

Hence, the health system has become known as the elephant in the room. This is not accurate. The health system has multiple elephants in the room – each with its own agenda, each with its own view of the system.

One of these elephants is the small medical practice. Seventy percent of doctors practice in groups of ten or less. These doctors resist computerizing their practices, which the Momma elephant, the government, wants them to do, so she can control, track, and rationalize their actions.

But the doctors resist, and for that reason, small practices are deemed “the elephant in the room” because they are so big in the health system they block computerization of the system as a whole.

The public itself is an elephant in the room. Over 60% oppose the health reform law, because of the questionable circumstances under which it was passed and because it threatens loss of their policies and elevates the cost of care.

Elephants are complicated, intelligent, social animals. There are Asian elephants, African elephants, forest elephants, savannah elephants, each with their own habitats, roaming grounds, and social interactions. Similarly, the health system is regional in a heterogeneous nation with different cultural views. Each participant in the system – physician, patient, payer, policy maker, supplier, and caregiver – may be blind to the views of others.

The health system is like the story of the elephant and the blind men:

Once upon a time, there lived six blind men in a village. One day the villagers told them, "Hey, there is an elephant in the village today."

They had no idea what an elephant is. They decided, "Even though we would not be able to see it, let us go and feel it anyway." All of them went where the elephant was. Everyone of them touched the elephant.

"Hey, the elephant is a pillar," said the first man who touched his leg.

"Oh, no! it is like a rope," said the second man who touched the tail.

"Oh, no! it is like a thick branch of a tree," said the third man who touched the trunk of the elephant.

"It is like a big hand fan" said the fourth man who touched the ear of the elephant.

"It is like a huge wall," said the fifth man who touched the belly of the elephant.

"It is like a solid pipe," Said the sixth man who touched the tusk of the elephant.

Elephants move in large herds. So too do the two political parties – Democrats and Republicans. Even though the Democrats travel in elephant herds- minorities, unions,the young, feminists, idealists, collectivists - they call themselves donkeys to show their independence and to distinguish themselves from Republicans, who use the Elephant as the symbol of their party.

The two parties are like two mighty elephants banging away at each other. The battle is carried on at high altitudes. It is accompanied by grunts, guttural noises, and guffaws. And nothing much happens for 22 months, the average gestation time for elephants. In the case of the health reform debate, although both seek some form of reform as the final offspring, the debate is loud and acrimonious, and the gestation period is scheduled to last ten years.