Wednesday, May 13, 2009

Reece, personal musings - Explaining U.S. Heath Reform to Rudyard Kipling

I keep six honest serving men
(They taught me all I knew)
Their names are What and Why and When
And How and Where and Who.

Rudyard Kipling, 1865-1936
The Just-So Stories (1892). The Elephant’s Child

If Rudyard Kipling were to return to view today’s health care reform scene, I might have the following conversation with him.

What is health reform in the United States all about? It’s about a deep moral problem – insuring all 310 million Americans – and a profoundly complex economic dilemma – providing this coverage in an affordably without plunging individuals and the nation into bankruptcy.

Why is reform so difficult? It’s difficult because we are a vast continental nation with multiple public and private health systems; with one of five of our citizens a recent immigrant or relative of one; with a capitalistic economic system that stresses individualism, freedom to choose, equal opportunity but not necessary equal results, and distrust of government; and an culture that believes in exceptionalism and the power of technology to help us remain forever young and to fix health problems brought on by unhealthy behaviors.

When are these difficulties being faced? Right now, with a deep economic recession, an activist president and with Medicare facing bankruptcy by 2017 and the Social Security system following in 2037. But the problems have been coming on strong for the last 10 years, with health information outstripping general inflation 3-4:1, health care costs becoming unaffordable, and growing numbers of uninsured.

How is the United States going to fix these problems? Our president says the “big fix” will have to come from government by having an inexpensive public plan competing with excessive private plans and Medicare dictating, regulating, and demanding compliance with federal guidelines, and perhaps even doing away with fee-for-service payment of hospitals and doctors. The loyal opposition to the president insists that only the market and patients using their own money and being sensitive to value and outcomes of that money will modify the economic crisis.

Where will this reform happen? The action this year will be in the U.S. Congress and in the White House, which is orchestrating the legislative action behind the scenes. There are two huge problems; 1) the Obama administration, despite all the sound and fury, has no real leverage over the major players and can only call for voluntary actions to slow the rate of health care inflation; 2) how to pay for sweeping reform without antagonizing Americans without massive tax increases and without driving doctors out of the system with punitive rules and reduced pay and without further weakening the economy, which relies on the health care sector as one of the few growth sectors in the economy. Reform will probably not happen this year in any sweeping fashion, but if President Obama has his way, will be spread out over 10 years.

Who will bring this reform about? Government, business, and health stakeholders, somehow acting together and doing what needs to be done, and somehow modifying the health habits, and somehow lowering but meeting the expectations of the American people.

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