Tuesday, July 28, 2009

It's Not Simple Being An American

Amid all the rhetoric about health care reform, one claim has emerged as a trump card designed to preserve the carrent patchwork of private and public insurance and to stop discussion of a government- sponsored Canadian-style Medicare-for-all system – is antithetical of “American values
.' ”

Allen S. Brett, MD, University of South Carolina School of Medicine, “ ‘American Values’ – A Smoke Screen in the Debate on Health Care Reform," New England Journal of Medicine, July 30, 2009

I respect the New England Journal of Medicine. I am a life-time subscriber. You can always count on the Journal. In its "Perspective" section and its editorials, the Journal always comes down on the side of single-payer, universal coverage, sweeping reforms, and the passel of priorities that come with government-based reform – comparative effectiveness research, data-driven physician controls, herding doctors into salaried groups, minimizing regional practice variation, and ending “waste” and “unnecessary interventions.”

The "Perspective" articles are well-reasoned, well-edited, objective, and are generally written by academics or policy wonks of impeccable reputations.

And like clockwork, the articles reach the same conclusions – government has to do something- anything- to fix our “broken” system and bring independent private practitioners to heel. What we need to do is save money by preventing disease, tracking doctor performance through ubiquitous EMRs, and coordinating care. By doing so, we could homogenize and standardize care and achieve 30% savings – the 30% being an oft-repeated loose estimate by the Dartmouth Group.

The only problem with this argument is that the American people and American doctors aren’t buying. These Americans have the audacity to believe America is an exceptionalist nation of individuals, capable of choosing the doctors, health plans, and treatment.

This freedome of choice may be a silly notion. Americans perisist in believing they are the “The Shining City on the Hill,” as Ronald Reagan used to say. It may be that we are egotistical and too caught up with ourselves in thinking America and Americans something special, a cut above the rest of humankind with spcial opportunities to offer immigrants that flock to our shores.

It may be, as Archibald McLeish,the famous poet, said in 1940 in The American Cause, “Races don’t bother the Americans. They were something a lot better than any race. They were a People. They were the first self-constituted, self-created People in the world.”

But despite Doctor Brett’s objections to the concept of "American Values,", there is something called the “American Culture.” Our health system is a creature of our culture. When asked what Americans believe, Garry Orren, a professor of political science at Brandeis, who polls for the New York Times and the Washington Post, said, “A good place to start is to remember we are pro-democracy and anti-government. It comes down to ideas that are essentially ant-authority and tend towards self=regulation. If there is an American creed, I think it might begin.

One, government is best that governs least.

Two, majority rule.

Three, equality of opportunity.”

That seems about right to me. It explains why Americans prefer local health solutions, why we reject federally-mandated universal coverage with rationing, why we feel capable of making our own health care decisions, why we seek equal opportunity access to high technologies, why we prefer pluarilistic payments systems, whey we allow marke-based and public-based isntitiutions to co-exist and compete, and why we permit doctors to behave democratically, seeking their own locals to practice, often ativing independently of hospitals, health plans, and government, and making their own deicisonns, free of the fetters of outsiders.

Democracy is a messy business. That’s the way Americans like it. It allows choice, freedom, and individualism. Each of us feels we are a person, not bound the rules of statistical averages, as dictated from Washington.

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