In a fascinating piece in the New England Journal of Medicine, Lawrence D. Brown (Columbia's Mailman School of Public Health) writes about The Amazing Noncollapsing U.S. Health Care System — Is Reform Finally at Hand?
While we have written about how bad things are and how close to falling apart the system appears, Brown writes about the meta-stable collapse... America's medical system seems always on the verge of collapsing, but never seems to finish the job.
The diagnosis of imminent collapse rests on three symptoms. First, without affordable universal coverage, the system leaves 47 million Americans uninsured. Second, health care costs are extraordinarily high: the United States spends about 16% of its annual gross domestic product (GDP), or $6,400 per capita, on health care, whereas France, for example, covers virtually its entire population reasonably well at 11% of GDP and half the per capita spending. Third, the U.S. system is in fact a nonsystem, an incoherent pastiche that has long repulsed reforms sought by private and public stakeholders. Yet this diagnosis misses as much as it reveals.
Indeed, what makes this article interesting is the analysis of why the collapse hasn't happened.
The problem with this analysis is that the U.S. health care system consists not of two sectors (private and public) but three, one of which, the safety net, rarely gets proper attention and is poorly understood. The safety net encompasses public and voluntary hospitals, community health centers, public health clinics, free clinics, and services donated by private physicians. Configurations of safety-net providers vary markedly among communities, as does their financing, a shifting patchwork of funds from Medicaid, the State Children's Health Insurance Program (SCHIP), the federal disproportionate share program, tax levies, foundation grants, state appropriations, commercial payers, and other sources. These institutions often live on the financial edge, but with 11th-hour infusions, they mostly manage to stay afloat. This fact is of paramount importance, for these providers also extend a safety net for the political legitimacy of the health care system as a whole. That Americans who lack coverage can "still get care," as President Bush recently declared, drains moral urgency from the health care reform enterprise.
Brown makes an excellent point about the existence and importance of the safety net, but my own observations of community hospitals is that things are worse this time than at any time in the last 25 years or so. Crowded Emergency Rooms/Emergency Departments and lack of inpatient bed capacity has grown more intense (and at a time in the economic cycle when things were, in comparison to what's coming, 'good').
There's no lack of moral urgency around here, or out there. Kaiser has an ongoing health care poll, and here are some stats from the latest one in December. First, what people want the candidates to talk about (hint: despite the surge, it's Iraq followed by health care):
Next, in terms of what issue people care about in choosing a President, it's Iraq followed by health care and the economy (although Republicans care more about character and experience than Democrats, who care about issues; indies are more like Democrats this year and care more about issues, according to the poll):
Lastly, if we look at the indies as swing voters, here's what aspect of health care they focus on:
All of the above argues that this time out, the amazing, always collapsing but never collapsed, medical system does have impetus for reform from the public. So, back to Brown and the NEJM:
So, though deeply dysfunctional by most standards, the U.S. health care system remains disturbingly stable. That no one really likes it does not translate into the inevitability of real change. Because the system is unlikely to collapse from within, reformers' best hopes lie with shifts in public sentiment and the election of activist and reform-minded political leaders. Such shifts can happen, as they did with lasting consequences in 1932 and 1964. But big bangs do not guarantee comprehensive health care reforms. Franklin Roosevelt declined to include national health insurance in his package of New Deal programs. Lyndon Johnson won enactment of Medicare and Medicaid but declined to fight for universal coverage. Since 1968, U.S. social politics have proceeded largely to the right of center, and the health care reform ideas whose time seemed to have come in 1993 crashed dramatically.
This is not 1993, and the right of center picture is changing. A Democratic WH win in 2008 along with the realignment in Congress in 2006 is likely to move things in a progressive direction, and progressive ideas are on the rise. The time for health care reform may actually be more likely because of where the public wants to go (leaders lead best when that's true).
Nonetheless, Brown's history and perspective are worth studying because there's no question that what the public really wants is reasonable costs. Government programs are fine, so long as people don't feel the costs are falling on them (exception made for children, where people are willing to pay). There is no compelling demand to cut government programs (good-bye, GOP talking points).
Still, reform will not be easy. Keep all of that in mind fpr perspective as we move forward in discussions of health reform, a major topic for 2008 for all the candidates. it can happen, but we'll have to make it happen. Same as it ever was for just about anything.