The greatest minds are assembled to discern the answer in health care reform. Powerful interest groups are aligned to design solutions to protect their turf. Rubrics, formulas, slogans and taglines get designed, spun, pitched and thrown out. The burden of finding alignment, an answer, a plan that suits everyone seems insurmountable.
Unless we don’t.
The idea of a fit for all is an illusion. Justice and equity are seen differently. We imagine some public consensus at our own peril. But honesty has been in short supply. To paraphrase Oprah: what do we know for sure?
Some people want a relationship with a trusted doctor who knows them well. They want to pick the doctor, the neighborhood and the hospital they attend. Others want immediate access and have little trust or interest in a personal relationship with a doctor.
Some people want interchangeable access to medical care in the most convenient venue – they care little if it occurs at Walgreens, Doc in a box, by a nurse practitioner or by a newly minted resident – it is about access that fits their lifestyle – which may be at a late hour, and may be chosen by shortest waiting time at an ER. To others, this type of medical care is anathema.
Some people do not trust the medical field – they want oversight, monitoring, zero errors, and do not want to rely of a doctor’s judgment. They prefer rubrics, computer generated solutions and objective control. Others live in fear of losing the right to confer with their doctor as to his best judgment,, with freedom to choose treatment, medication and plans made between doctor and patient.
Some people expect to pay nothing for their health care – they want health care provided as a right, an entitlement, a government administered program that can never disappear. They do not want to have health savings accounts, worry about saving for care, or plan for medical expenses. Others are prepared to pay for the type of health care they want and when they want it. These people would rather have choice and control over the security of someone else being in charge.
Some people see health care as a chance to exercise equity and redistribution – the chance to level the playing field in health care delivery trumps the issues of rationing, waits, doctor availability or any other front line problem. Others do not support redistribution or using health care as a method of forcing equity in a country that has thus far been thought of as a meritocracy.
We will not find agreement. If there is one thing we can agree on – it is that.
What to do then?
Most obviously, a forced solution shoved onto an unwilling public is wrong. A government that takes a position to advocate for either side of the preferences and needs listed above is on dangerous territory. Can both types of health care exist? What would that look like? Or do we kill one in the race to get to the other?
Much of our current conundrum is a failure of courage. We know what we secretly believe but we are unwilling to say it. If we publicly endorse health care for all as a right, while privately planning on paying for our own special needs at a future date – we hamper any honest resolution. We need to be honest about what kind of a society we live in and how we see health care fitting in. Guilt, shaming, intimidation and fear are poor policy planners. How do we explicitly acknowledge the differing needs and plan for them without denial of either group?
We will not solve the issue of trust. We will not solve the issue of lifestyle, cost, access, convenience, or fear of fairness. We will not make all patients compliant, responsible for their own treatment, or responsible for their own expenses. We will not change human nature so that all follow medical plans religiously, or stop chaotic lifestyles or master self-destructive behavior. So we must acknowledge this directly as we design solutions – multiple solutions.
Our society in unique in honoring individualism, freedom and plurality. Can our solutions for health care tomorrow reflect this?
We are not there yet.
Diane Fisher, PhD
Wes Fisher, MD