Monday, December 06, 2010

Our Health Care Reform Illusion

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


Dennis said...

I must say I have just read one of the most thought provoking texts on our health care problems as I have yet seen. It causes me stress, distress, and exhaustion.
It would bring to my mind the great struggle that occurred when Neanderthal Man encountered Cro Magnon Man and either became extinct or was assimilated... both taking eons. Some things are so entrenched and complicated by the hand of man only a god creature might untangle the complexities... I fear it will not happen soon and there will be dire consequences for some and for others... well there are always those others who have the money and power and position to escape the quicksand.

DrWes said...

I must say I have just read one of the most thought provoking texts on our health care problems as I have yet seen. It causes me stress, distress, and exhaustion.


It would be interesting to know what part of this essay left you so. Perhaps it is there isn't even consensus on the lack of consensus in this discussion.

If we fear complication, Dennis, then we force oversimplification, and that is what we should really be scared about. I dare say, we are doing just that.

jimbino said...

This post is full of dissembling on behalf of the medical status quo. According to Dr Wes, the varieties of healthcare models that people want vary among:

1. Choice of a trusted doctor and hospital.
2. Walmart convenience.
3. Government oversight.
4. Socialized medicine.
5. Means for wealth distribution.

While I see no great difference between 4 and 5 above, the post ignores the fact that government and medicine have been conspiring for a long time to hide all the pertinent information from view by a country full of patients. No Amerikan, without great difficulty, can possibly choose a model without that information.

For example, it is virtually impossible to find a "trusted" doctor or hospital, since bad doctors and bad hospitals continue to function without being held up to the light of day. In Amerika, you find doctors and hospitals by trial and error--error meaning you are likely crippled or dead before you can find your "trusted" doctor or hospital. Just try filing a complaint against a practitioner at the medical or dental board! I have; the board exists to protect the practitioners, not to discipline them; the board in my case did nothing and I had to sue. I won in small claims, but the practitioner is still defrauding patients.

If eBay or Amazon ran health care, you could read reviews and do instant comparisons of price and quality, just as you do for a camera. And they have a problem resolution department so you don't have to file a lawsuit to get justice or simple fair treatment. And they don't have an idiot at the front office whose first response to your product inquiry is "Do you have insurance?"

Walmart, eBay and Amazon publish all their prices and treats all clients fairly, charging everybody the same for a product. You will die before you can find out the pricing of a medical or dental procedure on the web or by calling around. In every case, you will be charged far more (up to 5 times as much!) than the doctor or hospital charges Medicare, Medicaid or insurance for the very same procedures!

I consider posts such as this one disingenuous. Medical practitioners will end up government employees under Rubric 3 above, something they well deserve for their history of self-serving dissembling and failure to act on behalf of patients. Medicine will go downhill, but we patients will still have Walmart and Mexico to look to for fair and proper treatment.

Dennis said...


It is the complexity that causes my my grief. At 71 I am basically in a holding pattern waiting to check out to the big ocean in the sky and I will not be a part of the conundrum that future citizens will face. I find it disgusting that the majority of rules and legislature is wrangled and fought over by politicians that are only guided by personal power positions or lobbyists for gains that the average citizen has no clue. These same politicians are exempt or go about their own lives with impunity which gives them a sense of security that only those in the halls of power understand.
I try to make some effort to be informed but it is difficult at best and I feel it is far from my hands or vote and thus I bury my head in the sand and thank my Joss that I have lived the bulk of my life whereas the military and now a combination of Medicare and Tricare for live gives me my own sense of security... at least for the moment. Then there is always my 'Final Exit' tome tucked away for that day when I feel all my own decision making on the verge of collapse and I fall victim to the system or indecisive loved ones.

DrWes said...


You make many good points, but you miss the point. Not everyone wants authority and agency in their health care decisions. Is that really a profound tragedy?

You have articulated the libertarian perspective that implies all patients would be interested in doctor ratings, web pricing and direct costs. This ignores the reality of a large number of health care users who care only about access and their co-pay. If you see transforming all patients to managers of their own health care, needs, and costs, ask doctors how many patients do with responibility for their health now in even minimal ways. Only some. I'd like it too, Jimbino, but Utopian thinking makes for failed policy.

jimbino said...

True, Dr Wes, that my position is libertarian, but what you seem to fail to appreciate is that the libertarian policy does not preclude any of the others but, indeed, encompasses and facilitates them.

Do you want a God-Doctor making your decisions for you? OK, libertarians allow not only that but suicide as well.

Do you want to be stupid, relying on religion and supplements to cure you? OK, libertarians, but not Obamacare, will let you do that.

What you and Obamacare do not seem to embrace is the idea that folks that choose to have the inalienable right to make their own choices and the right to information that permits an informed decision as to their healthcare, just as they would expect in choosing a spouse.

But it is the healthcare profession, in cahoots with the government, that favors licensing, regulation, information hiding, insurance and all the other impediments to informed patient decision making.

Stop implying that there are forces out there beyond our control that enforce our medical miasma. Look in the mirror and admit that medicine should be totally deregulated in the interests of the Amerikan people.

jimbino said...

And another thing you fail to realize, Dr Wes, is that, tiny minority or not, we libertarians are those who examine our lives and options, who, like the tiny band of Founding Fathers, will agitate to change the system and, if need be, go to war to secure our inalienable rights.

Lots of eggs were broken in the Revolutionary War, lots of rich folks and exploiters with sinecures lost their fortunes if not their lives or liberty.

Likewise in the Civil War. Rich slaveholders, favored then like physicians are now, faced a different reality once the tiny band of Quakers and other abolitionists prevailed at great cost to society.

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