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Health Insurance Reform - The Morning After


We had a seat at the healthcare reform table, but we were window dressing, not leaders. Now we must recognize, not only that life will go on, but that this bill is written in pencil. We must now assume our proper roles as the primary advocates for rational, efficient, and encompassing maximization of our patients', and the nation's, health.

Surprise to some...we're still here and the world as we know it still pretty much goes on.

But we can learn something from the rhetoric that blew, and blows, from Washington. We can learn something from the bill itself. But mostly the point of the matter that will linger is that Congress got off the dime to Do Something.

Facts not at political issue (and there really are some), include:

  1. Health care in this country costs too much;
  2. Far too many people do not have functional access to it;
  3. Health care is inefficient; and
  4. If we do not make some systemic changes to deal with 1, 2, and 3, the US will find itself in an acceleratingly deep financial hole that will reduce our standard of living and our strength in the world, all by itself. Just healthcare.

Health care is woven so thoroughly through every aspect of our lives that improving its myriad aspects, or even agreeing upon what an improvement would look like, has left us pretty much frozen in place, squabbling.

The free market has not done an adequate job in solving some of these problems, and cannot, in part because of the peculiar way in which we established the health insurance industry during and after WWII. And so, necessity has forced the clumsy hand of Congress.

In effect, to cope with wartime manpower shortages and its associated wage freezes, two things were done out of short term necessity that eventually drifted into institutionalized practice. The first was tying health insurance to employment and the second was making the benefit tax deductible.


Employers attracted new employees at a then-cheap, subsidized price, and employees received a historic new benefit - financial access to medical care.

So what went wrong?

First, newly strengthened unions and companies agreed to pile on the coverage.

Second, technology advanced further and faster than at any time in human history with a geometric increase in costs.

Third, traditionally low pay in healthcare jumped to catch up with other employees, aided by compliant insurance companies who could simply pass on increased costs from doctors and hospitals to employers, and still get rich skimming off a percentage of a booming river of unexpected premium money.

In a rapidly growing, second-half-of-the-20th-century economy (like topsy), the healthcare (sickness, actually - another column to come) sector of our economy "just growed" to reach the current 17% of GDP. Alarms were raised on all sides, but the task of making sensible the burgeoning healthcare industry was so daunting, and there have been so many other national problems along the way (pesky wars and such), that everyone on all sides has been happy to rationalize and just kick the can down the road.

What's the difference now?

One difference is that the can has gotten mighty big and heavy to keep kicking, and the accumulation of voices of concern have tapped into the mainstream of the newly-empowered Democratic party's instincts - (long overdue) social reform.

We saw similar developments as part of the New Deal, with Medicare, and the civil rights legislation of the 1960s. One could argue whether social evolution chased the Congress or vice versa, but these elements are now integral to our culture. We can only hope that what inevitably will be an ongoing debate about further changes in health services will shed a little light in addition to the ferocious heat and hot air.

The basic argument is really about who we are and how we want to live. The problem, and conceivably our strength, is that "we" are about as diverse a nation as there exists. So we argue from all points of the vested interest compass and we get worked up as we struggle with the interface between rational planning for all, and emotional parochialism.

How many docs thought that when they signed up for medical school that they wouldn't be scientists as much as sociologists, psychologists, and business people? Yet here we are, swimming for our lives and the lives of our patients, and (as always, I circle back to this point - drum roll...) we are basically not trained or prepared in any meaningful way for these important additional roles.

Docs wear many hats, so we are awfully busy to stop and better organize what we do, to more properly think things through. Yet we must step up to a new leadership role in the nation's discourse. I am almost ashamed to acknowledge how little a role doctors played in this last brouhaha.

Yes, we had a place at the table, and yes the AMA and others signed off in support of change. But we were window dressing, not leaders. We are doctors of medicine and it is our sworn obligation to defend the health of our communities, even if the people who set our curricula and manage our training are short sighted enough to send us into the world with only one arm.

It's well past the time when we should have risen up to better equip ourselves with the requisite knowledge and training to achieve a higher level of function both inside and outside our offices and hospitals. And it's long since we should have been prepared to assume our proper roles as the primary advocates for rational, efficient, and encompassing maximization of our patients', and the nation's, health.

This health insurance reform, while historic, is written in pencil, not ink, and we should bear in mind that, happily, these changes are not the Beginning of the End, but rather the End of the Beginning.

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