Posted on | March 8, 2017 | No Comments
Republicans this week demonstrated with clarity that further tinkering with our broken health care system will almost certainly add cost and undermine quality and coverage. To begin to define a way back home, we need to initially focus on two fundamental challenges.
Problem 1: Defining a National Health Care Vision
There is an actual “American Dream”. The phrase is attributed to New England social historian and writer James Truslow Adams. In 1931, he wrote The Epic of America in which he described “a dream of a social order in which each man and each woman shall be able to attain to the fullest stature of which they are innately capable, and be recognized by others for what they are, regardless of the fortuitous circumstances of birth or position.”
When Canada embarked on developing its national health care system in 1947, they identified the most knowledgeable and respected leaders they could find on the national, provincial, and territorial stages, and empowered them to create a mission and vision for Canadian health care.
Their output, reaffirmed in 2005, mirrored Adams vision. It said, in part, “As a nation, we aspire to a Canada in which every person is as healthy as they can be—physically, mentally, emotionally and spiritually.”
They defined a healthy nation as “one in which all Canadians experience the conditions that support the attainment of good health. The strategy identifies two goals: improved overall health and reduced health disparities.”
The U.S. skipped this critical strategic planning step and has been paying the price every since. Our government needs to appoint a representative body and charge them to create a consensus national vision and guiding principles for our nation’s health.
Problem 2: Disentangling the Medical Industrial Complex.
Seeing the premier academic medical institutions to the south veering off into speculative entrepreneurism, patent seeking, and fortune hunting, Canadian health leaders took the time to define the social accountability responsibilities of their medical schools. The set of principles linked the schools to the national health care system and stated in part that:
“Medical schools respond to the changing needs of the community by developing formal mechanisms to maintain awareness of these needs and advocate for them to be met”, and “Medical schools work together and in partnership with their affiliated health care organizations, the community, other professional groups, policy makers and governments to develop a shared vision of an evolving and sustainable health care system for the future.” In contrast, America’s premier academic health care systems chased the golden patent ring and research discovery laden profitability, leaving patient care and medical education in the wake.
Our “system” began as a series of self-interested professional guilds, industries, hospitals, insurers and government agencies which together formed a messy, unruly aggressive complex. For a time their conflicts with each other created some element of informal checks and balances on the system. But in the past half century, the major players in the sector infiltrated the government, and cross-fertilized each other to the point that they realized it was better and more profitable in the long run to collude behind closed doors than to fight with each other out in the open. Cooperating as an invisible united front, they now maintain control of policy, legislation and future profitability.
Piecemeal attempts by reformers have been easily repulsed. In 2008, Don Berwick acknowledged an absolute need for universal coverage and for organizational leadership. He called his leader an “integrator” who’s roles included guiding individual and family partnerships, primary care network building, population health, finances, and macro system integration. But compared to the Canadians, his faith in prevention versus carefully re-engineered high-tech intervention was qualified. His words: “Good preventive care may take years to yield returns in cost or population health.”
At around the same time Mayo Clinic’s CEO Denis Cortese, now director of Health Care Delivery and Policy at Arizona State University, endorsed “a U.S. Health Board modeled after the Federal Reserve Board… An independent board made up of providers, payers, and patients could focus on the complex decision making that must be insulated from the politics of Capitol Hill.” Yet, as we see today, politics remain front and center.
A few years earlier, two former NEJM editors offered their prescriptions for change inside the Medical-Industrial Complex. In 2004, Marcia Angell zeroed in appropriately on the pharmaceutical industry defining “how they deceive us and what to do about it”. But she appeared to deliberately leave academic medicine’s culpability unaddressed. A year later, Jerome Kassirer filled in the dots, focusing on “how medicine’s complicity with big business can endanger your health”.
He correctly concluded that “Like-minded people with ‘unique’ knowledge may have similarities of thought and come up with a uniform conclusion that is biased (or even completely wrong)”. Lending a term from the military, he highlighted “incestuous amplification” and recommended that, when filling governmental medical science advisory boards, the nation “save such ‘prizes’ for those with no financial ties, that is, to reward people who stay free of personal financial entanglements with industry.”
This is not the place, nor is there adequate space here to address how best to disentangle co-conspirators from industry, academic medicine and government. I will only say that where there is a will there’s a way – many ways.
President Obama realized, in looking for a starting point, that Governor Romney was on the right track in Massachusetts in 2006. Republican or not, the governor realized there had to be a plan; leaders had to held accountable; all citizens had to have mandated coverage because history had proven more than once they would not do so voluntarily. Channeling the spirit of our northern neighbors, Romney ally, Democratic Speaker of the House (MA), Sal DiMasi, spoke truth to power, “It was supposed to be a community of people where laws were made for the common wealth. That’s why we became a ‘commonwealth’. Nobody in Massachusetts will ever be turned away for health care”.
How should we re-organize to deliver health in America? That’s next.