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“The Commitment to Mutuality is Fragile in the U.S.”, Says Berwick.

Posted on | September 25, 2018 | No Comments

Mike Magee

Earlier this month Donald Berwick published a thoughtful article in JAMA titled “Politics and Health.”  It touched on a range of themes that I addressed in a speech in 2005 at the Library of Congress.

In that speech, I said, “There is a growing political disconnect between those who make health policy and those most affected by health policy. While the former continue to reinforce silos and the status quo, the latter seek broad, fundamental and comprehensive reform. Such reform might include expansion of insurance coverage, realignment of financial incentives toward prevention, increased reimbursement of physicians and nurses for team coordination that includes home health managers, support for early diagnosis and screening, and expansion of education and behavioral modification for individuals and families.”

Berwick’s current commentary touches as well on this disconnect. He says, “Presidents, governors, senators, and congressmen take no oath to serve patients. Their oath is to a broader, vaguer duty: to uphold the Constitution. Nonetheless, their choices invade the clinical arena continually.”

The disconnect is fueled by money and power. The Medical-Industrial Complex now consumes 1 in 5 dollars, and clearly its financial objectives and the needs of everyday Americans are often at odds. As Berwick notes, “A nation that values entrepreneurship and protects private profits cannot expect that those motives will fail to engage the enormous financial opportunities through every possible channel of influence. The fragmentation of ownership, governance, and oversight of US health care makes it possible for a vast industry of political pressuring to flourish.”

Adding fuel to the fire:

1. Disagreement over state versus federal prerogatives.

2. Lack of trust in science in the era of Trump.

3. Hijacking health care in support of religious ideology.

4. An American mythology that over weights individualism and self-determination.

Without saying it, Berwick suggests that the health care battle is really a cultural battle. In his words, “Politics enters health care through attitudes toward solidarity…Government, and therefore politics, is the avenue for the expression or the negation of that sense of solidarity.”

Berwick suggests with some deference that “the commitment to mutuality” is “fragile in the United States.” He places the onus on physicians (and health professionals) subtly suggesting they lead the way stating:  “The basic credo of physicians—to put the interests of patients before their own—at its best reflects a form of solidarity: that those who are fortunate are duty-bound to help those who are less fortunate.”

Polls leading up to the 2018 mid-terms are now clearly demonstrating that the majority of Americans agree that when it comes to health care in America, Berwick is right. We are all in this together.

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