As the United States moves into the 21st century, nowhere are the long-term adverse consequences of its political choices during the previous century more in evidence than in health care. Today’s dysfunctional health care system is a palpable example of the lessons that come from our national obsession with markets at all costs. In the face of explosive evidence regarding the toll our choices have taken on our ability to protect citizens from the cost of illness and promote the well-being of our most vulnerable populations, our political leaders cling to them. Americans deserve better. During more than 60 years of work in public health and health policy, I have reached some conclusions about how to achieve meaningful forward movement in our seemingly unending national health reform struggle.
Health care reform is hardly the first issue over which the federal government has confronted the need to introduce a level of discipline and control over the private market to protect the public’s health and meet our desire for stability and reliability. Government has faced similar challenges in the areas of banking, industrial safety and transportation. Surely health care is as important to society.
Today’s approach to health insurance is a peculiar holdover from an earlier time, when medical care was far less valued and much less costly. As modern society moved to control and reduce more pressing public health risks, and as medical science and technology made almost inconceivable leaps, medicine’s relative social worth skyrocketed. To spur the growth of the nation’s modern medical industrial complex, Congress made a series of Faustian bargains, first through the guarantee of lucrative tax breaks and the promise of an unregulated market in the case of health insurers and, later, with the adoption of legal architecture in Medicare that was guaranteed to provide high profitability for hospitals and physicians. In 2003 this architecture of profitability was taken to new extremes through the distressingly named Medicare Modernization Act, which prohibits the government from negotiating the price of covered prescription drugs.
This approach has produced a system in which Americans face a one-in-six chance of exclusion from insurance coverage. It is a system that rests on an increasingly shaky foundation of voluntary employer and individual contributions, along with tax breaks skewed to the wealthiest members of society. The most vulnerable have Medicaid, but an equally large number — overwhelmingly workers with modest incomes — get no help other than at health centers, health agencies and public hospitals struggling against terrible odds to provide basic care.
This approach has also produced a supplier market like no other. The private forces that underwrite, organize and deliver care consist of a number of colossal private health insurers, as well as consolidated and entrepreneurial health care companies providing everything from specialty physician and laboratory services to nursing home care. These industrial giants, many of them publicly traded, have been enticed to the table by the promise of large profits and guarantees of total federal immunity from efforts to regulate their practices and businesses.
Our health care costs are astronomical compared with those of other nations. Our population health indicators rank poorly among industrialized democracies. And the cost of care means that our people get less of what they need. Millions go without coverage, and Medicare and Medicaid stagger under the weight of the system. Preventive investments are almost nonexistent.
The failed effort at national health care reform under President Bill Clinton taught us how difficult it is to try to address the crisis through a single federal approach. For this reason, I believe that the most important step we can take is enactment of legislation to give state leaders the resources and legal tools they need to begin addressing the crisis. Our nation has relied on state innovation before: Social Security Old Age Benefits grew out of a 1911 Missouri pension program for widows, and federal labor laws evolved from state efforts to demand basic accountability of the market. Other nations have also followed this incremental route. The modern Canadian health system is an outgrowth of a Saskatchewan experiment to ensure health care for everyone.
From a historical standpoint, it’s understandable that a large and heterogeneous country such as the United States — with a population 10 times as large as Canada’s — should move cautiously into a national program. This nation has considerable variations in underlying health care costs and customs that must be allowed to evolve over time. Population demographics vary enormously. Furthermore, pluralism is an important characteristic of the American political scene. We may ultimately decide to go the Canadian way, but it will only be after clear-cut decision making based on public awareness of all the facts, benefits and deficiencies of various approaches.
Congress could take steps to restore the state capability for innovation and initiative through a program that appropriates funds and asks for a few basic things in return: (1) universal coverage, (2) a single source of payment, (3) global budgeting, (4) quality-control measures and (5) guarantee of service. These ground rules, along with the power on the part of states to overcome federal preemption of their authority to meet these goals, would go far, in my view, toward giving us the models we need to move forward as a nation.
Taking this path will require concessions from all sides: professionals, patients and politicians. And it will require forsaking “sacred principles” on all sides. Wilbur Cohen, the onetime secretary of health, education and welfare, and a consummate politician, had an amusing and insightful response to arguments of procedure “on principle.” He would say, “Sometimes we have to give up our principles and do what’s right.”
George Silver is professor emeritus of public health at the Yale University School of Medicine. He was a deputy assistant secretary for health in the Johnson administration. This article originally appeared in the Washington Post and is reprinted by permission of the author.