NEJM — Health Care for All?
by M. Gregg Bloche, M.D., J.D.
Just some commments. Dr. Bloche describes the origins of state benefits such as heath care and notes that post war treatment of those who scraficed was an impetus:
In exchange for widespread sacrifice, citizens began looking to the state
to secure their welfare.
I always am taken aback when people view democratic governments as ‘the other’. As Pogo said, “We have met the enemy, and he is us.” I understand with the ridiculously low level of civil participation these days in the us, it seems like us v. them. And especially with the current administration, I definitely feel like I’m a “them” these days. But, “the state” is still us. Our government, our social contract.
The new compact is likely to start with an enhanced sense of individual obligation — to eat sensibly, exercise regularly, avoid smoking, and otherwise care for ourselves. It may include an obligation to buy insurance. Government, in exchange, can offer some protection against the threat of economic and social change that will disrupt people’s coverage by destabilizing employment and family relationships. Not only can the state provide subsidies to enable poorer citizens to buy insurance; it can, at low cost, combine people’s purchasing power and clear away obstacles to competition, empowering markets to extend coverage to tens of millions who now go without it. Government can also fashion incentives to foster evidence-based practice, health promotion, the elimination of racial disparities in care, and the reduction of medical errors.
I absolutely hate this “personal responsibility” and “individual obligtion” crap. The people who are largely harmed by issues typically cited (obese, smokers) usually either a) don’t start draining the system until they are in Medicare or b) save us money by dying young (we get all of their Medicare and Social Security money). The other personal responsibility issues, such as seeing your physician and buying your meds are at least as much economic issues as responsibility issues.
And again with the subsidiesand incentives! Many are so poor that this doesn’t help. And most don’t know how to put their risk into perspective. Why is this so incomprehensible?
What is possible is a new reciprocity of personal and public commitment, tailored to American self-reliance and the uncertainties of a global economy. This arrangement stands a decent chance of delivering near-universal coverage. Success could cement a new understanding of government’s role — not as a guarantor of easy living irrespective of striving but as an insurer of basic decency when self-reliance fails.
Ugh. Reaarange those deck chairs. Again.