In the interest of “showing my work,” and showing the process that got me to here, it occurred to me after writing my post about Political Sustainability of the US Healthcare System that I should share this. In 2014 I reached out to Don Berwick, Uwe Reinhardt, and a few others and had an interesting back and forth, particularly salient are Prof. Reinhardt’s remarks. Here’s a summary.
In 1997, Uwe Reinhardt asked a question of Americans and leaders of American health care in particular, “As a matter of national policy, and to the extent that a nation’s health system can make it possible, should the child of a poor American family have the same chance of avoiding preventable illness or of being cured from a given illness as does the child of a rich American family?” While every other modern nation has answered this question affirmatively decades ago, the US remains stubbornly divided on the answer. Our debate in 2009-2010 over the Affordable Care Act and the resultant ongoing reverberations continues to punctuate this point.
Wanted: A Clearly Articulated Social Ethic for American Health Care
Uwe E. Reinhardt, PhD
JAMA. 1997;278(17):1446-1447. doi:10.1001/jama.1997.03550170076036
In 2014, Don Berwick published an editorial in JAMA pointing out that American factionalization, dating back to the Founding Fathers, has limited our ability to act, quoting Madison, “to the permanent and aggregate interests of the community,” insofar as health care is concerned.
He argued that the “antidotes to health care’s confiscation must include something bigger, more forceful. This is the time for mobilization—not just the intellectual mobilization of clever community projects but also the political mobilization that ended the Vietnam war, began to deliver on civil rights, birthed modern feminism, and started down the long road toward equal rights for the LGBT community.”
He continued, “Who can mobilize? It will not be the health care behemoth; it is not evil, but it is too big to change itself. Instead, change will require the collective political will of those who are losing ground every day to health care’s unbridled confiscation of the future: laborers who want to protect their families, business leaders who want to survive in a competitive economy, a better-informed citizenry who want health, not procedures, and health care professionals who want not the hassles of complexity but work that adds meaning to their lives. Quite frankly, it will require leaders with the courage to take on the factional control that Madison rightly feared.”
After reading this, I was moved to write Dr. Berwick, Prof. Reinhardt and some others. I will largely confine the rest of this to the insights of the late, great Professor Reinhardt.
I noted that nearly every physicians’ professional organization in the country have already endorsed the ABIM Charter on Medical Professionalism, including its call for social justice in healthcare:
I would venture that every medical school and every health professional school would love to participate in such a discussion. I could envision this as a building and sharing collective effort starting in one city with all of the above professional stakeholders, plus the faculty of schools of population health and other academics, experts in international systems such as yourself and Dr. Reinhardt, business leaders (Paul O’Neill comes to mind), citizens and advocates, and many more, presenting work and having conversations, passing those conversations in summary form to the next group, and eventually building to a point of consensus among an important and broad coalition.
Prof. Reinhardt responded to my initial email as well:
My wife Tsung-Mei Cheng and I were part of the creation of the Taiwan health system, especially in the initial global survey of which Dr. Hughes speaks. Tsung-Mei’s classic paper on the genesis of that system is attached. It explains in detail how that country exploited a unique window of opportunity to get universal health insurance coverage virtually overnight. She may want to chime in.
But the governance system in Taiwan at that time was rather different from ours (or from theirs today). The country then was run by a highly educated and highly motivated elite that appears to have reached early on a consensus on the social ethic that was to dive Taiwan’s NHI, namely, an egalitarian ethic. The elite structured the NHI according to that ethic. Among other things, it made that elite rule out the US approach as a model from the get-go. There wasn’t a plebiscite or referendum on the issue in Taiwan, although politicians appear to have sensed that the public craved protection from the financial inroads of ill health.
As I once put it in a fairly angry essay that borders on Gruberism (after the failure of the Clinton plan; attached as well), the problem in the US is not that the plebs is confused. I believe in general that the plebs eats what it is served by a unified ruling elite it respects, here as elsewhere in the world. Recall how easy it was for a unified elite that had reached a consensus on invading Iraq, Hillary Clinton included, to make the public go along with that momentous decision even though, as country singer Alan Jackson so forthrightly puts it in one of his songs, many of the public probably did not know the difference between Iran and Iraq or what Iraq had to do with 9-11.
No, the problem in America is that the elite does not share a consensus on what the social ethic governing American health care should be. I am not sure it ever will reach such a consensus. So, in my view, any meeting of the sort you have in mind, Dr. Hughes, will end up as a Tower of Babel among the elite on the issue of social ethics. I made that point a while ago in debating Michael Cannon of the Cato Institute.
In my less cynical moments I have always found touching the solicitude with which America’s political elite professes to admire and consult the wisdom of the people whom, alas, that same elite spends so much time judiciously misinforming, to manipulate the public’s mind. In more somber moments I am reminded of de Tocqueville’s DEMOCRACY IN AMERICA (especially Chapter XV), in which he openly mocks that false solicitude when he writes that “the sycophants of Louis XIV could not flatter more dexterously” than does America’s political elite when it heaps praise upon the peoples’ wisdom. In fact, however, that political elite seeks “wisdom” and guidance mainly from the moneyed interest groups that are their financial patrons. What opulent operators of gambling dens think about in the shower in the morning, for example, surely counts for more in the way our country is run than does the wisdom of millions of the people.
True, the plebs is granted the right to change the actually ruling elite from time to time though general elections, but once in office that elite dances to the tunes of the moneyed special interests – often the same special interests, leading to the same dance by the elite in power. Was there really any significant difference in the way the Bush and Obama administrations dealt with the opulent miscreants of Wall Street? It all can explain, for example, why so many Americans simply have tuned out of the electoral system altogether and gone fishing. Therein, I admit, does lie a certain grassroot wisdom.
As it happens, I just got back from Taiwan where I delivered a lecture on The Political Economy of Health Care in the U.S. I made roughly the same points there.
Best regards,
Uwe
My response:
Uwe, would it be cheeky of me to say, “I feel your pain?”
I think it safe to say that the “liberal consensus” that resulted in LBJ’s Great Society and continued even far into Nixon’s presidency have taken on serious water in the past few decades, but I do think it is still there, in spite of, as Uwe points out, the misinformation being delivered to so many on a regular (and lucrative) basis.
Having said, that, I do believe there is much more consensus on what those of us in health care professions believe about social justice in health care than perhaps among the general public or the policy making elite. The public and elite hear what those with the most time and money in the system want them to hear, after all, and do not generally hear from the rest of us. I think voicing and amplifying that consensus and articulating it so that it can break through into regular public consciousness would not be a waste of time nor effort.
I do not expect to ever win over my uncle, a die-hard O’Reilly fan, but I could definitely work on my aunt…
Cheers,
Chris
