The contentions surrounding the current health care debate reflect the ignorance of most politicians about heath care. This is to be expected: they are politicians, not doctors or public health workers. However, a "look before you leap" ideology seems to have been forgotten in Washington, where legislative talks have centered around fantasized ideals rather than evidence-based policy making. One of the most level-headed players in the conversation, Obama's health care advisor Dr. Ezekiel Emanuel, has received some of the most heated and misinformed criticism about his policies.

As a pre-med, bachelor of Public Health, and health blogger, I felt that it was my obligation to join the ranks and write an article outlining my views on the current health care debate in America.

For what it's worth, I mostly support Obama's strategy, because frankly, he had to pick one, and whichever he picked was destined to be a compromise that is subject to criticism from those whose specific interests are not being addressed or prioritized. Right now he receives flak for coming off as scattered and unspecific about his intentions, yet being overly dogmatic about his own health care ideals would have gained much greater criticism. Indeed, following his speech on Wednesday, his opponents polarized themselves further from his stronger position about the public health insurance option.

In this post, I intend to summarize some of the challenges we face in fixing our nation's healthcare system, then suggest specific changes that policy makers ought to consider.

Insurance-Backed Health Care First, let's clarify some terms in the health care dialogue: Most importantly, the "health care" reform that we are talking about in America is synonymous with health insurance reform. To understand this better, it is helpful to know a bit about the history of health insurance in America. You can read my slightly longer account of the development of health insurance in America if you'd like. To summarize: health insurance in America grew out of post-war companies offering potential employees the benefit of several in-hospital days per year to treat medical catastrophes as an incentive to join their companies. As the system became more popular, employees paid a small sum out of pocket for this insurance, which was much less than the cost of paying out of pocket for actual hospital stays. This paradigm grew and expanded as more people accepted the merits of science-based medicine and saw frequent access to medical intervention as the hallmark of good health.

Thus, the health care architecture is fundamentally an insurance-based system. Healthy people who are not using the system finance the cost of care for people who need to use it. Unfortunately, "insurance," in any sense of the word, only works for catastrophe coverage. The most obvious example of this is car insurance. We don't expect our car insurance company to pay for our oil changes or new tires, but instead only for rare, expensive catastrophes. Otherwise, the system would fall apart because the amount of money we put into the system would be less than the amount that we want to take out of the system.

A recent Kaiser Family report noted that by 2019, family health insurance coverage will probably cost more than $25,000 a year. If this trend continues, the report observed, it will become increasingly difficult for employees to receive health benefits from their employers. President Obama noticed this report immediately, and during a recent convention exclaimed, "That's not just the fault of the employer, it's the fault of a broken health care system that's sucking up all the money. When are we going to stop it?" The reason I have emphasized the insurance-backed system is because I don't believe the system is broken; it's that we no longer want health insurance . but a fundamentally different approach to health.

Much of the public opinion regarding health care/insurance reform today demands the equivilant of paying the same for car insurance, yet having it cover all of our oil changes, windshield whipers, and potentially new unforeseen technologies that can make our cars run better. It's not rocket science: insurance only works if the average customer puts more money into the system than they extract. In order to get the broad scope of health coverage that many Americans demand, we would need to complealty move away from the insurance model of financing health care. And of course, everyone is asking the question, "Where does the $$$ come from?"

For the most part, this is the nature of the "health reform" being discussed around the country. We are NOT really reforming the nature of how health care is administered on a patient-by-patient basis; we are evaluating how Americans can access and pay for medical services. To give an analogy, if health care is a soup kitchen, we aren't spending very much time looking at the recipe for the soup itself, but instead modifying how people ought to stand in the line or how the ingredients are purchased. I think it's a poor strategy, because the soup itself may be inextricably linked to the efficacy of the entire kitchen. Perhaps if the ingredients had higher caloric value, we could serve more people with the same soup. Alas, politicians are not chefs, and cannot adeptly adjust the recipe. In terms of health care, the policy would benefit from greater attention being paid to the mechanism and philosophy of healthcare itself, alas, politicians are ill-equipped to legislate in that domain.

What is Health Care? If you've read my previous blog entry about how health is defined, you may agree with my stance that we don't have a particularly consistent grasp about what it means to be healthy or unhealthy. This also plays a role in the challenge of formatting policy to accommodate an ideal that we don't understand.

Perhaps an equally nebulous value for us to consider is what health care actually is. It seems that most people know that they do not want to be sick, and would like a system in place that alleviates and prevents the suffering of themselves and their loved ones. But what is the best system for accomplishing this goal? Occasionally, the western medical institution has been characterized as being saturated with stuffy and objective elitists in white coats who believe with dogmatic conviction that science and pills are the route to health.

For those who align themselves with these convictions, "good health care" means top-notch access to the artifacts of this approach to health. Yet for those who are skeptical of these conventions and the results they achieve, "alternative" forms of healing are within the domain of "health care" that an increasing lobby of Americans expect out of their coverage¹.

It may seem implicit, but the first step to getting what you want is usually first knowing what you want. There has not been enough discussion about what we really mean when we say "health care," and I cannot overstate that this is critical to producing viable reform measures. Policy Recomendations Thus, the old institution of health care is undergoing renovation, but the contractors do not have the original blueprints to the design or any architecture experience for this type of building. The following are my recommendations for health policy reform in the country.

Goals The "health reform" should have two very specific, well publicized goals: 1) To improve access to "fundamental" health services for Americans 2) To improve the quality of care given by instituting broad spectrum measures and incentives

Policy Changes Most importantly, we need to reevaluate the way that we use the word "rationing." On her bioethics blog, Summer Johnson aligns herself with former Colorado governor Dick Lamm in his position that "rationing is a real part of the healthcare system as it exists every day." The word triage is a bit more appropriate to describe the process.

Triage is the system of efficiently evaluating and sorting patients and resources during times that there are many patients and limited resources. There are many different kinds of triage. When a phone is picked up the to dial 911, the Emergency Response System is activated, which uses its own form of triage to keep careful track of what resources it is allocating in the form of ambulances, paramedics, and firefighters. Emergency Departments also use triage to sort every single patient who comes in and decide who needs what care. Ultimately, appropriately allocating patients and resources is an integral part of the medical process, and should not be discounted when considering the broad-scale of managed care. It simply cannot be denied that there is a scarcity of financial resources to adequately give everyone the amount of quality care that they would like, and HMO plans do their best to perform the difficult task of balancing patient needs with financial abilities.

We also need to be honest with ourselves about the way that money gets spent in the health care system. For example, Joe Wilson recently gained notoriety for accusing Obama of lying about whether illegal immigrants would benefit from the bill. They will, indirectly. Because of the Emergency Medical Treatment and Active Labor Act of 1986, US hospitals may not refuse treatment to anyone for any emergency medical condition. However, according to a RAND study, a relatively small percentage of public money is spent on illegal immigrants health care. It should be noted that these figures to not take into account the amount of private money that is spent, as well as the way that these costs affect hospital fees. A non-partisan study estimated that about 25 percent of the uncompensated costs that southwest border county hospitals incurred resulted from emergency medical treatment provided to undocumented immigrants.

My point is that it's hard to improve the health care system selectively. Tax-evading criminals will also benefit from health reform, but that doesn't mean we shouldn't go through with it. One solution may be to raise revenue for emergency departments with an excise tax similar to the the pone proposed in California's defeated Prop 86.

Among the two critical components I hope to see in the health care bill, a mandate for electronic health records ought to be explicit. The 2000 Institute of Medicine report, To Err is Human: Building a Safer Health System highlighted the high incidence of medical errors due to human mistakes, and the potential for electronic health records (EHRs) to reduce the incidence of these mistakes. In the last ten years, the technology available to implement EHRs has improved dramatically, yet we have not seen widespread implementation of this life and cost-saving system.

The second critical component I hope to see included in the health bill is a harsh restriction on insurance companies from denying coverage to people with pre-existing health conditions. This type of legislation will address one of the greatest concerns of those who fear that market forces are not enough to secure good health coverage for Americans. Requiring companies to cover expensive patients will force cost-saving in other areas, and increase competition between existing insurance companies.

Any leader ought to ask herself whether her legacy will be celebrated or infamous in years to come. I can only hope the dems can pull it together to present a national health care policy that is worthy of celebration.

Footnotes

I would like to explicate two of my beliefs regarding the western heath establishment:
1) Western medicine--that is, scientific medicine or allopathic medicine--is good at fixing physical problems with the body, but NOT at guaranteeing any degree of quality of life or happiness. That being said, it assumes that it is implicit that having these ailments cured is a proxy for quality of life. And when good lives are saved, it is. However, the allopathic medical system is very expensive, and there are times when it is inappropriately employed. I believe that we need to look to a fundamentally different professional domain to find practitioners whose chief concern is whether their interaction with patients guarantees happiness. Homeopathic or even osteopathic medicine are worth considering, but we must realize that each domain of medicine serves a specific purpose. You wouldn't ask a car mechanic to fix your water pipes, even though her knowledge of engineering might give her insight into those types of problems. Having a working car and working sewage is important to your happieness, but we need different types of expertise to guarantee that each is working well.
2) Health care is not, nor has it ever been, a "right" in the "natural right" sense of the word. Rather, it is begging to be seen as a natural law in the positivistic Hobbesian sense: It is a valuable resource that may improve one's standard of living, and ought to be worth putting effort into to improve and distriubute it as a primary goal of nations. ?

Published on January 14, 2010 in Medicine