Until his accidental death in 2007, Paul Gillmor spent 40 years in public office, first in the Ohio Senate and then in Congress. He had a habit of asking nettlesome questions. Sponsors of big entitlement programs almost always try to avoid those questions. Generalities serve their ends. Gillmor's questions revealed his sixth sense for a bill's weaknesses and excesses. Of course, that made him plenty of enemies. Gillmor's friends believe it also made for better legislation.
Who will ask the tough questions now, as the United States confronts reform of our system of healthcare delivery and financing? With practitioners, employers and most insurers reportedly ready to support the Obama administration's desire for major overhaul, will anyone ask those inconvenient questions?
If questions are asked, will they provoke a meaningful public discussion? Or will they be shouted in a hectoring way - a way that lets the proponents of massive reform off the hook?
More than that, will anyone in a position to influence legislation be able to ask the right questions, in the right way? Or will House Speaker Pelosi, Senate Majority Leader Reid and unconfirmed Secretary of Health and Human Services Daschle get their way and jam the bill through before it can be analyzed and amended? If the Democratic leadership gets its way, Americans could get a new healthcare financing system that restricts their access to the latest and most innovative medical technology. That will resolve some current financing problems, but at a long term risk.
Americans are demanding when it comes to healthcare. A decade and a half ago, those attitudes eventually doomed the Clinton administration's pushed for healthcare reform. The American people were not ready for radical changes in the way their healthcare was paid for and delivered. Most Americans were happy with the quality and cost of their care. They had not confronted the rationing of care that the Clinton reforms envisioned. Here's a poignant example:
During a Vancouver, B.C., conference about 15 years ago - a conference that was supposed to compare national healthcare systems around the world - representatives of the Ontario provincial system spent the better part of their allotted time disparaging the U.S. system instead of explaining their own. This made some participants uneasy. But the Ontarians had set the tone for more bashing of the U.S. system. The bashing was enlightening not just for what it revealed about the U.S. healthcare system but for what it revealed about other nations' systems:Soon, American participants were remarking that the U.S. system seemed to provide something for everyone else while failing Americans.
Then a strange thing happened. A Canadian recalled an article that had appeared several months before in Canada's national newspaper, the Globe and Mail, telling of a pregnant woman from Washington State who traveled north across the border to shop in British Columbia. She went into labor in a parking lot. Directed to a hospital, she delivered a baby boy who was below the birth weight required for extraordinary care under the provincial healthcare program. The new father arranged to get a certificate of live-birth and an ambulance and talked his way across the border back into the U.S. The baby was soon in an incubator.
The trouble with the U.S. system
The boy was fine. Unknown is whether he would have been fine if left in Canada, without the incubator. The hurried trip to a U.S. hospital might have been more traumatizing than leaving him alone. But the answer to what troubles the U.S. healthcare system became clear as participants reacted.
The Canadian who told the story did so to illustrate a point: Whether he had been the son of a migrant worker or the son of the prime minister, that baby would have received the same even-handed treatment. He would have been given the care that thoughtful Canadians - medical practitioners, ethicists, ordinary people - decided was best for the patient and the province of British Columbia. In this case, the baby would have been left to survive or die on his own, without intervention. Participants from several other countries - Scandinavians and Japanese especially - agreed: The Canadian rules, applied even-handedly, were fair.
Americans seemed stunned that so many accepted withholding care based on birth weight. An Asian participant argued that a newborn who survived a low birth weight would probably be sickly and cost the government a disproportionately high amount for medical care over his lifetime. Americans were further stunned.
Americans can't - or won't - say no. That sums up America's current problem of providing affordable, quality healthcare.
If treatment or technology is available, Americans think anyone who needs it - from citizens to illegal immigrants - should get it, regardless of ability to pay or arbitrary standards such as birth weigh. Withholding care for any reason seems cruel, inhuman. Rationalizing rationing through arbitrary measurements does not seem to be even-handed to Americans.
So out of good intentions, Americans have slipped into a different and no less insidious form of rationing. Americans do not ration care; they ration employer and government sponsored care. Not everyone is covered by job-based medical insurance; Not everyone who lacks employment-related insurance can qualify for government insurance. Those without medical insurance still get care, often at emergency rooms and public or charity clinics. That care may not be as good as employer or government paid care. Certainly, it takes more time and is less convenient. But everyone can get care.
Balancing cost and compassion
Some mistake care for insurance coverage. Many countries offer universal care, but at a lower level of competency than current technology could provide. Knowing that, citizens who can afford it opt out of the national system for a private plan. Other countries provide universal care, but have long waiting lists for treatment. Citizens with resources travel elsewhere. Country-by-country, the struggle to balance costs with compassion continues. A few small, homogeneous countries provide relatively prompt, even-handed care for their populations. But even in those countries, strains are showing as skyrocketing costs for new technology drown budgets.
Will any healthcare reform plan - especially a plan that is a blizzard of rules, regulations, "quality control review" commissions and "treatment outcomes research and analysis" boards - meet everyone's needs? The Clinton plan collapsed as voters began to understand that the plan would shift more costs to the very people who already had employer or government-subsidized care - while restricting their access to advanced treatments and curtailing medical research. The people who were satisfied with their medical care and costs would have paid more for less and the people who would benefit were those who paid low or no taxes and had bare-bones or no medical insurance.
Radnor will continue to follow healthcare reform. The American public is finally ready to accept reform - so long as certain features are included in any reform effort. Radnor conducted research during the recent German, Swedish, French and U.S. elections and found two common denominators that citizens of all four countries want - but that many Americans do not have.
Those two common denominators may become the basis for reform.
The stimulus package passed by the House includes an important - and thus far undebated - healthcare reform provision. The bill provides for a Comparative Effectiveness Research Council. The Council would identify medical procedures determined to be ineffective or too expensive. Those procedures would no longer be reimbursed under federal healthcare programs and Congress could remove the tax favored status of private plans that did not also ban them. This would be a dramatic step toward rationing of healthcare.
Tom Daschle, President Obama's choice to lead the administration's reform efforts, has advocated something quite similar - a Federal Health Board - that would determine which medical procedures and technology would not be eligible for reimbursement. Something so important as rationing healthcare should be debated, not slipped into a bill designed to stimulate the economy.
Eventually, the taxpaying voters with medical insurance overruled the Clintons. They became just selfish enough to deny the extension of medical insurance to those who opted out or could not afford to pay for medical insurance. Many, including the Clintons, called them selfish and shortsighted. Others called them anti-immigrant or racists. But give them credit for one thing: They believed that everyone should get every treatment, every technology, every medication that might help them. They just did not trust the government to do it. They were a clear majority of Americans at that time.
Of course, costs skyrocketed because those without insurance continued to receive care and those with insurance did not face treatment restrictions or new taxes. That is the background of the current crisis in affordable and comprehensive care. Future Radnor Reports will examine public opinion research that suggests what Americans will trade off and what they want to get in any reform.
What does Obama offer?
We face a competition between diminished resources and innovative technologies. Read Tom Daschle's book and you may decide that it is "Clinton Care" recycled, with a sugar coating to hide the bitter taste. Daschle and others say we are out of easy answers. We must take the bitter pill. They add a dash of guilt to their prescription: Selfishness by better-off Americans causes suffering and hardship for the less-fortunate.
What has changed since Vancouver? Innovations in medication and treatment have leaped ahead, with huge consequences for patient expectations and healthcare costs. It will be tempting to conclude that passive rationing, such as British Columbia applied to a baby boy, is the way to proceed. At least, that avoids the anguish of individual decisions.
But Americans, it seems, still believe that every single individual is entitled not just to care but to exceptional care when needed. We are so bound up in individualism that we are not good at deciding what is best for the group.
Soon, Americans will need to confront themselves about their healthcare and its financing. The world seems to be waiting.
To be continued.
copyright © 2009 Radnor Inc.