Five More Obstacles to Health Care Reform

The five obstacles to health care reform named in the America editorial of Aug. 31-Sept 7, is hardly an exhaustive list. Other obstacles keep getting in the way. I’ve identified five more below.

1. Distrust of government. Andrew Kohut, president of the PEW Research Center, asked rhetorically whether Medicare itself would be passed today, if a bill to establish it were up for a vote in Congress. He didn’t think it would pass, because Americans today are more suspicious of government than they were in 1965. That’s the year President Lyndon B. Johnson signed the Medicare bill into law, with an aged Harry Truman on hand as the nation’s first Medicare recipient. Readers may have their own explanations for why distrust and cynicism have grown. But it is hard to understand cynicism about the government’s role in health care because Medicare, which now has a long, positive track record, enjoys immense popularity among the seniors and others enrolled in the program. And Medicare is a single-payer, government run system. What I don’t understand is why seniors aren’t the biggest supporters of reform--that would make more sense to me.

2. Money and interest groups. Money talks. It air time, newspaper space, advertisements; it talks in Congress and in state houses. As an industry, health care makes up one-sixth of our Gross Domestic Product. Interest groups have sent lobbyists to Washington to promote their own particular interests. That seems to be the American way, but does it, can it, result in what’s best for us as a society? It is possible—indeed we may be watching it happen—to chip away at a reform package so that what starts out looking like a significant improvement, ends up a bare shadow of its original self. It will take concentration and focus for legislators not to trade away the basic reforms we need: to both expand and improve care, while also cutting costs.

3. Needing to work with systems already in place. America’s health care is currently a combination of private insurance (for-profit and not-for-profit) and government programs. It is politically unfeasible to start from scratch (anyone who thinks it is hasn’t watched the August campaign to derail reform). Still, some people wonder why Congress doesn’t expand Medicare to include more Americans, since it works, it is less expensive than private insurance, it’s popular, the program itself is a leader that other health providers follow. And the government has reason to think it can find real savings there. Again, Medicare is a single-payer option that members of both parties like.

4. Public ignorance. This may be the toughest obstacle to overcome. For the public will need to know what is actually in the proposed legislation if they are to evaluate it knowledgeably. Individuals should also know what kind of insurance they have or need. Instead, we have seen a protestor demand that government “take its hands off my Medicare.” And we’ve seen willful ignorance by commentators and members of Congress who should know better, like the assertion that Stephen Hawking, the British physicist who has muscular dystrophy, wouldn’t even receive care in Britain. Hawking, who lives in Britain, publicly refuted the absurd claim.  

5. Complexity. Health care issues are often difficult to understand; sometimes they require a level of expertise that most people simply do not have. Although medicine is based on science, it involves uncertainty and many unknowns, not just at the level of diagnosis but throughout treatment. And the stakes—life or death and quality of life—are complicated to sort out. Ethics and religion play a role. Illness, injury and disease are complicated, often not well understood, and typically connected as in “this treatment or drug can cause this side-effect, which can cause X and Y.” Prevention and treatments do not always work. Sometimes there is no cure. Health is multifaceted: body, mind and spirit are linked.

Medicine is also a big, complicated business: think of hospitals, rehab units and rest homes; think of boards, administrators, physicians, nurses, technicians, pharmacists, researchers, office workers and enough employees to maintain 24-hour care 7 days a week. Complexity makes people cautious about change; while trying to improve what is broken, one must not damage what works.