Sunday, September 20, 2009

Reform

Much has been said in the media over the past few months about health care in this country. Every so often, our nation faces a crisis, and this one is serious. The reality is that our current health care system is so incredibly messed up, there really is no single solution. It took generations for it to get to where it is now, and to think that it can be fixed in a matter of months is naive to say the least.

Over the course of my education, I spent much of it focused on our health care system. Beginning in college, through law school and into the public health program, I learned more and more about our system. And most importantly, I learned about how it developed. How we got ourselves into the mess we are in. I don't think that anyone can fully appreciate the current situation without at least a basic understanding of why it is the way it is.

You have to go back years, to the turn of the century before this one, to really see how it all began. Western medicine as we know it today really took off about then. Proclaiming scientific superiority, all other ways to heal people were discounted and proclaimed inferior. Midwives were forced almost entirely out of practice. Men replaced women as the experts on childbirth, when women had been looked to for thousands of years as the experts for obvious reasons. Unfortunately, those changes weren't always for the better. And they were almost never based on any proof. The so-called science was in large part untested and unproven. And more and more women started dying in childbirth. In the so-called safer, more sanitary hospital environment, more of them died. Was it really better? I'd argue it was not, and that change was a harbinger of doom for the future of the health care system in our country.

The general population started to believe that just because physicians said they were better, that they were. Hospitals flourished. Instead of treating sick people at home, we now were bringing them to a central location. One where the germs could multiply and spread easier. And hospitals were expensive. And physicians wanted to make money.

The invention of health insurance is another critical development in our country's health care system. It grew up in a fee for service regime, intended to trust that patients and doctors would only utilize it when they needed to, and that the insurance was there the reimburse for the costs. It was a good time to be a doctor. To be a hospital. You could perform all kinds of tests and procedures, and someone just wrote you a check. Life was good. It was good, that is, until the system started to fail. When the costs got too high. When pooling the risks didn't work anymore.

At some point, the insurance companies realized that maybe this wasn't the way to go. Maybe they were paying out too much for services. Maybe all these patients didn't really need all the care they were receiving. Utilization reviews started. Prior authorization was invented. The term in-network developed. Insurance companies started to reign in payments. The problem was that the system was already set up the other way. People wanted their health care the way they were accustomed to receiving it. Physicians liked making money. And by now an entire industry was blossoming, creating technologies, pharmaceuticals and devices, and convincing people that they needed them.

Essentially what happened is that a completely for-profit system developed. We put the motivation for care in terms of the almighty dollar. Then we tried to change it to non-profit. And it is a miserable failure. We are at a point now of a disconnect between what we can provide and what we do. We have the technology to have the best health care system in the world. But out infant mortality rates paint another picture. A large portion of our population is uninsured. Some are uninsured partially by choice, not because it isn't offered, but because they can't afford the coverage offered. And there are even more people out there with abysmal coverage. People like us.

In my opinion, I think that something radical must be done. The CEOs of the insurance companies are making multi million dollar salaries, the CEOs of the supposedly non-profit entities. Nothing non-profit about those numbers. Someone is indeed profiting from the condition of our system. And they are using that money to buy influence in the government. To buy commercial time on tv and use scare tactics to convince the general population that reform is bad. They like to make people believe that things will be so much worse when the government has a role in decisions about their care. They want people to believe that their health care decisions aren't already being shaped by someone else. By them. Someone else is very much indeed already making decisions about your health care my friends, and they are doing it with their own pockets in mind. It's earning them millions of dollars.

Throw in there the mess that is Medicare and you have yourself a quandary. Medicare was set up as an entitlement system. Reach a certain age, and you get benefits. For free. There was never a means test. There was never a requirement that those eligible on the basis of age had to also be unable to pay for it. It worked great when people died at younger ages, and the ratio of working people to retirees was different. But we can keep people alive for years and years longer than we used to, thanks in large part to the hugely expensive medications. Not only are they living longer, but they are living longer with chronic medical conditions. Ones which we, as a society, pay for. Medicare needs to be overhauled. It needs to be means tested. And the age of eligibility needs to be raised. Or the entire system will fail. It is failing.

There are so many facets of our health care system that are flawed. So many misguided places for motivation. I could write about this all day, obviously. It's something I am passionate about. And it is something that we should all be passionate about. It's your life, and your children's lives at stake here. Pay attention.

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