The sad state of health care is one of the leading issues in the presidential campaigns. Our system is a national disgrace. It costs twice as much per person as other industrialized countries, yet 47 million Americans have no health insurance, and our health lags behind most industrialized nations. And, except for those who pay extra for a boutique provider, service is often poor.
We need major transformation of our system. But without consensus on three fundamental requirements, political haggling over the matter will get us nowhere.
- First, we must ban the present system of piecemeal insurance reimbursement. The problem is not health insurance per se, but how it provides a blank check for health care professionals to do as they see fit. Think of the expensive repairs we'd all get on our cars if automobile mechanics could decide what repairs a car needs, with guaranteed reimbursement for charges.
Fee-for-service reimbursement has enticed physicians into specialties that provide excessive use of high-cost items, and away from areas with sparse insurance coverage. We need insurance that covers true medical needs, not profiteering by medical decision-makers.
- Second, there must be health insurance for everyone, without exception. A healthy society requires it. If some are not insured, everyone in the community is affected. Overall costs rise because prevention of disease drops and the uninsured must do without health care or get more expensive care in emergency rooms and hospitals.
A just society demands that we provide health care for all citizens fairly. All the great religions mandate it. "Life, liberty, and the pursuit of happiness" begins with good health.
- Third, to reduce costs and improve health, we must make evaluation of health care practices and treatments accurate and non-commercial.
Several years ago I was seated next to a woman on a cross-country flight. "I write about new drugs," she said. She was not a physician or a medical researcher, but used data from researchers on her company's payroll to write favorable medical articles about her company's drugs. It reminded me how pharmaceutical and medical devices companies influence medical practices by sending physicians on all-expense paid junkets to hear company-designed discussions of their products, financing clinical research and so-called "scientific" reports, and then promoting their products through marketing and advertising.
Yes, drug and devices companies should do research, and must be rewarded for innovation. But no, they must not be the ones to evaluate and set guidelines or rules for using their products. Assessments must be accurate and independent of those who may profit from what is assessed. Doing otherwise results in misinformation, misuse, and harm.
Why is transformation of American health care so difficult? The answer is easy -- entrenched self-interest. The health care industry ingests 17 percent of our GNP. The owners, investors and employees of Big Pharma and device or instrument suppliers reap billions in profits through the present form of insurance. Hospitals are in "arms races" to expand business with "centers of excellence" and the newest, most expensive machines. The private insurance companies get their cut out of bloated bureaucracies, overuse of services, and inflated costs. And, of all the "consumers" of health care, the wealthiest and most influential don't want to risk losing the special benefits they now have.
Unfortunately, cataclysmic change is necessary. Health care transformation is impossible without monetary loss for many who are now enriched by our failed system, so it will never come from within the industry. The electorate must insist on change through the political process, and this may mean new legislators who will work for the public interest.
To succeed, politicians must begin with consensus to eliminate financial self-interest from health care decision-making, guarantee health insurance for everyone, and restore independence in evaluation of treatments. Substantial challenges will remain, but transformation will then be possible. Thomas A. Preston, M.D., lives in Seattle.
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