Thomas C. Ricketts, PhD is a professor in the department of health policy and management and the department of social medicine at the University of North Carolina. He is the director of the North Carolina Rural Health Research Program and the Program on Health Policy Analysis at the Cecil G. Sheps Center for Health Services Research. Dr. Ricketts also serves as editor-in-chief of the North Carolina Medical Journal.
In the health care reform debate, now is the time for cooler heads to prevail. One thing we learned from the last effort to restructure our health care delivery system was that it was easier to imagine improbable losses and perversions than it was to carefully anticipate gains and improvement.
Our health care leaders themselves may be caught up in the rhetoric that tends to emphasize the negative. It’s hard to argue for a positive message when your motivations are driven by negative trends like rising costs and poor outcomes.
The opposition is following the pattern of reactionary rhetoric that Albert Hirschman wrote about. Proposals for progressive reform are often countered, in Hirschman’s view, with arguments that it will produce perverse results, jeopardize what we have, and will be futile.
The perversity argument goes something like this: If we are to cut costs by adding some element of government control, the reactionary will argue that we will only add costs–as that is what happened with Medicare. The progressive must reply that Medicare cost growth has been slower than market cost growth.
The jeopardy argument says we will inhibit technological progress and quality improvement in medical care by shackling the market. The progressive must reply that most of our real innovation has come from within controlled, non-profit systems and government sponsored research.
The futility argument claims that we cannot do anything that will actually change behavior of patients who want all they can get, doctors who want to maximize income, and government bureaucrats whose impulse is control and social engineering. The progressive must point out that the greatest gains in life expectancy in the US in the last 40 years have been for the people covered by Medicare and that universal coverage systems of all kinds have helped economies in Europe and Asia pass us by.
But most of all, we have to anticipate a reactionary rhetoric as a natural impulse of those who fear the future and only long for power. That is their way. Then we have to counter the reactionary rhetoric with a solid assessment of the likely future and probable state of a reformed health care system—better access to care, better health status for Americans and less anxiety about the financial burdens of medical care.
We have to argue, but we also have to act when health reform becomes reality.
Each of us needs to consider what we should do for the nation, our families, our neighbors, and “the needs of strangers” as Michael Ignatieff put it. The issue here is trust. We must regain our sense of trust in ourselves, our professionals, and our institutions. We will shoulder a burden in taxes and payments. Doctors and nurses will be asked to consider the needs of patients in a way that gives them both greater leeway and more responsibility.
Hospital managers will have to act wisely to maintain services for as many people as they can. Insurance companies will be asked to do what is fair for people as they become patients, in need of the help of others. We all know that we will need medical care at some time and we want to be able to trust all those who are asked and bound to provide it. At the same time, health care is what we do for others when we pay our taxes and ask our government and our community institutions to support hospitals, to train physicians and nurses, to build clinics, and to search for new cures. Let’s think more about what we as a community will gain, rather than imagine what we as individuals might lose.