The presidential election season is strange. Every four years someone thinks they’ve got the answer to all the problems of the world; they can fund national defense, education, health care, social security, etc… and still leave us with plenty of money for ourselves. Nothing could be farther from the truth. A government that can give you all you want must by necessity take from you all you have. We listen to candidates talk about health care problems in the United States and their answers to them, but I say it’s the same reheated mush we’ve heard before. I was the president of the American College of Emergency Physicians (ACEP) during the Clinton administration. The Clinton health care plan was dead on arrival when it reached the capital building. Not only could no one understand what was in it, they couldn’t understand what wasn’t in it. It was essentially impossible to know what the plan contained and how it was going to be funded. Unfortunately, the two current major party candidates for president appear to be mired in the same problem.

If you want to seriously look at health care reform there is only one place to start, with the service and benefits you intend to provide. Anyone can say that they want the citizens of the United States to be healthy. It’s in the specifics that we have problems. Everyone’s in favor of motherhood and apple pie but what if the apple pie has worms and mother has gonorrhea? Are you still in favor of motherhood and apple pie? You cannot say ‘yes’ to anything unless you are willing to say ‘no’ to other things. The other 17 western democracies, all of which have some degree of governmental control of health care, have at least a process in place to decide service and benefits. The question is not whether someone wants good health for the American people, its whether they honestly believe that bone marrow transplants are warranted in stage two breast cancer. If they can’t answer that question they really have no business commenting on health care initiatives in America. You have to drink deeply of this well or not at all.

The second major area of health care planning is the basic science which goes with it. The current scientific basis for medicine is moving at an astounding pace. Scientific potential, however, has gone way beyond the scientific output. When the human genome project concluded, we expected that within a few years most diseases would have been conquered. This is far from the case. More direction is needed in deciding where health care dollars should be spent and exactly what problems we want solved. The major problem in the country is not the science, it’s the application of that science in turning out positive results for the American people. For instance, I have no idea why every health care plan – at least in my state – recognizes chiropractic care. What is the scientific basis that defends why this should be maintained? It will take a government with courage to actually look at what is now being paid for and withdraw it as an option to be funded publicly.

The real question is not whether a service will be available, it’s who’s going to pay for it. Great Britain runs a health care system which clearly has two elements. About 90 percent of the care is funded by the government but there is another active 10 percent of medical services which are paid for out of pocket. It is this dichotomy between what is in the public sphere and the private sphere which is the issue. No one in the United States would be in the favor of taking away a patient’s right to receive any type of care they wish. The question is whether we as a group of citizens are willing to pay for that care and whether we think it needs to be provided on a broad distribution basis. That issue, of applying science to what will be provided, is an area where intelligence and factual knowledge of health care is absolutely required. No candidate at this point in time is willing to speak to those issues.

The last three areas which need to be discussed are the heath care workforce, legal system and finances. These questions are the very basis of any change in the health care system and require further delineation beyond what this column can provide. We’ll pick this up where we left off next month.

Greg Henry, MD, is the founder and CEO of Medical Practice Risk Assessment, Inc. Dr. Henry is a past president of ACEP and has directed an ED for 21 years.


# EPNeil Hay-Roe, MD 2008-08-15 00:37
Thank you Dr. Henry for those very insightful comments. I have no doubt that both presidential candidates are very reluctant to give any position statements other than very general descriptions - neither of them wants to bring up the unpleasant facts. Dr. Henry states: "If you want to seriously look at health care reform there is only one place to start, with the service and benefits you intend to provide." And that's exactly where both candidates are afraid that if they come out with ANY limitation whatsoever, they're going to appear unpopular to many.

This discussion is not just for healthcare people, but it isn't going to become a subject of much general discussion until we ALL feel the pain of not being able to get to a doctor when we need one.

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