In August I began to discuss the serious, but difficult, questions we must consider in order to create viable health care policy. This month, as we enter the “silly season” (of the election), we’ll tackle the remaining three areas: workforce, the legal system and finances.
In terms of health care policy, both presidential candidates have the same problem: Neither is willing to explain to the American people what they won’t get. Also, neither has addressed the issue of the shift in the dependency ratio – an issue that far too few Americans understand – and how this shift in demographics is driving us into recession. Health care is a victim of its own success. The number of old people is unbelievable and the fastest growing area, on a percentage basis, are those 80 and above. We cannot separate a discussion on health care from an understanding of this tidal shift in demographics.
Let’s start with the workforce question. No one has seriously asked who should be doing what jobs, what information needs to be maintained and by whom. It has long been my opinion that EDs need to run with fewer nurses and more techs. The differentiation between handwork and headwork is going to be essential, particularly with the obtaining of specific types of specialized procedures. However, since everyone is invested so heavily in their part of the system, these questions won’t be raised easily. The other workforce obstacle is that health care has failed to adapt, essentially running the same way today as it did 80 years ago. Think about it. We don’t assemble cars anywhere near the way we did when I was a child. U.S. automakers can produce the same number of vehicles with one-eighth the number of line workers as they needed in the 1950s. The world has changed and medicine has been slow to ask critical workforce questions.
The legal system is another major impediment to viable health care reform. First, every death cannot be a litigatable event. Questions of negligence need to be settled by panels of physicians and not tried in the general courts. This has essentially taken place in most of the world and we are, again, lagging behind. The fact that we continue to litigate so many frivolous issues is ridiculous and it stops us from actually concentrating on those physicians and other health care workers who truly are dangerous and should be removed from the system. The adversarial system is taking us nowhere, fast, and it’s about time we stood up and demanded better for the patients and ourselves. Physicians who would generally do the right thing do the wrong things simply because they think it’s medically-legally wise. It’s not medically-legally wise to spend money that does not need to be spent and put patients through procedures which are both time consuming and dangerous simply because they believe it might “protect their ass” in court. Nothing could be farther from the truth and we need to take aggressive steps to see that the current system is reevaluated and redirected.
Lastly, finances are always a part of the health care reform discussion. The major problem with the current presidential candidates is that they both want to use phrases like “total government health care”. What does this mean? Where does the money come from? How are we going to finance this type of activity? Here’s a little history lesson. Over the last 60 years, the United States has developed an employment-based model of health care insurance, which started as a direct result of World War II. At the beginning of the Second World War, less than five percent of people actually had a health insurance program. During the Second World War, wages were frozen and controlled by a price and wage board for the duration of the war. What were not controlled were benefits.
Kaiser Permanente in California became the first major employer to, without duress, offer health care services as a way of inducing workers to participate in their various industries. Between the auto industry and Kaiser, by the end of World War II the United States had developed the model of the employee-based health insurance which we now know in this country and assume will be the way to go. Let me be clear: I am absolutely against employee-based health care. People change jobs more often than they change their socks! This movement between jobs should not interfere with a health care product.
We need some universal standards as to what will be provided, and it should not be based solely on who you work for or whether you’ve lost your job. This kind of discussion would require a major shift in thinking, but one which is not opposed by major industries. The auto industry in the United States, for instance, feels it is at a competitive disadvantage with Asian producers because it must shoulder a relatively high cost of health care where other industries do not. You would be amazed on which sides of the line people will be found if this type of debate could ever come to fruition.
Well, there you have it; making health care policy isn’t simple. Churchill once commented that there are two things which people should not watch being made: law and sausage. The laws that will be required and the changes that will be needed for us to move into this century with a financially sound and well-funded health care product are enormous. It will take great courage and a challenge to conventional thinking for us to move in these areas.
Greg Henry, MD, is the founder and CEO of Medical Practice Risk Assessment, Inc. Dr. Henry is a past president of ACEP and directed an ED for 21 years.