Priorities and Choices -
Health Care Reform
Published October 12, 2009 as "A doctor's
view: priorities and choices” in Oregonian
(on-line edition) and The
Author: Samuel Metz
Health care reform involves much more than money. It
involves intense personal feelings about the society we
want. These feelings too often go unspoken, even
unappreciated, making intelligent discourse impossible.
Below are key principles taken from public health care
debates. All are important to a few of us, and some to all
of us. But we can't have it all - any one is achievable,
but not every one. It's a tough choice.
Therefore, to render our discussions more productive,
identify the single most important principle for you. Once
you determine which one is most appealing, with the others
being expendable, you can brace yourself for the sobering
task of health care reform.
Ready? Remember - pick the one, and only one, most
important to you.
- Preserve our market-driven health care system;
Specifically, protect our for-profit health insurance
industry. Some of us believe that not only will our
American free enterprise system solve this problem,
but that if the solution compromises our free market
we shouldn't even solve a problem. Perhaps our
for-profit insurance company sold our family a fine
policy. Why should we give it up for an unknown,
- Provide health care to all regardless of ability
to pay, employment, or medical condition. Some other
countries (in fact every industrialized country except
us) make this their highest priority. Should we join
- Avoid increases in taxes or national debt. Taiwan
cleverly avoided this issue when collecting money for
their universal health care. "You never want to call
it a tax," said Dr. William Hsiao. "If you call it a
national insurance premium, then you're asking people
to pay for a product, not to pay a tax to some huge
government entity." Is paying a premium for universal
health care better than paying a tax? Does it matter
if the premium goes through a government agency or a
for-profit insurance company?
- Reduce costs of health care. Guess what is our
health care system's single biggest expense? Here's an
answer: Our overall cost of health care is twice that
of the average industrialized nation, but the specific
cost of administering health care (through for-profit
insurance companies) is ten times higher than our
neighbors. Is this where we should cut expenses?
- No taxes for free services; i.e., How much will I
pay for someone else to get free health care? Is it
acceptable for my taxes to provide care to those too
young or too old to work? Or too lazy, too illiterate,
or too unmotivated to pay taxes? Curiously, we believe
it appropriate that taxes taken from working people
should provide universal police service, fire
protection, and elementary education to tax-payers and
non-tax payers alike. Is health care different?
- Avoid rationing of health care; i.e., unlimited
care for all. In fact, for those of us unable to pay
out of pocket, health care in the US is rationed by
insurance administrators and occasionally by Congress.
For us, the real issue is not whether to ration health
care, but who do we trust to do the rationing?
- Improve our public health. This is tricky. What
health care measures really matter to us? Wait times
for elective procedures? Access to essential health
care? Infant and maternal mortality? Life expectancy?
Avoiding preventable complications of common diseases?
Subjective satisfaction? If we can't measure it, we
can't improve it.
- Avoid public interference in private lives. If the
only method to improve public health, reduce health
care costs, or provide universal care is to tolerate
more government responsibility, is it worth the
Now you've picked your favorite. It's time for the tough
questions. Would you protect our for-profit private health
insurance system if it meant allowing our individual
health costs to escalate? Would you accept rationing by a
regulated agency if this provided universal health care?
Would you accept more government interference in your life
if your health (and society's health) improved?
And so on. Each choice of priorities requires trading off
another. We can't have it all. Pursuing the single issue
packing the highest emotional satisfaction may feel good
initially, but it may compromise another goal, perhaps a
more important one, when we achieve it.
This is not a rhetorical exercise. The answers define our
individual visions of our health care problem. If we
explicitly understand the principles that drive us and our
fellow citizens, we can define the challenge. When we
define the challenge, we will find a solution.
What's your answer?