Priorities and Choices - Health Care Reform  Author: Samuel Metz  Date: 09/28/09

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, untested program?

• 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 them?

• 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 sacrifice?

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?

Published October 12, 2009 as the "“A doctor's view: priorities and choices” in Oregonian (on-line edition) and The Stump