Healthcare’s Social Imperative: Is It How We Pay, or How We Plan?
In the shadow of political debate over “Medicare for All” and other health-related proposals by presidential candidates, last month’s ruling by the US Court of Appeals reconsidering the “coverage mandate” of the Affordable Care Act adds more to the chaos over how to productively and efficiently address the healthcare needs of Americans.
With the persistent distraction about how to pay for care, we are ignoring a far more fundamental question that needs to be answered, not by elected officials, but in the hearts and minds of Americans: as a society, do we want people to be sick or well? Or, put another way, is there a social imperative for health?
Since our nation’s founding, we’ve had a social imperative for education — an aspirational vision, based on its broad social benefit, for universal literacy and numeracy of our citizenry.
While this vision remains a work-in-progress — there remain inequities of access and differences of opinion on the process and content of such education — the shared value of, and responsibility for, our educational infrastructure remains largely undisputed: every child has access (and attendance mandates) to schools and licensed teachers. While the locus of control over these systems has traditionally been at the state level, federal influence — for better or worse — has tried to reduce state-to-state variation in educational outcomes that have hindered work-life success for some citizens.
However, with regard to the health of our citizens, we do not have a parallel commitment. Currently in the United States there remain opposing sides to the question as to whether, as a society, we want people to be healthy. In fact, there are individuals and organizations who are willing to use their power and influence to sustain avoidable suffering, disease and disability (and their otherwise avoidable costs) in our communities.
As a former public health physician, my bias is that there is value in investments to reduce the burden of illness on individuals that may impede their capacity to contribute — emotionally and economically — as active, productive members of family and community; preventing health-related disruptions to work and family life improves workforce productivity and economic vitality. However, in the years since my graduation from medical school, I’ve come to understand that there are complex networks of self-interest embedded throughout the healthcare ecosystem. When pressed to shift their focus to more altruistic objectives, these emplacements make desperate attempts to protect the economic benefits of their turf, often leaving patients stranded without credible social constructs for healthcare. Confronted with increasingly complex, dis-coordinated systems — often shaped by values that do not prevail towards patients — many people face major healthcare events with doubt and confusion.
However, currently more than 70% of American healthcare expenses are subsidized: 20% by employers and 50% (or more in the case of citizens over age 65, families with children at risk and adults with special needs) are paid out of Federal and State government coffers. Hospitals may write-off care under the guise of community contribution, but then seek fund-raising donations from the same community to make up the losses. This means we are paying for each other’s care right now and will continue to do so in one way of another.
But what are we paying for? As reported in a recent article in the Journal of the American Medical Association, 20–25% of healthcare expenses — our tax dollars, business expenses, and charitable contributions — are not being spent wisely. Yet we permit unnecessary delays in the diagnosis of colon or breast cancer, and allow people to acquire bacterial pneumonia, or go blind from diabetes or glaucoma. I can think of a few other things I would like my taxes spent on other than a completely preventable stroke and the subsequent physical, neurological and economic consequences; I’d rather invest in my neighbor’s health and free other money up for law enforcement, community services and better roads.
So, before designing any framework for “universal coverage” we need to make a decision, as a nation: do we have an aspirational vision for the health of our families, friends and neighbors?
If the answer is no, then let’s stop the madness now, because just changing the way we pay for care is not going to change how much we end up paying for illness.
If the answer is yes, then the solution may be less about how we pay for care and more about how we plan for care; there needs to be a universal understanding, and acceptance of what we expect such coverage to accomplish and how.
Perhaps there is a lesson to be learned from our education imperative: our shared investment in schooling is a foundation, not a pinnacle. Is there a parallel framework we can apply to health?
A “foundational” approach to universal healthcare would not automatically pay for every illness but ensure that every American has an opportunity to optimize their health status. Just like education, some aspects could be provided to everyone via public funding, some responsibly shared via insurances or other vehicles, and some require personal investment.
This could be accomplished by starting with a universal framework for care planning that would allow us to more accurately determine the requirements, and value, of investments to improve the health of our citizens. Adoption of such a framework would allow comparative population-based planning and help us understand what is necessary to improve (or sustain) the health of both individuals and communities, and support the decision making required to determine what investments and resources would most efficiently and effectively achieve the social imperative.
Our social imperative for health should be grounded in an aspirational vision for reducing avoidable indisposition or disability, with the goal of improving or sustaining quality of health in order to be active, productive members of family and community. This starts with a universal framework for patient-centered representation of health needs based on this imperative, which can then be used to shape the intent and purpose — and value — of our 21st Century systems of care.
Steven Merahn, MD is a veteran physician-executive and Chief Executive at Union-In-Action, a nonprofit organization dedicated to enhancing the capacity of our systems of care to improve the quality of health of individuals and communities using the principles of integration, collaboration, and orchestration.