Monday, May 18, 2009


In light of President Obama’s efforts to reform health care in the United States, and given the fact that I’m teaching a graduate course on Health Care Policy this summer, I decided to dedicate the next four blogs to health care reform.

This initial installment will suggest that the conceptual framework underlying much of the health care reform debate is based on discourse that is overly-idealistic and incompatible with health care as it currently exists in the United States. I shall, therefore, propose an alternative model of discourse: Health Care Realism, or the Real Model. Although the Real Model has already begun to take root (whether we like it or not) the lingering remnants of the Ideal Model continue to cloud our thinking.

The long-prevailing Ideal Model is rooted in the ethereal belief that health care is a moral system rooted in the Judeo-Christian and Hippocratic virtue of “care.” Historically, this model implied on systemic paternalism, which has been long embedded in doctor-patient discourse. Paternalism generally posits a rights-based moral relationship between “fatherly” physicians and “childlike” patients. Within this ideology, physicians are represented as self-sacrificing, duty-bound moral agents dedicated to healing their patients. In other words, patients have an inviolable, “right” to health care and physicians have a corresponding “duty” to provide it.

One of the corollaries of many duty-based (or rights-based) moral arguments is the underlying assumption that moral imperatives always trump economic imperatives. In other words, if it’s the right thing to do, then we are morally required to do it, regardless of how much it costs. This web of discourse is usually anchored by the Judeo-Christian and Kantian belief human life is of infinite value and that the cost of preserving it is morally irrelevant. Once it is established that a patient “needs” medical treatment moral discourse ends and the cost of filling that need becomes morally irrelevant. Throughout most of the twentieth century, this complex equation based on interlocking rights and duties contributed to spiraling health care costs, as physicians liberally prescribed non-competitively priced products and services (owned by other providers) to their needy, price-insensitive patients. This meant more tests, more drugs, and more hospitalization and a feeding frenzy for providers.

As long as health care providers were able to earn a comfortable living by charging non-competitive prices to price-insensitive payers, and as long as patients were insulated from those prices, the Ideal Model appeared to be a “win-win” arrangement. The Ideal Model began to erode in the 1990s when government programs (Medicare and Medicaid) and quasi-private insurance companies (Blue Cross and Blue Shield) became increasingly price-sensitive. That’s when physicians were first saddled with the added responsibility of serving as duty-bound “gatekeepers.” So while patients expected paternalistic physicians to selflessly, provide health care; public and private payers expected them to reel in costs. This steadily eroded public trust in physicians and the gradual collapse of the Ideal Model.

Although many physicians and other health care professionals and institutions still attempt to live up to the Ideal Model, the real world always has a way of undermining all otherworldly ideologies. After all, in the real world, health care providers are just as “worldly” as the rest of us. They must earn a living to support themselves and their families. Most must pay back enormous college loans, malpractice insurance and other business expenses (not to mention local, state, and federal taxes!) They also have personal mortgages, car payments, and also hope to save a few bucks for their children’s college education. Health care institutions are equally worldly. Hospitals, research laboratories, and colleges and universities still have to pay their employees, stockholders, suppliers, insurance companies, and lawyers.

As health care reform unfolds over the next year, lingering remnants of the Ideal Model will continue to obfuscate health care discourse as Idealists focus debate on providing “universal access to high quality health care at a reasonable cost.” My next three blog entries will discuss access, quality, and cost from the standpoint of idealism and realism.

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