Are We There Yet?
But we are different. We do not have a Canadian health care system because we are not Canadian. The Canadian credo is "peace, order, and...
But we are different. We do not have a Canadian health care system because we are not Canadian. The Canadian credo is "peace, order, and good government." Our American credo--life, liberty, and the pursuit of happiness--is about freedom and individualism, and certainly has nothing to do with "good government." So who are we? It is important to ask that question because who we are as Americans and, indeed, how America works, will ultimately determine the structure and principles that guide the development of our health care system. In exploring who we are, and the effect on our health care system, we can best describe ourselves by ten principles:
1. Rugged Individualism: The uniquely American "rags to riches" story is set in the national self image of idealism, opportunity, and sacrifice, with origins in the "Wild West" and the Depression, in which one "pulled oneself up by the bootstraps" to get wealthy. The emphasis was on individual effort and responsibility in order to "make it." With regard to health care, since we think everyone should be able to "make it," we are reluctant to provide our tax dollars to support someone else's health care. We are charitable as individuals to individuals and we perform amazing acts of kindness and humanitarian assistance in the face of natural disasters like Hurricane Katrina. But we have no interest in supporting large groups of "faceless" people, such as the uninsured, over the long term.
2. Entrepreneurial: Americans will make money doing virtually anything; we value capitalism and the power of economic markets. This attitude is reflected in our health care system. Like other industries, the business of health care values making money. Because profit is a measure of success, any health reform measure will continue to have for-profit hospitals, for-profit doctors and for-profit lawyers. We will continue to have insurance companies, as well as drug and device manufacturers, that are in the Fortune 500. We make a lot more money than our worldwide counterparts and it shows; it is the main reason our medical care is so expensive.
3. Simple Message Personalized to Me: The media is powerful and very successful in "priming" us for certain messages, including the promotion of certain products. The focus is on the individual consumer, and most marketing communications give a short and simple "personalized message." Likewise, when it comes to complex medical information, Americans also want something simple and personal. For example, the concept of "quality medical care" is extremely complicated, and so Americans prefer to rely on the recommendation of our neighbor to choose our physician rather than seek out expert information.
4. White Teeth: Remember, we live in a country founded on "the pursuit of happiness." This translates into, "I can have everything--white teeth, a fancy automobile, and I can have it all now. I don't take no for an answer." The same is true in health care. We feel we have a "right" to whatever makes us happy and, therefore, we have a "right" to all the care we want. Americans feel entitled to any available medical service, regardless of its direct benefit. Waiting lines? Absurd. Rationing--no way.
5. Optimistic: Americans and their loved ones are always the exception: "I can beat the odds. I will live through this." Statistics are too complicated and impersonal. A number of years ago a system was created that predicted with ninety-five-percent certainty whether an individual would leave an intensive care unit alive. It performed perfectly but was never accepted. Why? It failed because the patients' families were all convinced that their relative was in the five percent who would live. This is one of the reasons we spend so much in the last twelve months of life. In many Americans' minds, death is not an option.
6. "It's the Economy, Stupid": Our own personal finances as well as the economy of the country drive our views in so many areas. During the first presidential campaign of Bill Clinton, a sign hung in his campaign headquarters with the words, "It's the economy, stupid," to remind everyone working on the campaign that the American public goes into the voting booth thinking mainly about their own personal economic well-being. In a good economy with high employment, fewer people are uninsured (because more employers are able to offer insurance, and workers have more money to purchase it). As the economy worsens, employers reduce the amount they are willing to pay for health insurance, either dropping coverage entirely or shifting more payment to the employee who is less able to pay the premiums. These actions increase the growing numbers of the uninsured.
7. The Thirty-to-Fifty-Year Liberal-Conservative Cycle: In recent times, the attitudes of Americans cycle every thirty to fifty years from liberal to conservative and back again. In a conservative world, private ownership is "king," taxes are low, government is small, individual freedom and responsibility reign, and there is a deep belief in "traditional values." Conversely, liberalism chooses the collective welfare of a society over the needs of the individual and looks to government to protect the disadvantaged, to curb capitalism, and to promote social justice. It is clear from history that overall social and economic conditions have a highly significant effect on how we feel about our health care system at any given time. This is also true with regard to our willingness to tolerate the number of people without insurance in this country and how much we challenge the status quo. The possibility for major change will occur about as often as the political merry-go-round passes the liberal brass ring.
8. Diversity: We are a country built on diversity and thriving on diversity. In political terms, we have "red" and "blue" states. Since we are so different, our elected officials must appeal to a wide variety of individuals who have varying interests and priorities. Given this marvelous diversity, agreeing on any large-scale national change is much less likely than incremental steps that offend the least number of people. States that have a more homogeneous population (for example, Maine and Minnesota) are more likely to take on initiatives that advance a particular goal, such as reducing the number of the uninsured in their state. States are laboratories for change, and many experts believe that letting states experiment with programs that address health care coverage and cost problems within their boundaries will be more feasible than large-scale efforts for the entire country.
9. Mistrust of Government: "I don't need federal or state bureaucrats who have their jobs for life (or those politicians who spend more of their time getting reelected than worrying about me) telling me what to do and spending my money. I certainly don't need to give them any more money--no more taxes." Sound familiar? Our ethic of "rugged individualism" applies here as an attitude that is anti-tax and anti-government. With this generalized mistrust of the federal government, employers as well as many individuals do not want government mandates to provide health care or to purchase health coverage for themselves. Americans may desire some government involvement like extending COBRA or unemployment benefits during an economic recession but they do not want a "government-run" health care system.
10. A Unique Government: Our government thrives on powerful groups of health industry lobbyists such as the pharmaceutical and medical device industries, insurance companies, physicians, and hospitals. These groups are likely to influence policy for long into the future because they provide generous campaign contributions for those running for office, or, they represent large blocks of voters. These various interests work alongside a divided Congress (with multiple committees, views, and rules), which make it difficult to come to any kind of consensus. For this reason, incremental health care legislation is more likely than sweeping change, mainly because of the many different groups that make up and benefit from the existing system. Similarly, our government is divided between the federal and state governments. States are required to balance their budgets, whereas the federal government is not, which means that states are more limited in the financial investments they can make with regard to any kind of health reform. While some of state-level changes have been popular, such as the Massachusetts universal coverage health program, the requirement that states balance their budgets each year often promotes long-term instability of new programs as the economic environment changes. For this reason, many believe that lasting health reform must begin with the federal government.
Characteristics of the American Health Care System Based on American Values
Any health care system reform in the United States will have to reflect the underlying principles, values, and politics that make us who we are. This is not easy, partially because the interests are so varied and may be, at times, contradictory. Not only will these American characteristics need to be satisfied in order to accomplish some kind of change in our health care system, but also the sun, moon, and the stars in the liberal-conservative cycle must also be aligned.
Have the sun, moon and the stars aligned? As of this writing, our country is closer to enacting comprehensive national health reform than in any time in our history. Yet the political partisan battle remains stridently divisive, thus jeopardizing reform's legislative viability. The political agendas continue to lose sight of the central issue: we have 50 million people without health insurance; as a group, they die a lot faster than those with insurance; as individuals, they have stories that we all know of misery and bankruptcy. It remains to be seen if the health care reform merry-go-round has finally arrived at the place in history where social policy moves politics. If the time is right and the interests align (enough), elected officials representing voters will respond, paving the road toward a rational health care system that promises basic coverage, cost control, and quality medical care for all its citizens.