Who’s it for?
Saturday, January 17 2009
As a way to tie together some recent themes on this blog, I want to ask a question: who is our health care system for?
The pat answer is “for everyone”, but that’s not entirely correct. Our health care system should be accessible to everyone who needs it, but the need is what defines and sustains the system. That is, our health care system exists for and because of the people who need it. The correct answer is sick people – especially people who are sick now, but also people who might become sick later.
The right answer cuts through a lot of false controversy. To wit: if our health care system exists for sick people, it’s obvious the “free market” is not the best way to meet their needs; sick people are exactly the people most likely to suffer in a marketized health care system. But if the system exists for or because of providers, government, or insurers, the flaws in a market approach are not so obvious.
The right answer also shows the illogic in our current system. Look at what we do: we give the FDA power to regulate medicine, (ostensibly) to protect sick people from bad drugs. We grant manufacturers a temporary monopoly on some of the drugs they create, on the theory (lately, more like a wish) that this encourages them to develop better drugs for sick people. But some drugs can be both good and bad, so we also require a prescription for many drugs. Then we license certain people to write those prescriptions to ensure that sick people get the right dose of the right drug. All this we do for the benefit of sick people (again: ostensibly), but it does have one major downside: it makes medicine a lot more expensive and difficult to obtain.
If we’re doing this much on behalf of sick people already, isn’t the rationale for universal health care kind of… obvious? With this much intervention so far, it’s surprising the whole thing isn’t government-run already. Of course, most people who think health care should be a “free market” aren’t arguing we should dismantle the FDA, nor end physician licensing, nor rescind patent protections. They’re not against all market distortions on behalf of sick people – just the one that would help sick people afford the final product. If the only other alternative was not being able to afford the medicine I need (i.e. dying), I would honestly prefer to see the whole edifice destroyed. That may sound selfish, but these protections are supposed to be helping people like me in the first place.
It really is this simple: health care is for sick people. And if the need for universal health care follows from the premise, it also follows that sick people ought have a say in the matter. Yet there are relatively few high-visibility people talking about our health care system – and its reform – from the perspective of someone who is sick. I don’t count as high-vis, but nice try.
Read people like Ezra Klein, Jonathan Cohn, Jason Rosenbaum and other high-profile health policy bloggers: none seems to have first-hand experience with health care. Maybe I’m wrong, but I don’t get that from their writing. But for comparison’s sake, imagine if they were the voice of progressive blogging about immigration, or Affirmative Action, or reproductive freedom. There’d be a problem, right? And this is a problem endemic to the health care debate at large, as near as I can tell.
The result, it seems to me, is a bit of muddle as to who and what we’re talking about. Take Ezra for example: his archives show 10,400 resluts for “health” and 235 for “sick” or “ill”. For Jason, it’s 294 to 21, and so on. I do trust the sincerity and earnestness of their views, but empathy alone won’t get them everywhere they need to be – so they end up missing some of the urgency and humanity of this issue. Compare a progressive health care blog to a doc-blog on the other side: it’s clear who has a dog in the fight. That kind of intensity resonates for many people in a way straight wonkery does not.
Don’t get me wrong: I’m grateful that people like Ezra and co. are out there advocating on my behalf. Even more so, I’m excited that health care reform looks like it might actually happen, and glad for leaders like President(-elect) Obama, Tom Daschle, and Ted Kennedy pushing this issue forward. Believe you me that I will celebrate for the rest of my life the day President Obama signs a good universal care bill into law.
But as a sick person, when I see these things being done for sick people, I also can’t help but feel a tinge of regret that they aren’t being done by or with sick people. Of course, if I criticize policy wonks for not blogging about sick people, I also have to criticize sick people for not blogging about policy. There are some strong blogs run by sick people – A Chronic Dose, Six Until Me, Sick Girl Speaks and so on – but they have been mostly silent on health care reform. I sympathize: our system teaches patients whatever our problems with illness, there are only clinical solutions. Moreover, there’s a stigma attached to talking about the experience of illness as a societal problem, rather than a personal problem; I don’t understand it, but I definitely feel it.
I hope the next year or four or eight changes some of this – that health care reform helps erase some of the confusion about illness as a societal problem. I would feel a lot better about that process if the people running it showed more interest in the lives they’re proposing to transform, or if the people living those lives showed more interest in the process. And of course, I would feel best about both.
