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11.10.08

Can Obama Solve America's Health Care Crisis?

We need safer hospitals, electronic medical records, and dozens more improvements to our antiquated system.

Universal coverage is just the beginning—we need safer hospitals, electronic medical records, and dozens more improvements to our antiquated system.

Like millions, I recently watched a late-night televised appearance by Bill Clinton and Barack Obama. They were speaking in Kissimmee, Florida, of all places—not too far from where I grew up and nourished plans to become a doctor even though I can only recall seeing the doctor once, when I broke my arm in junior high. (It was set badly. For much of my childhood, our family of eight went without health insurance.) Along with tens of millions, I’d watched campaign coverage veer from one topic to another, with pundits finally agreeing that an economy in free-fall was Issue Number One. No argument that night and on that score, from either past president or soon-to-be president-elect. But what about health care? When asked in a debate if health care is a privilege or a right, Obama did not hesitate. A right, he answered, reflecting on his dying mother’s humiliating skirmishes with her insurers. For McCain, and in the current system, health care is a commodity you shop for and buy.

Patients and providers and employers alike need a new New Deal. And it looks like we might just have a Rooseveltian visionary—pragmatic, bold—headed to Pennsylvania Avenue.

It’s a mistake to think of health care as distinct from Issue Number One. The health-care crisis—and that’s what it is—is a big part of the economic challenge facing a country that we’re now told is entering a recession. Like most doctors, I don’t know enough about health-care financing, but I do know this: with outlays like those registered in the United States, surely we should have universal coverage. Surely we should have a more effective, more modern, way of improving both our hospitals and clinics. Surely we should have a safer system. (Quick: what is the eighth-leading cause of death in the United States? Medical error.) With his inimitable style and Dickensian eloquence, President Clinton put it this way: as regards health care, he said, “you’ve been sold out to a fare-thee-well.”

So we have. We spend more than any other nation on health care—now pushing 17% of the GDP, almost twice what is spent in Britain and other affluent democracies—and get less return on our investment. We compare unfavorably, in terms of health outcomes, with almost all the other industrialized nations. The most disturbing fact is that, despite huge differences in costs from one state to another, there isn’t a correlation between is the amount spent and health outcomes: an extra few thousand dollars per capita doesn’t buy us much of anything. Employers, responsible for the majority of insurance, are looking to dodge their obligations, grumbling that they can’t compete in the global economy because of the rising costs of health care.

Patients and providers and employers alike need a new New Deal. And it looks like we might just have a Rooseveltian visionary—pragmatic, bold—headed to Pennsylvania Avenue. Not a moment too soon.

I am writing this from central Haiti, where I’m a volunteer doctor, but last Tuesday night I was in Boston, glued to the tube. I was with friends, including medical colleagues, almost all of them Americans and most of us die-hard Obama supporters. We had a guest from the U.K., Sir Brian Jarman, a general practitioner from London. The honorific derives almost certainly from his long support of, and participation in, the National Health Service—that vaguely redistributive (or as some would allege, socialist) plot to provide a medical safety net to all Britons. I invited Jarman, who is visiting as a guest of the Institute for Healthcare Improvement (IHI), to come to the classes I teach with a great American doctor, Jim Yong Kim, at Harvard. (Full disclosure, as print journalists often goofily add: Jim is my best friend from medical school. We’ve worked together for over 20 years and founded, along with others, Partners In Health, which provides health care to the poor in ten countries, including Haiti, Rwanda, and the United States.) Jim and I had invited the founder of IHI, Dr. Don Berwick, to address our class and we thought it would be a good idea to have Sir Brian meet the students, too. The students are concerned about the future of health care and about their chances of being effective practitioners in a system that, in spite of its highs and lows, is broken. As physicians-in-training concerned about health-care costs, efficiency, coverage, and safety, these students have been sold out to a fare-thee-well, too. They’re not opposed to bold change. Although we often read about the medical profession’s opposition to national health insurance, I almost never encounter it among my students.

Listening to Drs. Kim, Berwick, and Jarman reflect on what ought to be done gave me hope. They’ve made the right diagnosis—all agreed that it’s the system itself that is broken and tinkering won’t fix it—and had some smart prescriptions. Policies and plans won’t suffice, warned Jim Kim, who’s made a long study of the gap between aspirations and the care that is actually delivered. We need a social strategy, one that will engage Americans eager for a major overhaul of the system. Make hospitals safer, said Don Berwick, who, though an American, was also knighted in Britain for his work averting deaths due to medical error and inefficiencies. We need electronic medical records, said both. (It can’t be that hard: Partners In Health has developed an EMR in Haiti and Rwanda, for heaven’s sake.) Assess each hospital’s performance for age-adjusted death rates, counseled Brian Jarman. And why not extend Medicare, or something like it, to all? (Bush has twice vetoed extending insurance for all children). He also observed that as long as we speak of the “health care industry,” rather than a health service, we should expect to see costs continue to rise. Sober estimates suggest that the magic of the market will have us spending more than 25% of our GDP on health care within a couple of decades. That’s a lot of dosh, as the Brits say. While I have no gripe with spending money on health care rather than pre-emptive military adventures or the bloated Farm Bill, what about education, green energy, fixing dilapidated public infrastructure (from bridges to broadband), and keeping Americans from losing their homes? And as in Haiti and many other poor countries, the drop into destitution—here, that means hunger and death; in the United States, that means foreclosure or choosing between heating your house and filling your prescriptions—is often triggered by illness and catastrophic health expenditures.

You don’t have to be an expert in health policy, I hope, to be part of the much-needed national discussion about how to improve both health and health care. But, happily, we do have experts on the topic, real experts of a different stripe than those so designated over the past decade (years during which banking regulation was in the hands of deregulators, environmental policy was ceded to polluters, and energy policy was dictated by the carbon-fuel cabal, to name just a few recent Orwellian developments). We need a bold new plan, and if we link sound policy to the groundswell of support for safe and equitable health care, this will be the time to extend insurance to all Americans. The impact such developments could have in places like Haiti, and throughout Latin America and Africa, would be enormous, too. Right now, it’s rare that citizens of the global South look north for inspiration, but that can all change.

Lots of health-policy experts are advancing dueling plans, and it takes real expertise, perhaps, to understand the fine print (“ Now you miss us policy wonks,” Clinton, husband of an encyclopedically informed health-care policy wonk, said in Florida). Jim Kim, one of the most visionary doctor-wonks I know, has been pushing from Harvard for an Institute for Health Care Delivery to go the final mile and make sure that we can move from policies and plans to real improvements in the prevention and care that Americans, young and old, need.

More disclosure: Jim Kim and I are part of a loose confederation called “Doctors for Obama.” But we’re doctors for Obama in the hope that we can be good doctors to our patients, regardless of social standing or party affiliation. Only a few days after the most remarkable and uplifting election in living memory, it’s not too soon to hope that our new president will call on the best and the brightest to help us make medicine live up to its promise. Are Americans today really opposed to FDR-style social insurance? We can learn something from the British on this score (OK, maybe not as regards dental plans) and from groups like IHI and visionaries like Kim. Patients (and who is not one, as some point?) and doctors alike may need to dig deep to find our inner New Dealers, but it’s high time we built a real social movement for a proper health service worthy of the American people.