The toxic politics of health care

Dec 13, 2013

The editors of the Journal of the American Medical Association have put together in the November 13th issue, a wide ranging collection of articles that address the current organization of health care in the US.  They say “The US health care system has reached a tipping point when there is both little doubt about the kind of change that is needed and much uncertainty about how to achieve it.”

Don Berwick, a physician and former head of Medicare and Medicaid in Washington D.C. has in my view done more than any other person to champion improvements in the quality of health care in our country.  He writes in this issue based on personal experience about the effect of the current political climate on supporting meaningful reform.  Rather than engage in discussion which could lead to action that improves our health care quality, we are dealing instead with a political agenda that seeks to capitalize on the difficulties of change.  The result of what he calls “The Toxic Politics of Health Care” is the continuation of enormous waste, and defects in care which result in poor health outcomes for millions of Americans.  The issues are already well defined.  

For example, patients, families and their health care providers clearly express a strong desire for dignified support at home in their last stages of illness.  Yet, there is overwhelming evidence that this preference is more often violated than honored.  People are much more likely to die in hospitals and are often put through expensive, invasive, and futile interventions at or near the time of their death.  We need to develop sane public policies which support better end of life care.  Instead, this needed process has been effectively derailed by unfounded political rhetoric about so called “death panels”.  

Montana itself is no stranger to this particular discussion.  We only narrowly avoided passing a law in our last legislative session that would have threatened jail time for physicians who provided potentially fatal medications to a terminally ill patient.  The immediate effect of that law if passed would have been a significant decline in the number of doctors willing to risk taking care of these people.  But the broader implications of this toxic political process are even more worrisome.

As long as the far right is stonewalling all change in our medical system, in order to try and gain more votes in the next election and the one after that, we all lose.  And this doesn’t just affect the poor uninsured folks in places like Montana who won’t be getting Medicaid coverage.  Effective progress in many important areas is currently stalled.  Issues like the obesity epidemic, patient safety, poor access, regional variation in care and costs, prevention, and archaic payment policies are unable to be dealt with in our current political atmosphere.

Dr. Berwick points out that the status quo supports a 2.7 trillion dollar per year industry, and nobody is interested in making less money.  These financial interests support lobbyists and politics that resist change. 

Some of the tactics used are well known but need to be named.  In medicine, we don’t always know the best way to treat some illnesses.  Scientific study could identify best approaches.  Yet trust and understanding of the scientific process is not at all universal.  Politics has played on these suspicions and raised the specter of rationing care.  Comparative effectiveness research has been effectively stalled because of this. 

Concern about big government is no stranger to many in Montana and other states, yet the ability of any one state to engineer its own solution to a set of national problems like this is very limited.  Stoking this federalism fear is another toxic political technique.  

American exceptionalism is another tactic.  Saying that we already have the best medical system in place because we are America is a hard argument to sustain when every international study says the opposite.  Yet we still hear that recurrent play on our patriotic feelings.

And of course, we have the American ethos of getting ahead with hard work.  Despite the reality that people born into the poorest segment of American society are the least likely in any developed nation to work their way out of that economic position, we still in many ways blame them.  Since providing health care for everyone largely means figuring out ways to help poor people, it’s easy for toxic politics to place the blame on the individuals and not on the system that created the problem.

Dr. Berwick and other writers in this issue maintain a certain optimism that progress will win out.  The Affordable Care Act remains the law of the land, the federal health care exchange seems to be working better, and positive change is in some ways inevitable if only because we can’t continue to spend this much money with such poor results.  Yet this positive change is certainly much slower and more painful than it would be if everyone together was aiming for solutions instead of political advantage.