No Free Lunch for Health Care Reform
I have a dream that our next President's inaugural address
will challenge us by proposing a national health system
that is based on a revised relationship between patients
and the health professionals and institutions that serve
them.
I envision a system that provides needed medical care
as part of a social contract where all participants -
patients and providers alike - have specific responsibilities.
There are two reasons for this focus. One is that our
nation's health care problem requires a broad solution
involving the entire population. The other is that a
new, better system must be a more efficient one where
everyone does a better job. We can't afford to simply
expand today's system to those now denied access.
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Jessie
Gruman
President
and Executive Director
Center for the
Advancement of Health
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Voters should not
ask what the nation's health policy will do for
them without simultaneously considering what they're
willing to do in return. Economists say there's
no free lunch. There's no truly free medical care
either.
That means care shouldn't be denied people because
they can't afford to pay. It means medical professionals
have a responsibility to efficiently provide quality
care rather than maximizing income. It requires
them to sustain relationships with patients, based
on their patients' abilities and preferences to
participate in their own care.
But it also means that patients have obligations.
Not only to exercise, eat wisely and wear bike
helmets, but also to manage their health care when
they get sick. This shift means, for example, seeking
care from appropriate professionals only when self-care
is not sufficient, participating in shared decision-making
about treatments, taking medications as prescribed,
asking questions when directions are confusing,
and returning for follow-up care on schedule.
Those are big changes for people taught that being
a patient means being a passive recipient of health
care services - a role that their doctors and nurses
remain comfortable with.
Patients and their caregivers are already expected
to assume administrative and clinical responsibilities
once performed by others or that have been added
as medical innovations proliferate. And there's
ample and obvious evidence that many of us aren't
living up to our part of this new deal that has
quietly slipped into current health care delivery.
We struggle with our weight, we are casual in our
use of cancer early detection tests and often fail
to finish a full course of antibiotics.
But there are many responsibilities that we
do not perform because no one has explained
what the
new deal is - that it is no longer prudent to
be a passive recipient of health care -
nor provided
the information and support we need to fulfill
our new responsibilities. This raises a difficult and sensitive problem.
There's a thin, flexible line between blaming the
victim and asking people to take personal responsibility
for their health.
When a patient fails to keep an appointment because
he lacks cab fare, he's the victim. When he fails
to show up on time after being issued a transportation
voucher, he's behaving irresponsibly. Assuming,
of course, that he's literate and isn't suffering
from memory problems.
America must provide the tools we need to make
this seismic shift in our relationship with health
care. And Americans must learn and use them.
Some useful guidance may be provided by the welfare
reform debate. There was agreement that most people
had an obligation to work, given adequate training
and support services. There was also an acknowledgement
that some people were simply too impaired to succeed
in the job market.
One lesson of welfare reform was that the victim-blaming
/ personal responsibility issue was an area where
reasonable people could disagree and each side
was required to compromise. And that, regardless,
all agreed that considerable resources were required
upfront to educate and support people to change
their behavior by entering the work force.
If we're going to have a serious debate about
reforming the nation's health care system, which
everyone believes is overdue, defining and renegotiating
the social contract between health care and those
it is intended to serve will be a difficult but
critical part of the package.
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