Thursday, June 14, 2007
The Prerequisites for Progress
BY MARY ANN BAILY

I read Raymond De Vries's commentary on American health care reform with a familiar sense of frustration – the one I often have when reading bioethicists on this topic. He recounts the usual statistics about our inadequate access to health care, says that we are a kindly people and should want to help our neighbors when they are sick, and notes that somehow we seem unable to do what all other developed countries have done – put a universal coverage health care system in place. He then speaks with disdain of the policy wonks who are trying to come up with concrete designs for systems that might actually work. Poor fools! They don't realize that what we need is not action – it's TALK! We need to have a "public dialogue about cultural values" – and implicitly, until we do that, they shouldn’t even bother with those silly proposals.

This time, the bioethicist’s argument is combined with an invocation of the way Americans rise to the occasion when there is a tornado. He asks “Why can't we take care of sick people as well as we take care of the victims of a natural disaster?” And I want to ask: “Um, what associations does the word ‘Katrina’ have for you?”

I agree with Mr. De Vries that Americans have a natural impulse to help when a natural disaster strikes, but I think we also have an impulse to help when catastrophic illness strikes. One has only to look at the fundraising events held for named individuals in desperate need of medical care, and the generous contributions made to organizations that help people with specific diseases and disabilities. What we don't have are the practical structures to reliably transform our impulses into effective and efficient assistance that is sustained over time. For that, you need policy wonks and, even more important, creative political leadership.

After all, we may not have access to health care for everyone, but universal coverage for the elderly has been around since the 1960s. Although Medicare is far from perfect, it has made an enormous difference to the elderly (and to the middle-aged who would be bankrupting themselves to get health care for their parents if it didn't exist). The program is very popular. So how did it come about, given our dysfunctional cultural values? I think most analysts would say that it was the remarkable leadership demonstrated by Lyndon Johnson and his Congressional allies that got the enabling legislation passed in the face of powerful opposition.

At this point in history, I don't think cultural values are the obstacle to health care reform. Rather, I think the majority of Americans genuinely want secure access to decent health care for all at affordable cost, but are afraid it can't be done. The problem is, doing the job properly will take government action at the national level, and after seven years of catastrophic incompetence in a wide range of federal government activities (including helping people after natural disasters), it's not unreasonable to worry that a federal initiative will only make things worse.

Trying to look on the bright side during this difficult period, I’ve reflected that at least it has provided an object lesson in the importance of choosing public servants who have a genuine interest in the nuts and bolts of public policy. Thus, I’m disappointed with the dismissive tone Mr. De Vries uses in speaking of “policy wonks.” Maybe it’s only because I’m a policy wonk myself, but I’m convinced that instead of more dialogue, we need a charismatic leader committed to health care for all, and a team of competent, hard-working policy wonks ready to help him (or her) make it happen.

Finally, as a policy wonk, I can’t resist asking: “But how would you do the public dialogue, Mr. De Vries? Focus groups with bioethicists as facilitators? Town meetings? Computer chat rooms? ‘Talk to your neighbor about health care’ days?” To me, calling for a public dialogue on values as a prerequisite to health care reform without any concrete ideas about what that means and how it could be done seems like just another way of saying reform is impossible.

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