COMMENTARY

Opening Our Eyes to the U.S. Health Care Crisis

David Kerns, M.D.

Posted by invitation on 10/18/2007 on Dr. Lynne Eldridge's cancer prevention website

On a recent Sunday morning, the headlines included an American president being hammered for obstructing the expansion of health insurance to four million children, a debate among presidential candidates for the best proposal to assure health care for all Americans, labor settlements across the U.S. auto industry whose central focus was employee and retiree health benefits, a national argument about rewards vs. punishment to improve quality throughout our health care system, and polls indicating that health care is our greatest domestic concern - greater than terrorism or immigration or education or abortion or the economy. It is the year of SICKO! and SCHIP and the highest number of uninsured Americans since the advent of Medicare and Medicaid in the mid-1960's. It is the year that the death rate of U.S. infants - already a disgrace when compared with other industrialized nations - began to rise, rise, for the first time in forty years in our poorest states. It is the year that the inadequacies of the U.S. health care system exploded front and center into the national consciousness.

When asked in 2004, one in ten of us said that health care was the most important issue for American leaders to address. Three years later, in the scrum leading up to the 2008 presidential election, three times that number want the candidates to address health care as their highest priority. This growth in intensity of interest is all the more remarkable because it occurs in a competition of concern over the increasingly unpopular war in Iraq, and because it is manifest across the political spectrum. Democrats want their candidates to give as much attention to health care as to the war, and Republicans are more interested in hearing about health care than their bedrock issues - terrorism, immigration and taxes. Predictably, Democrats and Independents are most interested in reducing the number of uninsured, and Republicans in containing costs, but remarkably only 13% of Americans are satisfied with our health care system. While there is great ideological and practical disagreement about the nature of desired change, a national consensus has emerged - the status quo is no longer acceptable.

How did this surge in dissatisfaction happen? Was there a singular event, a straw that broke the back of the system or at least of perception, that led to a major shift of thought and action about health care in our country? In The Tipping Point, Malcolm Gladwell talks about how a seemingly small occurrence can lead to a cultural epidemic, the "viral" spread of an idea, that can change an aspect of society, or society itself. There is not enough historical distance or acuity of insight, at least for this commentator, to discern a precise tipping point in America's perception of itself when it comes to health care. But our disillusionment is recent and deep and undeniable, and a critical mass of our failures is in plain sight. It is impossible to objectively examine the evidence and conclude that the American health care system is just or efficient or clinically good enough.

Of all our shortcomings, the least spectacular and most lethal is our neglect of prevention. We are not so much a health care system as an illness care business. We revere specialists and undervalue generalists. We suffer the challenge of a particular conservative strategy - consumer-directed health care - which places families at financial risk for, and disincentivizes, primary preventive care. We suffer a president who evidently believes that an emergency room is an acceptable substitute for health insurance and a doctor-patient relationship. As a matter of both patient care and cost-effectiveness, Ben Franklin got it right about 250 years ago. To deal with our 21st century epidemics - of cancer and cardiovascular disease and diabetes and HIV - we need our health care system to undergo profound structural and financial reform, and deliver not an ounce, but megatons of prevention.