Day Two: Richard Reflects
As we began our first day of meetings with community partners, I found myself constantly asking the same questions that I’ve been wondering since the beginnings of planning this trip: how did we get where we are today, and what is the true problems behind healthcare?
From the insights of Dan Goldberg, reporter at the Star Ledger, it seemed clear that the issue is much larger than the mere issue of coverage that we hear every day in the news with the Affordable Care Act. In fact, it is only once we wade past the inefficient politics of what the government ought or ought not do, that we can focus on the heart of the legislation and how it aims to better the lives of the American people. The framework of the adaptive preference rut that we have become engulfed in today can seemingly be distilled into three main issues: a deteriorating culture of health, rising healthcare costs, and a lack of coverage.
Initially, I had hoped to find out how policy and disruptive organizational work in synergy (or not) to promote better healthcare (however that is defined) and what the advantages of each were. I had hypothesized that it was the organizations that dealt with the culture of health, the policymakers who addressed coverage, and rising costs would be assuaged somehow in combination of both. What I’ve realized after today’s talk with Dr. Sue Walsh of the Jersey City Medical Center and Dave Knowlton, former New Jersey Commissioner of Health and CEO of the New Jersey Health Care Quality Institute was especially enlightening.
First, let address our culture of health. A deteriorating culture of health stems from a disappointing reluctance for patient responsibility, whether that be patients who refuse to follow the regimens that are prescribed by their doctors, or patients who feel their self-diagnosis and treatment plan from online resources outweigh a doctor’s opinion. Above all though, we have devolved into a society that emphasizes sick care, not health care. We address the symptoms of medical illness (often repeatedly) without ever resolving the root cause of a medical problem. Additionally, our legal system has reinforced the idea of defensive medicine, which causes doctors to order diagnostic tests that are often unnecessary in order to cover their bases and prevent medical malpractice suits.
All of these issues with our health culture lead us into our second problem with healthcare: rising costs. According to Dr. Walsh, rising costs when preached by the media do no refer to the costs of individual services, but rather the cost that Americans spend overall on healthcare. The notorious statistic is that over 17% of our national GDP is spent on healthcare for people in America. But why are these costs so high? Dr. Walsh attributed the rising cost to three main reasons: many Americans simply demand more healthcare (5% of Americans share a whopping 49% of the healthcare cost) because they have the money to and often order unnecessary treatments; many physicians practice defensive medicine; innovative treatments that may yield marginally better results tend to cost more. However, an issue that frustrated me is that these don’t seem to always apply to those who are poor and uninsured, or those who have poor patient responsibility by not following a doctor’s orders. At first, it seems that it is emergency visits by the uninsured and treatments to preventable visits shift costs to those who are insured. But ultimately, there seems to be a distinction between extraordinary cost of healthcare for those who can afford it, and for those who cannot.
On a first approximation, what seems to connect everything are the insurance companies. The affluent order unnecessary services, and the hospitals need to charge more to insurance companies, and as a result from the higher demand of services, the insurance premiums rise. This make it even harder for those not on insurance to buy into the system, and thus they cannot access preventative care and are treated when their illnesses are out of control and cost exorbitant amount of money. They cannot pay for their care, and this cost is shifted onto the hospital and translated into higher charges to insurance companies … which then raises premiums once again. It’s a viscious cycle that has gotten out of control.
But how did we get here in the first place? Dr. Knowlton of the NJHCQI (along with Princeton Sociology Professor Professor Paul Starr) cites adaptive preference formation and the policy trap that started from our arbitrary decision after WWII to have employer-based healthcare insurance. In path-dependent formation of systems, there is an impetus (in this case the post-WII decision) that leads to the development of a single preferred status quo. From an article written by journalist Colin Gordon,
“There is no good reason to let the distribution of jobs determine the distribution of a basic social good. This leaves many workers uninsured, burdens insured workers (for whom a decision to switch jobs, let alone to strike out on their own, exposes themselves and their families to the capricious risk-rating of private insurers), and penalizes responsible employers whose competitors (bottom-feeders in the United States, firms with socialized health costs abroad) faced no such costs.”
Given that our current system (our adaptive preference) no longer works because the circumstances no longer apply, we must change the system. But how? As Dr. Knowlton put it, the government’s role is to provide the impetus for the creation of new adaptive preferences. Just as our current system arose from a post-WWII need for employment incentives (health insurance through employers), the government needs to spur the action that allows for a more comprehensive healthcare system that covers more Americans. It is from this basis that we can begin developing changes that address the culture of health, and potentially the insufferable costs of healthcare. We saw this clearly today with the Robert Wood Johnson Foundation’s work with the ACA. Deborah Bae mentioned that the goal of the RWJF was not to cause systemic changes, as this is near impossible to do. Rather, they work from the systemic changes, such as the Affordable Care Act, in order to maximize it benefit and leverage the systematic disruption from a policy level to influence a change in health care culture.
It seems clear that the idea of an “integrated” health care system extends even beyond the health care professionals and social workers that interact with the patient, as these players can only operate as desired if our government paves a path for them to do so. It makes more sense now, that many of the non-partisan criticisms with the ACA (including Dave Knowlton) is that it is too little, too late, and doesn’t really do enough to change the culture of healthcare America. Our government does what it can amidst the storms of political warfare, attempting to build a bare framework upon which our organizations can strengthen with initiatives to alter our healthcare culture. Understanding this makes me incredibly excited to visit the Trenton Health Team and the Camden Coalition later this week to see how they are doing this. Policies and organizations finally come together, and to me it seems that only in this manner can we hope to seek meaningful healthcare reform.
