From the Dean: Putting the Health in Health Care
In this presidential election season, we see a renewed focus on the persistent issue of what to do about our broken health care system. The concerns seem to never change: we’re the only major developed nation in the world that does not ensure coverage for all its people. More than 46 million of our fellow citizens—men, women, and children—have no health insurance. We spend a fortune on health care—$2 trillion in 2005, or $6,700 for every American.
Approximately $140 billion of the total goes to administration, two-and-a-half times what the nation spends on “public health activity,” as it is called by government accountants. The administration cost reflects, in part, the fact that individual providers have to deal with literally hundreds of different insurance plans and variations within them.
The world-leading 16 percent of GDP (gross domestic product) that we devote to health care comes with a huge opportunity cost attached to it: less to spend on education, less on housing, less on repairing the nation’s crumbling infrastructure. Hospital bills can bankrupt even the most financially solid of middle-class citizens. Doctors have too little time to talk with their patients. And, of course, we are all convinced that we are exploited by the voracious pharmaceutical companies that subsidize controlled prices for their products in other parts of the world by jacking them up at home.
For all the money we’re spending on health care in this richest of societies, our vital statistics record is less than stellar: 29th among countries in infant mortality and 26th in adult life expectancy. Worse yet, our health status record varies, often dramatically, by race and ethnicity. The infant mortality rate (IMR) among whites is 5.7 first-year deaths per 1,000 live births. The IMR for African Americans—13.2—is more than 2.3 times larger. The African-American rate is better (lower) than that of only Romania among the 37 countries ranked in Health, United States, 2007. With some notable exceptions (suicide is one of the more intriguing examples), African Americans have higher mortality rates from nearly all causes than do whites. Overall, African-American life expectancy is more than five years shorter than that of white Americans.
That’s the bad news (and it’s pretty awful). The other side, of course, is that we have the best-trained doctors and the finest technology money can buy. Assuming you have that money, you can benefit from the highest quality health care available anywhere in the world. And most Americans do have the money. On one survey after another, 80 percent of respondents say that they’re happy with their health care.
We in public health, however, are not happy with our health care, collectively speaking. The problem begins with the fact that our “health care system” is not a system; nor does it deliver health care. With some shining exceptions, it is a sickness-care (non)system, responding to ailments as they arise and as (sick or injured) individuals approach providers for cures. Years ago we referred, far more accurately, to “medical care.” Then, as society began to distinguish health from sickness care, the medical-care establishment appropriated the very term “health care.” Indeed, the health care establishment’s public relations machine, working overtime, then decided to seal the connection between health and care by making them one word, “healthcare.” Voila! By rebranding itself, the “new” healthcare establishment obfuscated the meaning of, and need for, true health care.
What is “true health care”; or, more accurately, what would it look like if it existed? First of all, it would be a system, one that ensured access to high-quality care for all. The phrase is trite, reflecting its familiarity in conversations about our delivery system’s failures . . . and our apparent inability to resolve them. Second, true health care would place a premium on improving people’s health, and not merely grappling with their diseases. To do that, it would effectively educate the public as to what they can and should do to maximize their own health. Similarly, it would educate providers to care about disease prevention and health promotion. Perhaps more important, it would create expectations that providers would emphasize prevention and give them incentives, financial and otherwise, to do so. True health care would focus attention on the societal inequities that create unconscionable disparities in health across identifiable groups, be they racial/ethnic or socioeconomic.
How do we get here from there? I don’t pretend to have the answer. I do know that credible systems have been proposed. Their principal defect? None has figured out how to get our society—and our Congress—to bite the political bullet. The political opposition to any proposal that posits significant change in the system—and significant change is essential—will be challenged with immense resources by those institutions that benefit most from the profitable status quo.
While it’s hard to see sometimes, we have made progress on occasion, and your School of Public Health has contributed mightily to it. In 1939 Professor Nathan Sinai developed a voluntary insurance plan that became the prototype for Blue Shield. A couple of decades later, Professor Solomon (Sy) Axelrod led the charge nationally to make medical care a legitimate domain of inquiry and concern in public health. And Professor Avedis Donabedian wrote prolifically, and incredibly thoughtfully, about quality of care. Indeed, it is fair to say that the genesis of today’s research-based concern about this subject lies in his careful and important work.
That was yesterday. Today, numerous faculty in the Department of Health Management and Policy struggle daily to bring rationality and fairness to our health care system. They do so in their research and, of course, in the classroom. They lend their knowledge and insights to important governmental and nongovernmental scientific organizations. Recently, for example, at least two UM SPH faculty have chaired committees of the prestigious and important Institute of Medicine. Our faculty also take the challenge to the streets, working with citizens groups, advising political candidates, and meeting with legislators. Dozens of SPH faculty in other departments, and hundreds of their students and thousands of their alumni—you—also work daily to realize a public health vision of true health care, through their toil as health educators, their tenacious efforts to make our environment safe, their sophisticated search for the causes of disease.
With the election season upon us again, hope springs eternal. Perhaps this is the year we will seize the moment, and draw on insights from visionaries past and present to figure out, finally, how to put the health in health care. If that fails us this time, yet again, generations to come will face the challenge of reforming our health care system, as have generations past. It is a worthy quest, an important one, one to be pursued as long as it remains unrealized.
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