No Pain, No Gain, This is Going to Hurt, and other Medical Metaphors

We've all had that spine-chilling moment, sitting alone in the doctor's office to reflect on what will happen imminently: the door will open, the needle in that smiling orderly's hand ready to pierce the skin. For me, that moment is always filled with dread and terror, even though I'm a big boy now, and I know that the pin prick is necessary for my own well-being. Then it happens, and for a second the pain is horrific and unbearable and thoughts of fleeing the clinic in a sprint flood the brain; and then it's over, the blood sucked out of the vein or the vaccine now touring the body's bloodstream.

America as a nation now faces such a moment. Most people agree that the health care system in America is broken, and needs a fix. Call it reform, call it whatever you want, we know it's going to hurt before we get there, and we can sense it tearing our country apart whether we do something about it, or nothing at all. Costs are spiralling out of control, 45 million + people are uninsured, and America lags behind dozens of countries on any number of healthcare indicators, including average lifespan, volume of mental disorders, children narcotized on Ritalin, and percentage of the population receiving basic health procedures. On the prevention front we are near rock-bottom in comparison to most of the Western world, binging too much on all the wrong types of food and beverage, exercising too little, and working our obese bodies too hard at largely sedentary jobs. None of this is debatable.

The system is filled with perverse incentives and features, such as patients waiting in endless lines at emergency rooms for routine care because they can't afford general practitioner visits, families dumping their money to fall below the poverty line in order to qualify for Medicaid, unnecessary medical tests administered (quite rationally) to increase profits and pre-empt lawsuits, astronomical malpractice insurance rates, and the skyrocketing malpractice awards that breed them. Insurance companies are enjoying massive profit margins while disease and pain plague the lives of the insured and uninsured. In effect, Americans spend more on healthcare per capita than anyone else, 16% of our GDP, only to get a system that lags behind many others. We are in effect getting less and spending more for it. From left to right, politicians in Washington and at the local level admit that we need a shot in the arm. As the baby boom generation prepares to retire en masse in the coming years, the issue is as important now as it has ever been.

The agreement seems to end there in our famously divided land. The system is clearly not sustainable, but we cannot seem to come to a consensus about what to do next. It should come as no surprise then that we are engaged in a political circus, as President Obama, Congress, the media, doctors, insurance companies, pharmaceuticals, and angry citizens at town hall meetings have all jumped into the fray. The exchanges have been vicious, uncivil, and filled with the types of misinformation and lies that one can expect when Washington decides to go to battle over such a critical issue and the educationally malnourished public is brought into the discussion. Make no mistake: the health care debate will affect the life (and death) of far more Americans than the Afghanistan and Iraq excursions combined. The effects will be far-reaching, involving most Americans for many decades to come.

Often lost in the milieu are the facts, the data, the straight budgetary numbers, the science, and the policies that actually matter most, if and when these things are even truly available. The dialogue is instead infused with talk of "government takeovers" and "death panels" and "socialism" and other fictional constructs designed by political demagogues to scare the living daylights out of the populace. I am now attempting to insert my own two cents on this issue, which is exceedingly complex. To preface: it's not clear what the f*** is going on as no details are even solidified yet.

Why Healthcare Reform? The concept of health care reform has simmered at the national and state level for more than half a century. It has been a pillar of the liberal platform for most of this time, at the heart of the debates about what should be provided by the government vs. the private sector. Many people, like myself believe that it is incumbent on government to provide certain basic services as a right, not a privilege, and not left to the for-profit private sector to handle. I believe this must include basic healthcare. Many others feel that funding healthcare is best left to the private sector instead.

This debate already ended long ago, if incrementally, in other spheres of public life: most do not argue against the legislation that mandates the government running public libraries. It is expected to run a police force. It should run a fire brigade. It should run public schools and universities, and mandate that all American children attend through the age of 16. It should run national, state, and city parks. It should run national defense. It should adjudicate disputes in courts of law. It should manage the waste stream. That's not to say that the private sector cannot supplement the government's work; indeed, private schools and universities, private security firms, and private libraries are all thriving in America and many receive funding, grants, and contracts from the government itself. This isn't socialism or communism. It is the common-sense approach that certain business involving the common good should not be managed by for-profit industry; and for other business, such as making clothes and other commodities, it is more efficient for the private-sector marketplace to compete for the bodies that will wear the clothes.

I get what the other side is saying: that healthcare is fine as a privatized, deregulated sector. People and businesses buy the insurance they can afford, and those who do not have it made the choice not to have it, or put themselves in the position not to get it by not making enough money. And we don't need a "government takeover" so lay off!

The Myth of Government Takeover. A closer look at our healthcare system shows that the government is already heavily involved in providing and regulating healthcare right now, and most of us take it for granted. Medicare and Medicaid insure most older people and those below the poverty line already. The Veteran's Administration (VA) system insures millions of veterans and their families, as America decided long ago that taking care of its warriors was a basic service that Uncle Sam could provide for those who put their necks on the line to keep us safe. In addition, the federal government, state governments, and most local governments have a Department of Health specifically mandated to promote public health and respond to crises, such as the potential H1N1 outbreak. Then there is the FDA which approves every new drug, the National Institutes of Health (NIH), the Centers for Disease Control (CDC), poison control centers, and the health-related functions at a broad range of agencies from fire department EMTs to FEMA to the White House to the Department of Agriculture to dozens of others. Again, it's hard to argue that the government shouldn't be funding AIDS and cancer research for the common good. Be careful what you ask for if you want the evil government to "lay off your healthcare."

Why Now? Why is the healthcare debate raging right now like a Los Angeles area forest fire? It is because we are at a massive crossroads in history. President Obama recognizes that he is in a unique and fleeting position: a president with large majorities in both houses of Congress. Democrats have traditionally rallied around the cause, but have only had a legislative and executive majority in brief and fitful spurts of American history. The Clintons had it but failed miserably to reform healthcare before the 1994 Republican takeover of Congress. The recently departed Senator Ted Kennedy made it his life's work to expand health coverage, but did not live long enough to see it pass. He did, however, make it far enough to witness the ugly debate on the issue.

The basic sticking point is quite simple. Obama is being buffeted from both sides, walking on a tightrope pulled by opposite ends of the spectrum in a violent tug-of-war: on one side is the left wing of American life, that wants health care for all funded by a "single payer," aka the government, as exists in nearly all of the civilized world except America, and on the other we have the right wing, which wants to roll back even the government programs already in place, including Medicare and Medicaid. The two sides cannot possibly meet in the middle. The rope can be pulled in one direction or the other, but in this game Obama will fall off the rope before finding common ground somewhere in the middle. His worst-case scenario, which is still (unfathomably to me) possible, is getting no reform passed.

This has been Obama's biggest failure thus far: fueling the fiction that we can end up with real reform legislation while walking this tightrope, trying to please both sides and everyone in between, achieving an impossible bipartisan consensus that will get both Republicans and Democrats and their constituents to all sign on, all the while leaving the details to Congress. As we have all learned this year, this strategy was pure nonsense from the start, with a few qualifications. That is because Washington, and by extension, Obama's leadership has become dysfunctional. An quick examination of each major party shows why.

The Republicans. Nobody has summed up the position of Republican Congressmen, a bunch badly battered from sea to shining sea in 2006 and 2008 elections, better than Senator Jim DeMint: "If we're able to stop Obama on this, it will be his Waterloo. It will break him." Finally, someone in the Republican party elucidated what most of the Congressmen feel in their hearts: here is their chance to cripple the Obama administration and his Democratic party heading into the 2010 elections. DeMint is not wrong. Stop Obama on this signature domestic issue, and it will breathe life into the Republican party, even with their own pathetic minority status. It would be David defeating Goliath. Republicans have successfully begun their misinformation campaign, renewing cries of Palin's fictional "death panels" who would decide if Grandma lives or not, a far stretch from the real and good idea of having end-of-life counseling. There is also the manufactured outrage over the question of how many additional billions of dollars the plan may cost the American taxpayers, despite the fact that it would be mere drops in the bucket when taking into account the state and national budgets as a whole. This is all folded into the fear and hatred of immigrants and poor people, fears of higher taxes, fears of losing control over choice of doctor, fear of socialism, fear of higher premiums and copays, fear of death, fear of the government itself. Any legitimacy any of these concerns may have had are long lost in the amount of hogwash being presented, which the media is lapping up. A lot of it is gaining traction as the economy is still struggling, and people are worried about their financial positions. The media loves the drama in this fight, because it's far more interesting than the data.

Senator DeMint was right, but his rhetoric is still disgusting. He is openly thrilled to admit that to Republicans, the fight is more about politically damaging Obama than it is about moving the country forward. It should come as no surprise considering that two of the biggest leaders of the conservative base, Sarah Palin and Rush Limbaugh, care more about seeing Obama fail. They represent some of the worst aspects of America's conservatives: the ignorance, the intolerance, and the lack of empathy and goodwill towards others. The other pillar of the Republican party, the business of business, has loved to help fuel the misinformation campaign.

The Democrats. Obama's party looks as weak as ever right now. Given the chance to produce healthcare reform on a silver platter, finally given the unique opportunity to run the country, the party is now on the brink of pissing it all down the drain. How could this possibly have happened? Number one is the lack of discipline. Whatever one thinks of the Bush/Cheney agenda in the first term, the administration went after it single-mindedly and strong-armed the Republican Congress to move it along. They ignored the opposition on the issue, took controversial positions, broke laws, and ran extremely effective and aggressive PR campaigns. The Democrats, on the other hand, are a bickering lot. They sway here and there with the latest political winds, their knees buckling on every issue including healthcare despite large majorities. They are further hamstrung by political deals with the trial lawyers, which prevents tort reform, which I believe is key toward eliminating a large part of unnecessary healthcare costs. The Democrats are also in bed with the insurance companies, the pharmaceutical companies, and the AMA who read the tea leaves and decided to throw their weight, and dollars, behind the Democrats. What has it all achieved? No agreement on the "public option," or an expansion of government-run health insurance that would compete with private insurance. Waffling on the tax issues, and making sweetheart deals that benefit corporations at the expense of citizens. As the poll numbers show, the party is in big trouble heading into 2010. Waterloo comes not just for Obama, but also the Democratic Party.

Obama's Way Forward. Although the situation is dire for proponents of healthcare reform, the jig is not up yet. It's no accident why Obama has left much of the bill writing to his milquetoast colleagues in Congress. There are advantages and disadvantages to this perilous approach. The Clintons were in a very similar situation before, with a Democratic majority in 1993 and most of 1994, and their strategy was to attempt to steamroll the reform through.

Obama, a student of that debacle, understands that pretending to achieve consensus, by using the town-hall forums and allowing Congress to lead on the bills, would give the appearance of bipartisanship. As we have learned, this was never going to achieve harmony. His campaign promises of bipartisanship, the expectation of a team of rivals all working towars common goals, and the dream that we are now in a new era of hope and change were not meant to be played out as we optimists hoped for.

Obama would help his cause by defining, in much more simple terms, exactly what health care reform means. There is too much manure out there that the public and media are sifting through, to the point where health care reform as a concept has no clear meaning, and no clear goals. I believe that a nationalized health care system such as that of Canada or the United Kingdom, though they have their faults and problems, is a far superior solution for us, a no-brainer. However this would never happen in the current political climate, and Obama is right on that.

Anything less is therefore incremental. Therefore, Obama needs to define what these incremental changes are, and go after them. And he needs to circle the Democratic wagons around the reforms, and ram it through. The pretense of bipartisanship and consensus should now officially end, though it was useful tactic for the earlier part of the battle. He is giving a speech on healthcare next week, which we can only hope will be a landmark Obama speech akin to his speeches on race or the economy. I hope that it will include health insurance coverage for all. Anything else would be a loss.

Health care reform is far more complicated than all of these political angles, however we have already delved far enough for one installent. In Part 2, we will dig deeper into the nitty-gritty, technical stuff: the role of doctors (where any reform of healthcare must begin and also end), insurance companies, pharmaceutical companies, HMOs, government bureaucracies, and hospitals, examining the critical role of each one. For all of these players have created different symptoms of the sick man that is American healthcare today.