This commentary is by John Steen of South Burlington, who, before he retired, was a teacher of philosophy, had a 20-year career in health planning, health regulation and public health, was a professor of health policy, and is immediate past president of the American Health Planning Association.
Recently, Paul Manganiello wrote a commentary for VTDigger titled, “Health care reform needs systemic changes,” Though it’s been 14 years since I last wrote about that question, his fine judgment about it now causes me to want to add my perspective to it.
His is the perspective of a physician concerned with practicing medicine for the benefit of people. Mine is that of a philosopher concerned with how logic, moral values and politics can be used to explain what is involved in the larger questions of health care from farther upstream.
You can call my approach a gedankenexperiment, and as one who has spent his career in education, writing and teaching, I will agree. The value in this approach is to understand the ideals involved in answering the question of the best health care reform, and how much is given up by accepting compromised answers to it.
As a philosopher, I often explain concepts by starting with what we learned from Socrates, Plato and Aristotle: Politics is the highest form of ethics. (Yes, in the last 2,500 years, we have fallen far below that level of thinking in our politics.)
The delivery of health care is a very complicated process, but the principal reason it is so costly in the U.S. is that great profits are made from it. If a health system is designed to benefit those who own it and those who work in it instead of those who receive it, it will be expensive.
It is in politics that we decide how to address the welfare and the well-being of peoples in any nation, and we do that through legislation. The best legislation proposed to satisfy the goals of health care reform is H.R. 1976 (3/17/21), the Medicare for All Act of 2021, of which our Rep. Peter Welch is a cosponsor. This legislation is the current version of what has been proposed over the last half-century, starting when Sen. Jacob Javits of New York proposed covering all Americans under Medicare. There has been a bill in the House of Representatives to do that since 2003. Sen. Bernie Sanders has introduced a parallel bill in the Senate.
There is considerable support among the population for such legislation, including among physicians. The principal defect in these bills is that they would continue to fund the role of profit in health care delivery much as Medicare has done. Medicare pays bills submitted by private health care providers, and most of the health care system is in the hands and pockets of Wall Street investors.
In the United Kingdom, the socialist Labour government nationalized the health care sector after the Second World War, and today the British government still owns and operates most hospitals and directly employs most health care professionals.
Here in the U.S., the simplest plan to eliminate the profit motive would be to fold everything we have now into the Veterans Administration Health System. The VA owns and operates hospitals and clinics in every state. These are staffed by government employees, most of whom belong to public employee unions. Under the VA, all of our privately operated for-profit facilities would be nationalized, and everyone would be working for a VA salary. No one would be able to invest in the delivery of health care, for it would all be publicly owned.
Much research on our national health systems has shown the VA system to be the best-performing health care system we have, one driven by mission, not profit. That fact is suppressed by orthodox private medicine and its politically conservative supporters in order to protect medicine as a business.
All the facts about the superior performance of the VA system can be found in Phillip Longman’s :Best Care Anywhere: Why VA Health Care Would Work Better for Everyone. Longman is the senior editor at the Washington Monthly, a research fellow at the New America Foundation, and a lecturer at Johns Hopkins University, where he teaches health care policy.
Regardless of how a health system is structured, its quality will always be a function of the conscience and dedication of its caregivers, so their ethos of devotion to their patients is priceless. How ironic then for us to see profit-driven, high-cost medicine as the price we pay for incentivizing physicians to perform well, instead of as a measure of the depreciation of professional life, the corruption of medicine.
I wish to see a national debate that addresses what is needed rather than merely what is politically feasible, avoiding the trap of offering only partial solutions. We haven’t dared mighty things since the Great Society gave us Medicare and Medicaid and Bill Moyers said, “Ideas are great arrows, but there has to be a bow. And politics is the bow of idealism.” (Time Magazine, Oct. 29, 1965) It is the moral view that ennobles public discourse, and to start from a position of compromise is to start from a compromised position.
