For all the change represented by the election of Barack Obama, one likely goal of his administration—reform of the country's healthcare system—is decidedly not so new. Presidents as far back as Theodore Roosevelt, and as varied as Harry Truman, Richard Nixon, and Bill Clinton have all proposed national health insurance plans.
While the goal has proved elusive, it does seem that as we enter a new year and a new presidential administration, the political stars are aligning in a way never seen before: even the health insurance industry has proposed a plan to guarantee insurance coverage for every American.
The debate to come will surely focus on questions of cost and quality—as it should. But there are some even more fundamental questions that must be answered first, if we are to get passed the stumbling blocks that have, so far, prevented the United States from joining the rest of the industrialized world in offering universal healthcare for our citizens.
The first question: is access to healthcare a right? During one of the presidential debates, president-elect Obama declared it so, but for most of our history, the answer has been no. Even though making care more widely available motivated the founding of many of the hospitals that arose in the 19th and 20th centuries, it was not until President Johnson and Congress created the Medicare and Medicaid systems in the 1960s that we enshrined the idea of healthcare as a right—for those over 65 or poor. For everyone else, healthcare essentially remains a privilege. Those with means get better access and better quality.
Ironically, today we tend to think about healthcare as a right but distribute and pay for it like a privilege. That doesn't work, as the staggering costs and inefficiencies of our current system prove every day.
The second question: what role should profit play in the delivery of healthcare? Most Americans remain in denial that healthcare is big business. While approximately 85 percent of our nation's hospitals are non-profit institutions, they represent a minority within the total healthcare industry. The MRI used to diagnose your gimpy knee, for example, might have been built and sold by GE. There's little doubt that this is a wonderful technology that has benefited millions of patients, however if GE didn't make a lot of money selling MRIs, your doctor would still be relying on x-rays to diagnose your knee problem.
And it's not just GE and its corporate brethren out to make a buck, either. Most doctors work in private practice, and as such are small businessmen and businesswomen. While no doubt personally motivated to help others, doctors too seek profit for their services.
The problem is, while government, employers, and the public demand lower costs, every professional, institution, and company within the healthcare industry is trying to maximize profits. Healthcare costs are high because that is what the market bears. Ignoring the role of profit-making in healthcare is ignoring reality.
The third question: what should insurance cover? Proponents of universal coverage often say that citizens should have access to "basic" healthcare services, but nobody really knows what that means. Most Americans abhor the notion of healthcare rationing (even though our current systems rations care everyday). So what happens when your "basic" physical uncovers a rare or complicated disease whose treatment is not covered in your "basic" plan?
These are difficult questions, and it is easy to see why elected officials have so far preferred to talk in generalities about lower cost, higher quality, or more insurance. But we've been talking about these vague goals for a hundred years. If we can get beyond the platitudes and answer these three fundamental questions first, healthcare reform might yet be achievable.
