Health Care Reform and 'American Values'
By PAULINE W. CHEN, M.D.
New York Times
September 10, 2009
I was born, raised and live in the United States, but recently a neighbor asked me, “What are you?”
As the daughter of Taiwanese immigrants, I have gone through this line of inquiry my entire life, so I understood that while well-intentioned, my neighbor’s question carried the assumption that I was not, at least in his eyes, entirely American.
On that day, however, I decided not to elaborate on my family’s immigration history. Instead, I threw the question back to him, hoping in part that he would tell me about the countries from which his family originated.
“Well,” I said, “tell me first, what are you?”
“I’m an American!” he replied without a moment’s thought. But then he asked once again, “So what are you?”
According to a recent editorial in The New England Journal of Medicine, my neighbor is not the only one who holds erroneous assumptions about the meaning of “American.” Dr. Allan S. Brett, a professor of medicine and bioethicist at the University of South Carolina, argues that politicians and pundits from both sides of the aisle are now doing the same, using incorrect beliefs about “American values” as a smokescreen in the health care reform debate. Phrases like “uniquely American” have become high praise, while “Canadian” and “British” are fighting words or frank defamation.
As Dr. Brett writes, “[T]he underlying premise is that an identifiable set of American values point incontrovertibly to a health care system anchored by the private insurance industry. . . .Discussions dominated by references to uniquely American individualism, uniquely American solutions, or narrowly defined conceptions of choice tell us more about the political and economic interest of the discussants than about the interest of the Americans they claim to represent.”
I spoke to Dr. Brett recently and asked him about the notion of “American values,” the assumptions made in the health care debate, and what system, if any, might come close to representing what is American.
Q. What assumptions do public figures have when they use the term “American values”?
A. They assume several things. First, that you can take just about any American walking down the street and reliably make an inference about what their views will be and what they deem important in health care. But anyone with his or her eyes open knows just how heterogeneous we’ve become in this country.
They also assume that these “American values” can be predictably translated into organizational structures. But that’s not true. One cannot assume, for instance, that if a person prizes liberty and freedom, he or she will prefer private insurance. Instead, maybe what that person wants is freedom from worries about what will happen should he or she suddenly became ill. Maybe that person wants the liberty to accomplish what he or she wants to accomplish. Those goals are better served by a seamless health care system where the individual doesn’t have to worry about what is coming from around the corner.
The concept of American values is used to tell people what they should be wanting rather than objectively trying to understand what Americans are all about.
Q. What about freedom of choice in health care? Isn’t that uniquely American?
A. There are three types of choice in health care.
The first is the choice of your preferred physician. In the most popular health plans, the choices are virtually unlimited; people can chose whom they want to see and where they want to go. But a single-payer system, for example, does not necessarily change that, since all the facilities and practices as we know them today are left in place. In fact, if you take away all the insurance restrictions we have today on whom you can see, your choice is increased.
A second type of choice is the freedom to choose a health care plan. We do want to choose our hospitals and doctors. But do we really look forward every November to choosing between one of five plans with permutations and combinations of physicians, providers in network and providers out of network? What people really want is a user-friendly system to get what they need.
Finally, the third kind of choice has to do with deciding on whatever tests and treatments you might want as a patient. But that element of choice has to be carefully handled no matter what kind of system we have because those choices affect cost. Over the last 10 to 20 years, the pendulum has swung toward patient autonomy — which is a good thing — but it has also swung to the point where doctors sometimes feel they must give patients whatever they want without thinking critically about the risks and benefits. That has led to a huge proportion of money being spent on care that is not only marginally beneficial but is also of no benefit at all. I think that if we had a way to eliminate that — which means using our clinical decision-making skills and saying no when appropriate — we would have more money to spend on care that does matter and that makes a difference.
No matter what system we ultimately decide upon, there will have to be mechanisms in place to insure that we spend money wisely.
Q. So is there anything that is uniquely “American” about our way of approaching health care?
A. Yes. We are unique almost worldwide in that we deny health care coverage to a proportion of our population.
I do not believe there are pivotally important distinctions between our “American values” and those of other Western European and North American countries, and certainly not the kind of distinctions that would prevent us from sorting out our health care system. I don’t think we are as unique as politicians make us out to be. Even if we were that unique, the important thing is to get health care right and not to harp on the uniqueness of the system we come up with.
Q. How would you envision a health care system that is imbued with “American values”?
A. In virtually every opinion poll conducted in recent years, a majority of Americans favor government guaranteed health insurance. While a single-payer system isn’t the only way for the government to guarantee coverage for all, I think one way to think of such a system is to consider it “Medicare for all.”
But such a system would have to be accompanied by a really hard look, led by medical experts and members of the community, at what works and what doesn’t, an assessment of how we can best budget our health care dollars to achieve the best possible health care outcomes. Such a system would take time and there would be hard choices, and not everyone would be happy. But we might come closer than we are to representing the interests of most Americans.