Yesterday the California Senate Health Committee killed California’s vigorous foray into health care reform, by a 7 to 1 vote, with 3 abstentions. California’s reform effort, which was modeled on Massachusetts, suggests three important lessons about ethics and politics.
1. For now, public fear of expanding government run insurance is too strong to overcome. I believe this fear is largely driven by 28 years of Republican led attack on government itself. Medicare and Medicaid have flaws, but we should ask the insurance program without flaws to cast the first stone. But whatever the source of the fear, even in a state as liberal as California, it wins.
2. We haven’t figured out how to integrate communitarian values with individual responsibility values. Like Massachusetts, California depended on a jerry-rigged combination of individual mandate and communitarian tax support. This led to political opposition from the left (the reform was not a single payer plan) and the right (the reform taxed individuals & businesses and involved governmental activism). We need a policy level vision of what every experienced clinician knows: successful health care requires both communitarian values (“you are my patient & I will not abandon you”) and tough love (“we won’t get anywhere unless you do XYZ”). Good clinicians integrate TLC and tough love seamlessly. To solve the health care reform puzzle, political leaders must do the same.
3. Health care reform won’t get anywhere until we own up to the need for rationing. In my view, cost control is ultimately an ethical problem. We in the U.S. are paralyzed by the idea of rationing. We rely on the fairy tale that efficiencies will produce painless cost containment or the hard nosed claim that “skin in the game” (financial risk for individuals) will do the job. Efficiency and individual responsibility are required, but we won't put in the necessary muscle into them until we recognize that the alternative is even more rationing. (Dan Brock's recent article - "Health Care Resource Prioritization and Rationing: Why is it so Difficult" - discusses U.S. confusion about rationing in depth.)
Happily, Governor Schwarzenegger says "I am someone who does not give up, especially when there is a problem as big as health care that needs to be fixed...One setback is just that - a setback." When the Terminator promises that he will be back there is hope that health care reform will move forward.