By J.T. Young on 6.23.09 @ 6:09AM
Will healthcare reform again be America's Afghanistan?
Afghanistan is the graveyard of empires; healthcare is the
graveyard of policymakers. Yet Washington reformers are massing
again at the healthcare frontier. Like their predecessors, they
will march in with flags unfurled, bands blaring, and intentions
good. And like their predecessors, they believe they have it
right this time – the country's receptivity, the politics, and
the policy. Without predicting today's outcome, it is worth
pausing to survey the past and terrain.
Today's healthcare reformers face a tall order, not only in
shaping policy but facing history. Both Afghanistan and America's
healthcare system have been most unforgiving to those seeking to
affect change on their respective landscapes.
Afghanistan is called the graveyard of empires for good reason.
Since Alexander, the invader can only hope to reach accommodation
with the indigenous. Rulers who have left their names indelibly
in the history books, have left barely a trace in that
country.
It could well be argued that Afghanistan was the final undoing of
the USSR. A failure in crafting domestic policies for its
citizens, the USSR held one claim of insuperability: its military
might. It had defeated the Nazis and still could protect Mother
Russia. When after ten years futility in Afghanistan, its
military might had been transformed into military myth, no
justification remained for the Soviet state itself.
The U.S. healthcare system has been no more welcoming to those
policymakers seeking to remake it. The case could well be made
that the failure of healthcare reform in its first year
essentially undermined the Clinton administration for the
remainder of its time in office. Truman and Nixon also tried to
create a national healthcare system without success. In contrast,
the list is also notable for its absences. FDR and LBJ, authors
of the expansive New Deal and Great Society programs, both knew
to leave well-enough alone, despite having ambitious agendas and
overwhelming political majorities.
Like Afghanistan's rugged and inaccessible frontier, the U.S.
healthcare system has evolved into a similarly perplexing
inaccessibility. Its most prominent feature, the ability of
employees to receive health insurance tax-free from their
employers, is the product of attempts to circumvent WWII's price
controls. As a result, the private healthcare system is largely
comprised of beneficiaries and providers with third party payers
between the two. This creates a bizarre dynamic separating
customers from cost, helping fuel America's health cost spiral.
American healthcare is also pockmarked with government-run
healthcare systems. Medicare and Medicaid at the federal level
pay hundreds of billions of dollars annually to provide
healthcare to tens of millions of individuals. Independent state
systems also abound. And finally, relatively straightforward
customer-provider relationships exist in areas such as eye and
dental care, where cost increases have been restrained and
quality is highly.
As odd as this mix-and-match payment-provider system is,
Americans are attached to it in large part and easily can become
opposed to change of it.
Because of the healthcare system's complexity and immensity -- it
comprises almost 18 percent of the nation's GDP -- it is
dauntingly hard to placate all the sectors and stakeholders in it
when it comes to reform. And it is correspondingly easy to
assemble a coalition resistant to change.
Reformers too are bedeviled by their own plans to bring order to
disorder. A pride of lions pales in comparison to a pride of
authorship. Reformers find it hard to alter their approach to
rationalize the healthcare system to accommodate parts of the
system's prevailing irrationality.
For these reasons, no other area of U.S. public policy has proven
so difficult to reform. Tax, energy, agriculture, trade, finance,
and a host of other policy areas have all been overhauled --
usually multiple times -- in the time since reform of the
healthcare system was attempted back in the Truman
Administration. Instead, the healthcare system at most has had
additional layers added to itself without appreciably reordering
the underlying layers. The onion has gotten larger, but it is
still an onion.
None of this is to say that America's healthcare system should
not be reformed. It should. Or even to say that it cannot be. It
can. It is just a reminder that it has not been…at least up to
this point. Despite the best of intentions and some thoughtful
policy proposals, reformers have repeatedly marched out of
America's healthcare system much the worse for wear from when
they marched into it. It will be interesting to see if in today's
attempt, the reformers make a bigger impression on the healthcare
system, or if the system makes a bigger impression on the
reformers. And if either impression is positive.
topics:
Health Care, Afghanistan
