Guest Post by Michael Stehney, M.D., M.P.H.
Wow, your blog is impressive! I’m amazed at how deeply you’ve delved into this convoluted business of healthcare reform, and how broad your thinking is. Not just issues like cost-benefit and quality, but political, cultural, ethical, and moral questions as well. So my basic critique comes down to ‘Right on!”
I couldn’t agree more that empathy, compassion, and dialogue are key to any reform. The changes we need won’t work if simply imposed from above or left to the amorality of ‘market forces.’ There must be participation at the grass roots level, not just for ‘buy-in’, but as an exercise in participatory democracy.
I used to keep up on these things. My MPH area of concentration was health policy and management. But when decade after decade, efforts to contain costs and improve quality had little to show, I had to ask myself: what’s really going on here?
The answer, of course, is that our healthcare system is merely a reflection of our larger political and economic system. You can’t change it in isolation. The status quo suits our country’s most powerful interests just fine. They don’t see a problem because they’re invested in hierarchical systems of domination that perpetuate racism, patriarchy, sexism, agism, income disparities, etc. So they nibble around the margins for show.
It shouldn’t surprise us that changing the system is so difficult, because it’s a truly revolutionary task. But a revolution must be moral or else it’s not a revolution, and to be moral it must be first and foremost non-violent. That’s where your empathy and dialogue come in, and the models you cite are intriguing ways to promote them. We all know the American healthcare system is expensive, wasteful, and potentially dangerous. Over the past forty years there has been no end of hand wringing and finger pointing. But despite countless initiatives —DRG’s, HMOs, ACOs, Quality Indicators, Pay for Performance, EHR’s, Patient Empowerment, Value-Based Payment, Bundled Services, Safety Initiatives, you name it—the bigger picture hasn’t changed much. Costs keep going up, but the health of our communities doesn’t.
Which should come as no surprise if “Every system is perfectly designed to get the results it gets.” The American healthcare system was never designed to improve the health status of the American population, or even the health of individuals (though it accomplishes the latter for the fortunate among us as a secondary result). What it’s designed to do is maximize the consumption of medical goods and services. And it does that better than any health system in the world. Monetizing fear of death, fear or disease, fear of disability, pain, anxiety, depression, and grief is like falling off a log. So cha-ching, it’s a success story writ large! High quality outcomes are nice if they increase consumption, but low value care will do just as well. Cost containment is for suckers. Insurance companies can always raise rates, and the government can raise taxes or take money from other programs. So until we get serious about radical change, we might as well just shut up and write the check.
To follow on one your main points: in order to do good, empathy, like knowledge, is necessary but not sufficient. We know perfectly well what a more effective, efficient, and equitable health system looks like. Healthcare is filled with caring, empathic people. Augustine, a Neoplatonist before coming to Jesus, tells us in Confessions that the will must be brought to bear as well. But the will, he says, is divided between old habits we want to cling to, and new ones we wish to have. In the case of healthcare in the United States, entrenched interests are perfectly happy with the ‘old habits.’ And according to their standards and values, they should be. Healthcare tends to attract empathic people, business less so. Look who’s in charge. This started long before 1994, but became turbocharged under the economic policies of neoliberalism.
I’m not sure if empathy is something that can be learned. I think it’s something innately human, though not necessarily present in everyone—there are undoubtedly genetic and neurological variations. But it’s innate in most of us, if for no other reason than it gives the species a survival advantage. It can’t really be learned but it can certainly be suppressed (how that happens is interesting). Fortunately, there are methods to undo the suppression. But if empathy becomes a trendy buzz-word, I fear it will become just another box to check in the EHR.
So people of good will must keep working to enlist us all to make the changes necessary for a more just and free society. From that will follow a healthcare system that is efficient, effective, equitable, and affordable. Not before. My $0.02.
Michael Stehney M.D., M.P.H., is a retired family physician with a background in urban medicine, medical education, and public-private partnerships. He resides in Connecticut.
Title: St. Augustine
By: Nheyob, CC BY-SA 4.0, via Wikimedia Commons