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Why is Real Healthcare Reform So Hard to Pass?

I mean, come on, America. We’re the industrialized nation that claims to be the “freest” in the world! And yet there are people living in this country who have to file for bankruptcy if their kid busts his knee at softball practice and has go to the emergency room! Not to mention if we’re sick, we can’t afford to get medication. Sounds like we’re prisoners of our own free system, does it not?

It’s the same government denying us healthcare that’s feeding us subsidized corn, that feeds hormone-pumped beef, that gives us e. coli poisoning. But, I guess: Welcome to Democracy. Where freedom isn’t free, and insurance doesn’t insure for anything, except maybe a fat check for CEOs and other special interest groups who operate in another realm, above the law.

So why is real healthcare reform so hard to pass? That’s a question to which Governor Howard Dean, M.D. is intent on getting answers.

The following is an excerpt from Howard Dean’s Prescription for Real Healthcare Reform: How We Can Achieve Affordable Medical Care for Every American and Make Our Jobs Safer by Howard Dean, MD, Igor Volsky, and Faiz Shakir.


At times, the organized opposition to the principles of health care reform seems overwhelming—the insurance industry, big business, the list goes on. There are too many groups with too much at stake to allow for real healthcare reform.

Reorienting the system from one that treats sickness to one that promotes and nurtures wellness will require holding special interests— whether they be insurance and pharmaceutical companies or politicians—to account.

There have been several major attempts since Harry Truman’s presidency to put healthcare reform into effect, with a significant enough government role so the reform is fair and healthcare dollars are spent efficiently and yield comprehensive care for every American citizen. Those efforts have always been framed in terms of what we ought to do for the 16 to 18 percent of Americans who have no insurance. But while most Americans have an altruistic streak, they are not willing to put a stranger’s welfare over their own family’s. Although 16 percent of the American people adds up to a little less than 50 million souls, that is a relatively small minority.

Furthermore, our healthcare system and Congress have something in common. Most Americans do not like Congress, but they do like their own representative. That is why most members of Congress are reelected time after time—even during periods of political upheaval. Likewise, most Americans recognize the significant deficiencies in our healthcare system, but they do like their own doctor, and most of the 84 percent of Americans who have health insurance believe they’re going to get good care if they become ill. Therefore, despite the fact that they know what the problems are, they are reluctant to see significant changes in their personal situation—unless of course they become ill and find out they really don’t have the health insurance they thought they did.

Therefore, health reformers must assure Americans who already have insurance that our prescription for change will secure their access to coverage. Reform isn’t just about covering the uninsured or lowering costs over the long term. Reform will protect Americans and their families from a medical or financial catastrophe and preserve the care they already receive, provide them more coverage options, and strengthen the doctor–patient relationship.

The debate also needs to be framed around the economic impact that rising healthcare costs have on American jobs. As I write in chapter 2, health reform is business reform.

And the debate also needs to be framed in terms of the plight of the uninsured. As a nation, we are only as healthy as our sickest link. To lower our healthcare spending and really reorient the system away from just treating sickness and toward preventing illness, we have to insure every American.

The Debate Has Focused Erroneously on the British Model

The political fault lines in the development of a comprehensive healthcare program are the result of history. Every system devised by human beings has built on that which has come before it. In Europe, the massive destruction of infrastructure, including healthcare infrastructure, during World War II ushered in reform with a heavy government hand. As Atul Gawande described in The New Yorker, the war compelled the British government “to provide free hospital treatment for civilian casualties, as well as for combatants.” Financial responsibility for all this healthcare fell largely on the government, a situation that only intensified after the Blitz of September 1940, which devastated medical infrastructure. Government programs were intended as temporary fixes, but, according to Gawande, “the war destroyed the status quo for patients, doctors, and hospitals alike. Moreover, the new system proved better than the old.”

As a result, Gawande explains, the universal coverage that “emerged in Britain was not the product of socialist ideology or a deliberate policy process in which all the theoretical options were weighed. It was, instead, an almost conservative creation: a program that built on a tested, practical means of providing adequate health care for everyone, while protecting the existing services that people depended upon every day.”

America and other industrialized nations haven’t chosen to forgo the British system because it didn’t work. Rather, other nations didn’t adopt the British model because they constructed their universal healthcare under different circumstances. First of all, in this country, we did not see the destruction and depravation which was widespread in Europe during World War II.

It is no coincidence that Canada, Australia, and New Zealand developed their systems significantly later than the Europeans did, since they, like the United States, did not have massive homeland privation and destruction to cope with as a result of the war. Even in Europe, though, healthcare systems, while having in common a high degree of government involvement, have evolved very differently based on what happened before the war. The German and Dutch systems, for instance, feature significantly more decentralization and less government involvement than, say, their French and British counterparts.

In America, healthcare reformers will have to embrace reform that builds on the patchwork of private insurance networks and employer-based healthcare that developed in the wake of World War II wage restraints. In other words, rather than completely dismantling the existing healthcare institutions and transferring all Americans into a new system, reformers must ensure care continuity—building on what works, while fixing what’s broken.

Special-Interest Groups Defend the Status Quo

As you’ll see in chapter 10, another major reason reform is so hard to pass is the lobbying done by powerful special interests, whose knee-jerk reaction is to defend the status quo. Until now these interest groups have included pharmaceutical companies; doctors, in the form of professional organizations such as the American Medical Association; health insurance companies; and employers, who, while suffering under the burden of rapidly increasing costs, have been innately suspicious of greater government involvement in regulation of the healthcare industry. Hospitals, which want as much autonomy as possible, fear payment reforms that could drive down their revenue, and ancillary medical supply groups and other providers want as much independence from government regulation as possible. During President Clinton’s attempt to reform the healthcare system, this medical-industrial complex successfully convinced the American people that Clinton’s reforms would jeopardize their existing coverage.

These groups have successfully defeated almost all past reform efforts. Their coalition has been remarkably effective. In the early 1990s, now Secretary of State Hillary Clinton, as first lady, led a task force to revamp the healthcare system. The group, through a somewhat opaque process, developed a very complicated proposal. The proposed new system itself made sense and offered the average American more choice of physicians and insurance plans than the existing system (the system we have today), but it suffered from two weaknesses. The first was that it was hard to understand. The second was that it was put together behind closed doors in a way that played into the hands of its opponents.

The attacks that followed became a political legend. Specialinterest groups defined Clinton’s plan before the administration could define it itself, despite the public’s overwhelming support for greater government involvement in healthcare.

The insurance industry sponsored a series of “Harry and Louise” ads, falsely claiming that President Clinton’s efforts to reform the healthcare system would undermine existing coverage and leave healthcare decisions in the hands of government bureaucrats. One ad was set “sometime in the future” and depicted actors Harry Johnson and Louise Claire Clark sitting at a kitchen table, shuffling through medical bills. “This was covered under our old plan,” Louise reminds Harry. “Oh yeah, that was a good one, wasn’t it,” he recalls nostalgically. Then an ominous announcer’s voice reminds viewers, “Things are changing, and not all for the better. The government may force us to pick from a few healthcare plans designed by government bureaucrats.” Louise: “Having choices we don’t like is no choice at all.” Harry: “They choose.” Louise: “We lose.”

The assumptions behind the ads—that people would no longer be able to choose their doctors, that there would be enormous amounts of paperwork, that the government would run everything— were disingenuous. But the campaign successfully played on the fears of the American people, who couldn’t understand what the real plan said because it was so complicated. Harry and Louise, portrayed as quintessential Americans, pleasantly and plaintively threw out “facts” about the proposed plan that simply were not true. But they did help opponents of the Clinton plan sow doubts, many of them unfounded, about what might be in the plan.

In 1993, when the Clinton plan was under consideration, most Americans believed that the government must reform the healthcare system. According to one poll, 83 percent of Americans believed that it was very important that any healthcare reform plan made sure all Americans were covered. Sixty-one percent said they were willing to pay higher taxes to achieve this goal, and more than half said they were “willing to have the Government require employers to pay most of the health insurance premiums to cover their workers.”

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