December 1, 2008
From Liberty Street

Health Care

John Turner

The lead story in the Los Angeles Times this morning is about health care. In an article titled "Health Reform Goals Sharpen," Noam M. Levy says there is now a broad agreement that the national government must get involved in structuring a medical treatment program that will cover all citizens. The adequacy of private insurance available only to those who can afford it is now rejected. But also rejected is the notion of a single payer plan on the European or Canadian model.

Despite general agreement that the time has come for a national program, however, there is little accord on the details. These will continue to cause points of contention and could get so sharp as to undermine any effort. It seems that the belief we have to do something is far from the same as actually doing it.

A point that's absent from all the reports I've read so far is the probability that unless the techniques of treatment are themselves remarkably improved we won't get a system we can afford or that will make the actual health of the people acceptable.

In concentrating on making the current system available to everyone we may be missing the essential issue. And if we are, it will be because we have not yet freed ourselves from the mythology of medical genius. Clearly, there are many bright people practicing medicine in the country now, and there are procedures which far outperform techniques widely used as recently as just a few years ago. Yet, overall, medical treatment is astoundingly crude compared to what we have the right to expect from our current state of scientific knowledge.

The number of inaccurate diagnoses is astounding. And the level of misery and death caused by them is absurd. Patients often have to search for months, and even for years, to find physicians who are familiar with the ills besetting them. As far as I can tell from observing health systems, doctors generally work in isolation far more than they should. They pretend to consult, but the processes of consultation they use don't really amount to picking one another's brains. The kind of vigorous debate we see depicted in popular TV shows like House is fictional in more ways than one.

Whenever you attempt to raise these weaknesses with medical people you are generally met with bromides like, "Well, the human body is tremendously complex," or "Medicine is an art and not a science." My sense is that doctors often see themselves as minions of the system rather than people who are responsible for improving it. The reform of the system is always somebody else's responsibility. But exactly whose no one is prepared to say.

If a patient does manage to get an accurate diagnosis he still faces the difficulty of the treatments available. There are presumably hundreds of new procedures being investigated which are languishing because adequate funding for them is not available. How come, in our public debates, we don't ask, "Why not?"

We spend vast amounts of public money on activities that that are highly questionable, and probably just as much on projects that are purely wasteful. Yet money that could save hundreds of thousands of us every year somehow can't be accumulated. We do not fund the National Institutes of Health at a level that bespeaks sanity. Right now that key federal agency provides less than a third of the support for biomedical research in the nation. And the total from all sources is only about 30 billion dollars. When you consider the amounts thrown around recently to bail out single financial institutions, that figure is sickening -- literally as well as symbolically.

This is a political failure of the highest order. In truth, it's worse than that. It's criminal. And the horror of it is that we're all engaged in it.

Our willingness to put up with ineptitude we could repair is a fair indicator of our level of civilization -- or culture. That reading is far below what it should be, if we were indeed the people we tell ourselves we are. The medical debates that will take place during the first year of the Obama administration should give us indications of how ready we have become to take significant strides. I wish I could be more confident about them than I am. But, I confess, every time I walk through the doors of a hospital, either as a patient or visitor, I find my heart sinking over who we, as a species, really are.


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