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Sunday, July 19, 2009

What is health care reform?

The health reform train has left the station. Yes, there is tremendous resistance to change from many quarters but the truth is the status quo is not sustainable. Perhaps the best thing about what is being proposed is it is so flawed it will hasten the collapse of our present system. Unfortunately I am afraid this will be accompanied by no additional insight into why things went so wrong.

In my opinion the major problem with health reform is the assumption that somehow health care activities are fundamentally different from other human activities. If I am engaged in health care how do I know this? Obviously there are specific activities associated with direct patient contact which are clearly recognized as health care activities such as nurses changing dressings or phlebotomists drawing blood. What about those who answer the phones at a clinic, those who track the money at a hospital, those who park the cars, and those who change the light bulbs? What about the contract workers who clean the rooms at night, or deliver the food to be cooked in the clinic lunchroom, or those who administer the retirement programs for any of the above workers. The health care industry cannot run without these people and the services they render any more than they can operate without doctors, nurses, technicians, or administrators. One can make the case that fulfillment of all human needs can fall under the classification of health care.

If we cannot separate health care activities from non-health care activities, what does that mean in terms of our efforts to reform the delivery of such? There are multiple implications. Perhaps the most important is the present activities to bring health care under increasing control of the federal government without defining boundaries of where it stops and something else begins will inexorably result in the overall economy coming under greater federal control. Furthermore, the increasing cost of health care will result in initiatives to control behaviors of people justified on the basis of saving money by improving health. These are all reasonable on face value, but history is replete with examples of good intentions serving as the basis of state driven coercion resulting in tyranny.

As complicated as things appear to be, there is a simplicity which we can fall back upon. As the world has become more complex and our roles as individuals become more specialized, we need to rely on many other people to fulfill our many needs and wants. How the activities of all these people, many of whom we don't know and never will know, are coordinated is almost impossible to fathom. The coordination of human activities within the health care realm cannot be distinguished from coordination of human activities outside of health care for the simple reason that no one can distinguish between these.

Our anxiety centering around the feelings of loss of control in our complex world drive us to look for institutions that create at least the appearance of control. Despite the unmitigated failures of the state in the 20th Century to serve the purpose of creating order out the apparent chaos of a market driven world, we still listen to the siren song of politicians who promise us a perfectible world ordered by more rules. Less than optimal outcomes in health care is not likely going to be made better by increasing state control, particularly when that control will likely spread to involve much of the economy.

There is never enough "stuff" out there to meet human wants and needs and our only hope to help alleviate this situation marked by scarcity is to harness the productive activities of human beings and provide environments which stimulate the production of more things that humans need and want. This applies to everything, including activities directly or indirectly related to health care (which is everything). The state driven command and control model has never worked...ever. In the same sense that many were burned by the arrogance which marked the most recent financial bubble collapse, viewing their immediate gains from the perspective that it is a new economy and the old rules don't apply, we will be scorched by health care reform based upon a management and financial model history has shown to have a perfect batting average; perfectly awful at 0 for whatever.

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