It is health that is real wealth and not pieces of gold and silver. – Mahatma Gandhi
One of the things I find so frustrating about the problems that plague us is that we’re not having the adult conversations needed to solve them. I’m a firm believer that if people talk together and truly listen to one another, better solutions result. As Margaret Wheatley has said,
Nothing has given me more hope recently than to observe how simple conversations give birth to actions that can change lives and restore our faith in the future. There is no more powerful way to initiate significant social change than to start a conversation. When a group of people discover that they share a common concern, that’s when the process of change begins.
Over the next few months, I’m going to occasionally post what I’m calling “Conversation Starters.” The posts will be about important and contentious issues that impact all of us, our communities and our country. For each, I will try to lay out a non-ideological, non-partisan framework around the issue, trying not to inject my personal prejudices (remember the word “trying”). Even though we all know that I’m infallible (Right!), I do occasionally have weak moments. So, please, feel free to point out things I’ve missed. Or to involve me in your own conversations.
We need just such an adult conversation about health care. Many are calling for some form of “Universal health care” saying it’s a fundamental right. Others decry it as “socialized medicine.” Everyone recognizes that we in the US are paying far more than any other country for health care and not having better outcomes as measured by indicators such as life expectancy

or infant mortality.

And too often we ignore the fact that our health, our wellbeing, is far more dependent on our lifestyle choices and our environments than on our health care. To me, the conversation about universal health care encompasses four dimensions.
• Purpose. Generally speaking, few countries have a true health care system – one that comprehensively and relatively seamlessly maximizes well-being. We certainly don’t have that in the US; what we have are treatment systems with a few preventive overtones. We have separate systems for the aged and for long-term care, and for those with mental health issues. We also have what I’ll call for want of a better term a “wellness system” (e.g., gyms, walking paths, tennis and pickleball courts); its purpose is to keep us healthy.
Without a clearly defined purpose, I’m not sure we can arrive at an acceptable solution. So what do we want our universal health care system to be – a better version of what we have now (with “better” to be defined)? A more comprehensive systems that incorporates all aspects of health including wellness? Or something in between?
• Access. Finances ultimately limit access to our current systems in at least two different ways. From an individual’s perspective, my access depends on my ability to pay (and, often, who’s paying me and how). However, in much of rural America, finances limit access indirectly. If there are not enough patients (i.e., paying customers) to support hospitals, clinics or sometimes even a doctor in a given location, there is unlikely to be one.
We also should recognize that solutions that work in smaller countries may not work for a country of 340+ million people scattered across 3.5 M square miles. In addition, discretionary income limits access to the “wellness system” for those with limited incomes; you don’t see many of the poor at a gym. We also need to decide under what circumstances we’re willing to pay for the care of non-citizens.
• Payment. This is where so much of the attention has been focused. In the US, we have a complicated multi-dimensional tug of war among patients, care providers, insurers and governments (local, state and federal). We have Medicare for older and disabled Americans; TriCare for the military and the VA for veterans; Medicaid for the indigent; private health insurance; catastrophic insurance; long-term care (and a host of others I can’t remember!). Costs are exploding for each of these. Payments are going to doctors and other health professionals, hospitals, testing labs and equipment manufacturers, drug companies, pharmacies, pharmacy benefit managers, and insurance companies (whew!). We have federal regulations and programs, state regulations and programs (and sometimes city or county regulations and programs). Recent revelations have shown just how fraud-prone some of these are. Given the relatively poor lifestyles of so many, and the fraud surrounding the systems intended to pay for care, it’s really no surprise that our life expectancy per dollar spent on health care is so low compared to other countries. So here we need to ask, “Who pays? How? How do we limit the opportunities (some might even say built-in incentives) for fraud that we have in the current system?”
It’s important to point out that there are several models for paying for so-called Universal Health Care. For example, Norwegians pay high federal taxes for hospital and specialty care, while primary care is funded through local government taxes. The UK’s model is the most centralized – financed through income taxes. Canada’s system is the least centralized – each province levies taxes for its own single payer plan, which are augmented by federal funds. In the US, this would be the equivalent of having 50 different state plans, operating within federal guidelines. Several foreign countries have included a competitive aspect in their payment plans – citizens of Germany and Uruguay can choose between several different private insurers. No matter how health care is funded, there are usually co-pays or limited coverage for some aspects (e.g., vision or dental).
• Quality. Getting access to care says nothing about the quality of that care. “Quality” of care means getting the needed treatment in time for it to be effective. In almost all foreign countries the central government mandates a minimum level of care. In general, there are no mandates for timeliness so “quality” is not mandated. If we look at Canada or the UK, we see long wait times for some specialized treatments. In too many sad cases, patients have died before they could get the treatment they needed. We in the US have earlier access to emerging life-saving drugs and technologies than almost any other country.
In most other countries, health care is provided by the private sector – the government (or a fund operating under government auspices) pays private providers. Several countries have a competitive aspect to care – Uruguay and Germany, for example.
Our experience in trying to establish “Universal health care” in the US has been at the state level, aiming to set up a state single payer system. Vermont got close, but ultimately couldn’t make the finances work – large (unpalatable) tax increases would be needed. In Colorado, voters resoundingly defeated a proposal to establish a single-payer system. Massachusetts has also looked at a single-payer system several times, but again and again states encounter three problems:
- Large tax increases are needed to keep programs solvent.
- Changes in federal laws would be needed so that employer-sponsored health care plans could be folded into state plans.
- State plans would also require federal funding (e.g., diversion of Medicare and Medicaid funds) to ensure program solvency.
Our current health care system isn’t serving us very well – we’re paying more than any other country to get poorer outcomes than the rest of the developed world. Change is needed – we as a people should come together to devise the most effective [health? treatment? …?] system we can. Whatever system we devise will have trade-offs; that’s inevitable. But if people of goodwill reason together we’ll find our way to something better than what we have now. And that’s the purpose of this post: to provide a framework to start that conversation. So talk to your friends. Ask your representatives at all levels the tough questions. And push for something better than we have now. But it all starts with adult conversations…



