If you have spent any time with the Understanding It section of this website, you'll agree that Quadrant III healthcare, based on covert rationing, is a lousy way to run a healthcare system. Not only is covert rationing harming millions of Americans - on both ends of the stethoscope - but it is also eroding the fundamental American principle of individual autonomy. It is doing all this without solving, or even slowing in any substantial way, the fiscal crisis that makes the rationing necessary in the first place. There has got to be a better way.
This section of the website provides a cursory exploration of what such a better way might look like and how we might achieve it. A much more comprehensive treatment of this topic can be found in my book, Fixing American Healthcare - Wonkonians, Gekkonians and the Grand Unification Theory of Healthcare.
The following discussion presumes you've read the brief explanation I provide elsewhere on this website of the Grand Unification Theory of Healthcare (GUTH).
In our brief summary of the GUTH, we saw that neither of the lower quadrants supports an equitable or sustainable healthcare system. This suggests that we ought to aspire to an upper-quadrant healthcare system, where high quality and transparency reign. Unfortunately, as soon as we begin to consider what a pure Quadrant II or Quadrant I healthcare system might look like and what it would take to get there, neither of those options appears to be feasible either.
A pure Quadrant II system is easy to dispense with right away. In Quadrant II, patients would pay for all of their own healthcare themselves, thereby regaining control over their own medical destiny. But such a scheme has been priced out of the realm of possibility. There aren't enough people who can fund their own healthcare, at least not when they become sick and actually have to use medical services.
On the other hand, a pure Quadrant I system, with a completely equitable, centralized system of open rationing, is equally difficult to visualize in the U.S. Other Western nations ration healthcare much more openly than we do, but the methods they use would be next to impossible to sell to Americans.
The bottom line is that we're going to have to devise a healthcare system that incorporates open rationing (from the First Corollary of the GUTH) but that is suitable for Americans. In trying to envision such a thing, I am going to suggest straddling Quadrant I and Quadrant II, with one foot in each quadrant. We can conceive of a healthcare system that preserves the best parts of Quadrant I and Quadrant II, while limiting many of the negative aspects of each, and that honors the worth of every individual.
What features are needed in an American healthcare system?
A healthcare system that includes a component of open rationing and that is equitable, just, and palatable to Americans has to embody two characteristics omitted from most healthcare systems around the world. These are: ensuring the autonomy of individuals; and guaranteeing continued medical progress.
Individual autonomy and empowerment
Healthcare rationing, by withholding useful medical care from one person in favor of another, asks individuals to suppress their pursuit of life and happiness for the good of the whole. Under the best of circumstances rationing will present a challenge to Americans. However, rationing does not have to violate the autonomy of the individual.
Rationing that is done openly and honestly, with full disclosure of all the rules that determine how the rationing is conducted (rules that are developed in an open process), and that employs fair and transparent procedures that apply to all individuals can be compatible with a culture of individual autonomy. Covert rationing, on the other hand, with its incomplete disclosure of the facts, its obfuscation, deception, and lies, cannot. A healthcare system that employs rationing and supports basic principles of American culture will have to ration openly and transparently.
Such a system will have to find ways of empowering individuals within that system. "Empowerment" here means two things:
1) Patients must be empowered to pursue every option available to them within the system of rules that determine how their healthcare is rationed. This implies that patients will have access to true advocates, to professionals who understand medicine in general and the patients' medical needs in particular and who, placing the patients' individual needs ahead of every other consideration, can work within the system of rules to assure that they get all the necessary medical care that is coming to them. In other words, this form of empowerment requires a full restoration of the doctor-patient relationship.
2) The second form of empowerment applies to the patients themselves. We need to develop tools and systems that enable interested patients to take a direct hand in guiding their own medical care and making appropriate medical decisions. This second form of empowerment flies in the face of traditional thinking on the proper role of patients. Most societies have taken a paternalistic view that the doctor knows best. The patient's role is to go to the doctor, then do what the doctor recommends. Despite recent lip service to patient empowerment, the paternalistic view of the patient's role is deeply embedded, nurtured, and, in fact, necessary in our own system of covert rationing.
Achieving a sufficient state of empowerment will not be easy. Even for patients of strong intellectual capacity, the tools for this sort of self-empowerment are generally inadequate today. It takes a special patient to become empowered through knowledge and to use this empowerment effectively. Many of those who disparage patient empowerment as a strategy have nothing against it in principle; their objection is a practical one; it's just not possible, they'll say, for most patients to become empowered.
Making the autonomous, empowered patient the centerpiece of our proposed American healthcare system is going to be even more problematic than making the system universal. Why, then, must we insist on it? There is no other way to assure patients that their rights and welfare will be sufficiently safeguarded.
The era of covert rationing has shown that neither the insurance carriers nor the government nor even the patient's own physician can be relied upon, when the going gets tough, to do their best for the individual patient. The pressures to do otherwise are too great. Empowering individuals within the healthcare system is not so much an attempt to reach some new pinnacle of medical ethics as it is an admission of failure, a recognition that nobody can be relied on to care what happens to the patient except the patient himself.
As difficult as it will be and despite all the good arguments about its impracticality, assuring the autonomy of the individual patient and putting systems in place that enable him to oversee his own medical care will have to be part of our new American healthcare system. Fortunately, once a demand is recognized for products and services that enable and facilitate patient empowerment, our free enterprise system will respond. My book explores some of the tools available today, and some that are likely to be developed, to advance this kind of empowerment.
Ensuring continued medical progress
While our traditional Quadrant IV Tooth Fairy healthcare system was fiscally doomed from the beginning, its effects were not all bad. It was the if-you-build-it-and-it-works-it-will-get-paid-for paradigm of the Quadrant IV system that stimulated the amazing progress in healthcare and medical technology we have all enjoyed since the end of World War II.
During the last five or six decades, most important medical advances either originated in the United States or were stimulated by the knowledge that the American healthcare system would provide a ready market for inventions and products originating elsewhere.
In developing our new American healthcare system we're going to have to back off from the no limits mentality that obligated us to push ahead to find cures for every disease, up to and including death itself. But medical progress over the past sixty years has prolonged the lives of our loved ones, has relieved suffering, has mitigated or prevented disability, and has provided a powerful stimulus not only to the American economy but also to our native American optimism and can-do spirit.
It would be a crime against humanity to abandon the vast and mature infrastructure that has produced this kind of progress, to stop advancing healthcare progress, and to agree to settle forever for the level of medical care that we have today (or perhaps even a lower level). To continue finding new ways to prolong lives and relieve suffering and disability, to stave off our own societal enervation and fatalism, and to nurture our national spirit, our new American healthcare system must assure that incentives remain in place to guarantee continued innovation and progress in medical care.