Independence Day in Healthcare

Since 2009, I have carried a copy of the Declaration and our Constitution along with my passport tucked in my briefcase. As the Affordable Care Act was debated, I found it useful at times to see what our forefathers had to say about our healthcare system 240 years ago. In short, not much!

The Second Continental Congress signed the Declaration of Independence in Philadelphia July 4, 1776. Its 56 signers asserted their separation from British control on the basis of natural law: “We hold these truths to be self-evident, that all Men are created equal, that they are endowed by their Creator with certain unalienable rights, among these are life liberty and the pursuit of happiness.”

Eleven years later, on September 17, 1787, after a war with Britain’s King George, Congress met again in Philadelphia to agree on how new Republic would be governed. President Washington and 39 Delegates from 12 states pledged themselves to a government run of and by the people. Significantly, it begins “We the people.” They crafted a government around the enumerated powers of three branches-- Legislative (Article 1), Executive (Article 2) and Judicial (Article 3). Since its signing, 27 important Amendments were passed that addressed hanging chads left out as our nation grappled with its sometimes clumsy experiment in democracy, like constraints on the scope of government i.e. “Congress shall make no law..” (1st)), the powers of states (10th), voting rights (15th, 24th, and 26th), the rights of federal taxation (16th) and others.

I read both documents again this weekend. There’s mention of the “the general welfare” of our citizens and reference to “the pursuit of happiness” but nothing about healthcare. Seven of the Declarations signers were physicians and five of those who signed our Constitution, but scant attention to healthcare. When these documents were signed, our forefathers were conscious of important industries like agriculture and transportation as they debated the role a central government would play. Oddly, on healthcare, both are silent. No one imagined the Central Government would become the biggest influence in the healthcare system that evolved now covering 33% of our population and 44% of its payments.

On the 240th anniversary of the Declaration today, the parallels between the journeys of our government and our healthcare system are insightful.

First, there is no Declaration nor Constitution in healthcare. There are no widely accepted “unalienable rights” upon which its moral purpose is defined nor a set of core tenets upon which it is structured and governed. Thus, there’s no consensus on fundamental questions--Is healthcare a right or a privilege? Is healthcare inclusive of safe food, clean air, and safe communities or more narrowly about services for those who are sick or injured? Is a private system with pluralistic payers and private providers our intended design or simply the result of circumstances? Is it a system of health or a collection of loosely related publicly and privately funded interests? As a result, it has evolved as a complex, disorganized public-private industry that’s 28% of the federal budget and a persistent source of conflict among elected officials. 

Second, like our government, healthcare vests powers in three major branches--providers, suppliers and payers. But unlike our government, their powers are not enumerated. Our three branches have staked out positions for themselves asserting their desired powers:

Providers—doctors, hospitals, post-acute providers, allied health professionals, pharmacists and others—believe theirs is the most noble role in the system.  They claim the power of patient care and the public’s trust as their domain.

Suppliers—device, drug and technology makers—produce goods and services that change improve how diagnoses are made, treatments appropriated and care delivery is designed. They claim the power of clinical innovation and the public’s expectation that the latest and best is accessible first in the U.S.

Payers—private health insurers, brokers, insurers, state Medicaid agencies, Medicare-- pay the bills and keep providers and suppliers honest. They claim the power of the purse-strings.

Tension between healthcare’s three branches is a constant. Each believes the others serve a less noble purpose. Each believes the others have too much power. And each prefers less regulation, media scrutiny and consumer curiosity. Little wonder, healthcare is in such disarray.

Through the years, general practice has given way to specialty care featuring increasingly precise diagnostics and treatments that produce longer lives and less pain. Our hospitals transitioned from alms houses serving the poor to community hospitals to a vast array of medical centers, clinics, and specialty care facilities.  Insurers became providers and providers became insurers. Healthcare became big business with significant clout in politics and substantial impact on the pocketbooks of all households. And “we the people” defaulted to “we the patients” as the complexities of science and the confounding pluralistic payment system metastasized.

In 1948, the United Kingdom’s four countries agreed their system of health needed a fresh start after its flaws were exposed in World War II. The result was the National Health Service providing its citizens "comprehensive health and rehabilitation services for prevention and cure of disease.” In its 68 year run, the NHS has attracted its share of critics and undergone periodic changes, but it remains popular among Brits. It was heralded as their crown jewel (Opening Ceremony of the 2012 Olympics), costs 30% less than our system and produces outcomes on par with our own.

Pushing the reset on their healthcare system was a necessity in the U.K., and the same might be said in the U.S. Our costs are soaring, dissatisfaction is growing, and access is uneven.  There’s widespread discontent with its performance, growing frustration with its business practices, and a desire to see it improve. Medicare enrollees want the status quo protected; Millennials and Young Boomers want substantial changes.

Maybe it’s time for healthcare’s continental congress to convene to discuss the system’s future. The looming insolvency of Medicare (by 2028), the reality of our global economy and the ongoing tensions between our three branches suggest fresh thinking is timely.  Perhaps citizens from all walks of life could be assembled to draft healthcare’s Constitution beginning with the unalienable rights on which it is based: “We the people of the United States, in order to create a more perfect healthcare system, affirm that…”

Maybe the enumerated powers of the health system’s key players could be outlined in a framework where the interests of “we the people” come before “we the providers, payers and suppliers”.

Maybe it could declare independence in healthcare from old ways of thinking that limit our effectiveness, avoid tough decisions and protect the status quo.

Our forefathers did not spell out how healthcare in our democracy should be structured or operate. Maybe it’s time for “we the people” to think about it. Something to consider on Independence Day!

Paul