Stymied

Hilda Dail, in The Lotus and the Pool,¹ recommends asking four questions when trying to solve a problem or clarify one's direction. To paraphrase the questions:

Where are we now?

Where would we like to be?

What are the obstacles to achieving the goal?

What would it take to overcome, go around, or transform the obstacle?

So, where are we now? U.S. health care is in shambles. People die or become disabled daily because of lack of access to care. People get access after they have renal failure, but not before, when failure might have been prevented. Health care costs are skyrocketing. People and health professionals feel stymied and stuck with a non-system that is out of control. People and their lives do not fit into 15 minutes slots. Remarkable, caring physicians are burning out right, left and center, choosing other fields, choosing no-patient-contact specialties, watching their marriages sputter and die.

Where are we now?

As a result of our fear of so-called socialized medicine or government care, we have run eagerly, with arms outstretched, into the arms of managed care. What is it we fear? At least these three spring readily to mind:

1. 1. Being controlled, loss of autonomy

2. 2. Administrative waste

3. 3. Losing health care benefits

Often, out of our fear, we create the thing we fear the most. Americans value freedom above all. They fear being controlled or losing autonomy. In our fear of government-run health care, we have created a system in which both physician and patient often feel completely controlled: the physician not able to work at his/her own pace nor to order the tests s/he deems necessary, nor to arrange for counseling; the patient faces bills left and right, can only see certain physicians, and is often denied care. People also fear that government-funded health care would entail great waste. The irony is that the amount of administrative waste due to duplication of services, multiple forms, denial and regulation, is far greater than one would have with a single set of forms, a single method for billing, a single reimbursement plan, and no need to determine eligibility, because everyone would be eligible.

In his book 1984, George Orwell coined the terms doublethink and newspeak, sometimes now blended into doublespeak to refer to what government representatives do when they say one thing and mean another, usually the opposite. The last six years have seen the American revival of doublespeak. Confining our attention to the arena of health care, we need only consider the very mixed prospects for the Medicare Prescription Drug, Improvement and Modernization Act of 2003, a law that may imperil Medicare rather than improve it. To not be able to negotiate pharmaceutical prices, as the law provides, allows for the pharmaceutical companies to set their prices at any level they want, raising the specter of skyrocketing medication costs that bleed the taxpayer and the program dry.

The system we have now is not working well: In 2000, the World Health Organization reported that the U.S. health system spends a higher portion of its gross domestic product than any other country but ranks 37 out of 191 countries according to its performance.²

Where would we like to be?

Although the arena of health care is fraught with controversy, it is probably still safe to say that we would all like to have affordable, humane and effective health care for all Americans, complete with preventive care and end-of-life care.

Imagine a humanistic, empowering, relationship-centered model of care for all people living in America. Both patients and health professionals would have a sense of freedom and security in a system in which health professionals help people take charge of their lives and achieve the World Health Definition of health: a state of wellbeing.

Dentistry is an even more challenging arena, though it is an ideal choice to show how effective preventive care is in cutting costs and morbidity. (One has to look no further than the demonstrated effectiveness of sealants in preventing tooth decay among children.³ ) The Surgeon General's report indicates...