Uninsured in America: Life and Death in the Land of Opportunity
http://www.100md.com
《新英格兰医药杂志》
These two books document the consequences of the lack of universal coverage for health care in the United States and then recommend national health insurance. Each book is readable and perceptive and offers fresh information and helpful syntheses of familiar data. Even experts in health policy will find news in these books.
Both books are vague, however, about how to address the fundamental problem of making policy for access to care, which entails mobilizing the political will to achieve substantial reform. The authors of these books, like many before them, imagine (perhaps even hope) that a combination of increasing physical and mental suffering and the rising cost of care will create a crisis. This crisis, they believe, will precipitate a political situation in which thoughtful policy design could overcome the inhibiting effects of ideologies and interest groups.
The authors of each book tell compelling stories of pain and suffering drawn from their interviews with persons who are uninsured. John Geyman includes "more than 30 family stories and patient vignettes"; Susan Starr Sered and Rushika Fernandopulle interviewed "more than 120 uninsured Americans" and "approximately four dozen physicians, medical administrators, and health policy officials." Geyman has read widely about the problems of access to health care and recommendations for solving them in the research literature, the media, and reports commissioned by official bodies and advocacy groups. Starr Sered and Fernandopulle command much of the same information. In addition, they apply the findings of studies of related subjects in the social sciences. Both books argue that a social-insurance entitlement program for health and long-term care is in the best interests of most Americans.
These books contribute to the running debate about health insurance as a method for expanding access to care in America that began in the second decade of the 20th century. Geyman's comprehensive survey and synthesis of an enormous amount of information are marred by a few minor errors (for example, mistitling several people and misstating the governance of a few organizations). He amply documents the negative effects, direct and indirect, on almost everyone in the country of lack of access to care. Geyman criticizes, and occasionally caricatures, interest groups that have opposed proposals for a national program of social insurance or even for near-universal coverage. He is especially offended by the pharmaceutical, insurance, and investor-owned hospital industries.
Starr Sered and Fernandopulle offer an original conceptualization of the poignant stories told to them by uninsured people across the country. They contend that the "current American system in which health care is linked to employment is creating a caste of the chronically ill, infirm, and marginally employed." This caste — a word they chose with care — is experiencing a "death spiral" as a result of which its members are "sucked into a lethal vortex of ill health, medical debt, and marginal employability." Like castes in India, these "millions of Americans" are increasingly set apart from more fortunate Americans by a "physical marker" — for example, "rotten teeth, chronic coughs, bad skin, . . . addiction to pain medication."
Geyman, Starr Sered, and Fernandopulle want to believe that a crisis in the health sector would create incentives for the reform of policy for coverage. The causes of this crisis would be the rising costs of insurance for employers, individuals, and families, in combination with anxiety and untreated illness among increasing numbers of Americans. In the post-crisis politics of health care, masterly public officials, in alliance with leaders of business and a resurgent labor movement, would overcome resistance to reform, including the inertia that would result from a majority of Americans' believing that they are adequately insured.
Starr Sered and Fernandopulle do not make the observation, however, that none of the 120 uninsured people they interviewed mentioned politics or their elected representatives (and they seem not to have asked about these subjects). None of the persons interviewed, moreover, described a telephone call or a visit to the office of an elected official or mentioned a campaigning politician inquiring about their problems.
In contrast, in my professional work I talk most days with persons who hold leadership positions in state legislatures or have been elected to state-wide office. These colleagues, both Democrats and Republicans, have firsthand knowledge of their constituents' problems with access to health care. Moreover, they work hard to ameliorate these problems by making policy and helping individuals receive care. The absence of politics and politicians from Starr Sered and Fernandopulle's account supports my undocumented impression that my colleagues and their constituents are atypical among persons in public office.
But most of my colleagues have been reelected, which suggests practicable next steps in actualizing reform of access to care. The political work of solving the problems of health coverage may have to begin with the organization of individuals, one by one, into coalitions for change in states and communities. Geyman offers examples of such work in several states, but he focuses on results rather than on the hard work of politics (the "slow boring of hard boards," as social scientist Max Weber wrote more than 80 years ago). Elected officials who try to make policy to improve access to care encounter many obstacles, not the least of which are strong opinions that are frequently grounded in ideology about markets and choice and the money and persuasiveness of health-sector interest groups. These officials need all the help they can get from voters, as people with health care needs and as members of organizations that favor policy to expand access to care.
In the absence of a new approach to the politics of access, our pluralistic, expensive, and inequitable methods of paying for health services are likely to survive unchanged during any foreseeable crisis. Patients and families are well acquainted with the suffering described in these books. Communities have the burden of aggregate costs of the schooling, jobs, and productivity lost by people without insurance, as well as the expenses of treating and caring for such people — expenses that are shifted to public and private payers and absorbed by professionals and institutions. There is little reason to believe that patients, families, and communities will not adapt to new crises in the health sector, just as they have adapted in past crises. The most likely alternative to mobilizing sufficient political will to achieve at least near-universal coverage is that, as a society, Americans will learn to tolerate more suffering.
Daniel M. Fox, Ph.D.
Milbank Memorial Fund
New York, NY 10022
dmfox@milbank.org(By Susan Starr Sered and )
Both books are vague, however, about how to address the fundamental problem of making policy for access to care, which entails mobilizing the political will to achieve substantial reform. The authors of these books, like many before them, imagine (perhaps even hope) that a combination of increasing physical and mental suffering and the rising cost of care will create a crisis. This crisis, they believe, will precipitate a political situation in which thoughtful policy design could overcome the inhibiting effects of ideologies and interest groups.
The authors of each book tell compelling stories of pain and suffering drawn from their interviews with persons who are uninsured. John Geyman includes "more than 30 family stories and patient vignettes"; Susan Starr Sered and Rushika Fernandopulle interviewed "more than 120 uninsured Americans" and "approximately four dozen physicians, medical administrators, and health policy officials." Geyman has read widely about the problems of access to health care and recommendations for solving them in the research literature, the media, and reports commissioned by official bodies and advocacy groups. Starr Sered and Fernandopulle command much of the same information. In addition, they apply the findings of studies of related subjects in the social sciences. Both books argue that a social-insurance entitlement program for health and long-term care is in the best interests of most Americans.
These books contribute to the running debate about health insurance as a method for expanding access to care in America that began in the second decade of the 20th century. Geyman's comprehensive survey and synthesis of an enormous amount of information are marred by a few minor errors (for example, mistitling several people and misstating the governance of a few organizations). He amply documents the negative effects, direct and indirect, on almost everyone in the country of lack of access to care. Geyman criticizes, and occasionally caricatures, interest groups that have opposed proposals for a national program of social insurance or even for near-universal coverage. He is especially offended by the pharmaceutical, insurance, and investor-owned hospital industries.
Starr Sered and Fernandopulle offer an original conceptualization of the poignant stories told to them by uninsured people across the country. They contend that the "current American system in which health care is linked to employment is creating a caste of the chronically ill, infirm, and marginally employed." This caste — a word they chose with care — is experiencing a "death spiral" as a result of which its members are "sucked into a lethal vortex of ill health, medical debt, and marginal employability." Like castes in India, these "millions of Americans" are increasingly set apart from more fortunate Americans by a "physical marker" — for example, "rotten teeth, chronic coughs, bad skin, . . . addiction to pain medication."
Geyman, Starr Sered, and Fernandopulle want to believe that a crisis in the health sector would create incentives for the reform of policy for coverage. The causes of this crisis would be the rising costs of insurance for employers, individuals, and families, in combination with anxiety and untreated illness among increasing numbers of Americans. In the post-crisis politics of health care, masterly public officials, in alliance with leaders of business and a resurgent labor movement, would overcome resistance to reform, including the inertia that would result from a majority of Americans' believing that they are adequately insured.
Starr Sered and Fernandopulle do not make the observation, however, that none of the 120 uninsured people they interviewed mentioned politics or their elected representatives (and they seem not to have asked about these subjects). None of the persons interviewed, moreover, described a telephone call or a visit to the office of an elected official or mentioned a campaigning politician inquiring about their problems.
In contrast, in my professional work I talk most days with persons who hold leadership positions in state legislatures or have been elected to state-wide office. These colleagues, both Democrats and Republicans, have firsthand knowledge of their constituents' problems with access to health care. Moreover, they work hard to ameliorate these problems by making policy and helping individuals receive care. The absence of politics and politicians from Starr Sered and Fernandopulle's account supports my undocumented impression that my colleagues and their constituents are atypical among persons in public office.
But most of my colleagues have been reelected, which suggests practicable next steps in actualizing reform of access to care. The political work of solving the problems of health coverage may have to begin with the organization of individuals, one by one, into coalitions for change in states and communities. Geyman offers examples of such work in several states, but he focuses on results rather than on the hard work of politics (the "slow boring of hard boards," as social scientist Max Weber wrote more than 80 years ago). Elected officials who try to make policy to improve access to care encounter many obstacles, not the least of which are strong opinions that are frequently grounded in ideology about markets and choice and the money and persuasiveness of health-sector interest groups. These officials need all the help they can get from voters, as people with health care needs and as members of organizations that favor policy to expand access to care.
In the absence of a new approach to the politics of access, our pluralistic, expensive, and inequitable methods of paying for health services are likely to survive unchanged during any foreseeable crisis. Patients and families are well acquainted with the suffering described in these books. Communities have the burden of aggregate costs of the schooling, jobs, and productivity lost by people without insurance, as well as the expenses of treating and caring for such people — expenses that are shifted to public and private payers and absorbed by professionals and institutions. There is little reason to believe that patients, families, and communities will not adapt to new crises in the health sector, just as they have adapted in past crises. The most likely alternative to mobilizing sufficient political will to achieve at least near-universal coverage is that, as a society, Americans will learn to tolerate more suffering.
Daniel M. Fox, Ph.D.
Milbank Memorial Fund
New York, NY 10022
dmfox@milbank.org(By Susan Starr Sered and )