What's the secret of survival of a health system that for years has been diagnosed and denounced as exorbitant, neglectful and crisis-ridden?
Answer: For a majority of patients in the system, it works quite well. They either like it the way it is or are suspicious of change. The same goes for doctors, nurses and investors in health care, the last booming industry on the American landscape. A bright economic future for health care is evidently expected by career-seeking students. For the second consecutive year, medical school applications are up substantially, following a decade of decline.
Selfish and myopic though it may be, there's an invisible contentment factor in attitudes on health care. And it's bound to be a drag on the efforts at wholesale reform now coming onto the political stage. The contentment factor can't compete for public attention with the failings of the two-tier system that excludes millions and saps the economy with wildly rising costs. But it's there.
Polls do indeed reflect anxiety about the costs of medical treatment and admiration for Canada's tax-financed system of care for all. American business and industry are writhing under the rising premiums for their employees and turning to self-insurance and cost-controlled "managed care" programs. Some have even joined the call for a national health system, though consensus on basic details is nowhere in sight.
Nonetheless, about 60 percent of those surveyed expressed confidence that they have the insurance or the private means to weather a major illness, according to the American Medical Association. Surprisingly, that's an increase of about 10 percent in a decade. Large majorities tell the pollsters they're satisfied with their medical care, even if they are increasingly worried about paying the costs.
With professional and high-paying blue-collar jobs almost invariably accompanied by reliable insurance coverage, the need for health-care reform is least felt by those who tend to be most politically active and articulate. Some 12-15 percent of the population has no health insurance. But in terms of political power, this group's numbers are relatively small and it lacks political cohesion.
Not often noted about health care is that it's a thriving business, with 8.4 million employees. If only in subtle ways, they constitute a resistance to getting health-care spending under tight controls. Hospitals and doctors' offices are rapidly adding employees while other sectors of the economy are shedding workers. Health-related employment -- from physicians to hospital clerks -- rose 7.7 percent last year, the biggest jump in any major job category. Health care is one of the few industries today that's hungry for workers, as can be seen in help-wanted ads throughout the country. In response to shortages of nurses, salaries have risen sharply in recent years from their traditionally low levels. But the help-wanted columns are still filled with offers for nurses.
With health-care costs year after year galloping ahead of inflation and millions priced out of the system, there's broad agreement that major changes must be made. But there's no consensus on what remedies to adopt. And the sectors of the health industry that might have to bear the cost are already counter-attacking, while congressional Democrats and the White House study the political terrain for advantage.
The health-care proposal recently introduced by the Senate Democratic leadership would require employers to provide health insurance for their workers or pay into a pool that would finance coverage. It would also phase in cost controls. Though not offering a plan for reform, the Bush administration has expressed a distaste for what would in effect be a tax on business. Many firms that already insure their workers are for the plan, while many firms that don't provide insurance are digging in to oppose the so-called play-or-pay scheme.
The American Medical Association says reform is needed, but balks at cost controls. The health-insurance industry is disputing a congressional study that says its administrative costs are excessive and that the savings from a single national payment system could easily finance health coverage for all the nation's poor. And the elderly, covered by Medicare, are on alert, as usual, against any additional costs for their coverage.
The key question is whether the system is in such distress that the case for reform will overwhelm the status quo. Many signs indicate that the politics of health care are heading that way. But many more people will have to become personally unhappy about their health care before changes will occur. Despite the system's many failings, the contentment level remains fairly high.
Daniel S. Greenberg publishes Science & Government Report, a Washington-based newsletter.