I have asked some of my colleagues to read this blog and offer their comments. The following comes from one of the brightest thinkers in medical education I know. He is the Dean of a medical school, and I have always respected his judgement. His comments have some important implications. I ask you to read them, and try to answer the questions he poses. They will form the basis of what we will discuss tomorrow.
Russ, I'm not sure what you might be seeking, but here are some thoughts. They are largely posed in economic terms, but they have a broader implication.
1) If the solution to optimal health service coverage (universal coverage, true payment for disease prevention and management - as well as - interventions) will require major modification that will significantly impact all sectors of the business (e.g., hospitals, physicians, insurance companies, state government, big pharma, etc) in a negative manner initially, who should pay for the "cost of activation"?
2) Should the basic science research arm of medicine be amputated in the public sector (i.e., academia) such that more essential health care services can be delivered or is the basic research America's international advantage? If the latter, how does America get the rest of the world to pay?
3) Is personal health really dependent upon community health (economic drivers, strong education, healthy lifestyles) rather than doctors, nurses, hospitals, and pills? Of course the latter help, but if the former is more important, shouldn't our effort be on job creation? If yes, what sort of jobs? What can be done in America that is not likely to be outsourced?
4) The US economy is focused on material production and consumption. The production is largely outsourced and unless consumption is largely outsourced as well, we will have a growing trade deficit. What sort of business bring local value and create local jobs without requiring every expanding consumption. Indeed, this effort to expand consumption through marketing and mass production is one of the reasons we have such an obesity problem. What are our alternatives? Is knowledge generation valuable without a consumable product? If not, is there a future for academic institutions?
My colleague understands that health care is COMPLEX!
Comments (2)
Great questions!
1) I don't live in the US, so it's easy for me to say... but I'm not aware of anywhere in the world where "Federal Government" has not had to pay the activation cost to make health system change happen. It can claw some of that back in taxes on particular players perhaps but more likely it will have to "stuff mouths with gold" to make change happen.
2) I think this miscasts the problem, although I can accept there may be a need to get some more money out of the rest of world, which I'll deal with in 2b. However, I'd pinpoint that the first constituency free-riding on basic research is big pharma. That's not something everybody sees because there's a lot of propaganda to the contrary, but they are the direct consumers of basic research and do not actually fund it to the level that they use it.
2)b) Rest of the world. I said I can accept this premise, but I'm not entirely convinced - but that's a discussion for another day. There's no avoiding market mechanisms here and as such the transition will not be short and likely not pleasant - but the rest of the world will only contribute more when the US stops subsidising. Once not enough basic research is being paid for, other countries will start to accept that they need to pay more. Of course, the reality then is that we'll find out how much of an actual international advantage the US has, some countries will choose instead to do it at home... which might seem to conflict with point 3.
3) I think it's Westside(?) in Chicago who are already working on this in a direct manner, making sure their health services source locally. However... there's a set of hard questions about "what isn't likely to be outsourced" which is a fascinating discussion that goes far beyond health.
4) This is where the rubber really hits the road... not sure that anyone has many answers. I think the question "Is knowledge generation valuable without a consumable product?" also points us to ask hard questions about the notions of a "knowledge economy" that many have promoted as the way forward through the jungle of deindustrialisation...
Posted by Indy | January 27, 2010 3:34 PM
Posted on January 27, 2010 15:34
Solid questions. Answers on a postcard?
Q1. A functioning health system is as systemic as a functioning financial system. Fund the "activation stage" in the same way as the banks were funded if it is as systemic.
Q2. The rest of the world will probably pay through devaluation of the dollar. Regard the basic science research of the US as an insurance premium for a rainy day. The scientific infrastructure is too valuable to the rest of the world for it to reject those devalued dollars.
Q3 and 4. These are boundary questions. Why has the US so ordered its affairs that it makes sense to outsource its jobs.
I hope I will be excused the following attempt to cobble together an explanation for the boundary fence using the craftsmanship of Bourdieu's concept of economic, cultural and social capital.
Economic capital is the resources, finance, energy that are essential to get anything done, but on their own are inert. They need the cultural capital or skills, knowledge, professions to become useful. Both have no value without the social capital of why and how they combine in a particular way.
The question is how does a society construct the boundary fence that distinguishes it from the chaos outside.
The answer in the US seems to be a concentration on the economic capital and the physical projection of its power. An anti ballistic-missile system appears to have a higher priority than a community health system.
Both are legitimate choices within their own boundary values, they just represent different uses of economic capital.
The science research area is an example of the development of the cultural capital using the available economic capital.
Change will not come easily. Maybe there are deviants out there that could be an example to others.
Posted by Conor | January 27, 2010 4:37 PM
Posted on January 27, 2010 16:37