How to build a health care system that works

A Lewin Group report for the Advanced Medical Technology Association shows that hot new devices are not getting to older Americans. In the middle of the most rapid technological development period ever, the Health Care Financing Administration (HCFA), which oversees Medicare, insists on approving each medical device, one at a time. Often it demands separate approvals for each region of the country. This process can take from 15 months to five years. Once the device is approved, HCFA pays no more for the use of the new technology than it did for what it replaced, even if the new technology saves costs further down the line. The question here is: Why is this necessary at all? These devices have already jumped through the hoops of both peer-reviewed medical journals and FDA approval, and HCFA already sets the amount it will pay for each case, no matter what device is used on the patient. The question here is: Where is the single vision for the care of older Americans? Who is really thinking about this? The rise in drug costs is not just about the greed of the "Big Pharm" companies. It's about powerful new drugs, far more capable than any we have had before, extending people's lives and functioning. It's the age of the "miracle drug." And the trend is not slowing. Any look in the health care crystal ball shows pharmaceuticals taking over more and more of health care. In fact, drugs will eventually replace much of the surgery and other therapies that we do today. But we're still arguing about whether to pay for it for older Americans, as if drugs were somehow not part of what we call "health care," but some weird Golden-Ager self-indulgence. The question once again is: Where's the vision? These three articles, picked from a random recent week, carry a huge theme: U.S. health care is drifting in the dark. The theme echoes down the pages of health care news, week after week, year after year. Health care is the weakest link in the world's strongest economy, the sad and disheveled sector in the midst of bright wealth and revolutionary vigor. No mind directs health care, and no debate invigorates it. We are having trouble building the health system of the future because we have no health system of the present. We pretend horror at the thought of "nationalizing" health care. The reality is that through financing, rule-setting, and legislation, the federal government is already in charge of health care in the United States. Could we admit that? Apparently not. In Canada - in fact, in most countries - "how to run health care" is an open social and political discussion. In the U.S., we have separate discussions called "who should pay for health care," "ain't those HMOs nasty," and "look at those greed-heads running the hospital," mixed up with red-flag, over-simplified issues such as abortion and cloning. We have no discussion about "how to run health care," let alone "how to build a health care system that works" or even the deeper question: "What is health care?" To build a system that works, we have to think about - and talk about - a whole system. As long as we focus on one piece at a time, we are doomed. The discussion would have to start with the question: What are we after here? Is it just the lowest cost health care that doesn't actively kill people? Is it a tiered and "nuanced" system that matches our class-and-status society, with the best for the rich, nothing for the homeless? Is it optimal health for all - as a way of cutting costs? What about simplicity, ease of use? Right now everyone in the United States has two jobs, their day job and the other one, called "figuring out the health care system." What about a sense of connection, caring, and meaning in what are, after all, our greatest trials and final moments?