Where Are We Now in the Health Reform Process?

,In 1973, after Massachusetts was the only state not to vote for Richard Nixon's reelection, bumper stickers appeared all over the state: "Don't Blame Me - I'm From Massachusetts."

Now our bumpers should read - "Blame Me for Health Reform tanking - I'm From Massachusetts."

I've been reading the pundits and mulling over where we are in the effort to get a better grip on our out-of-control health system. Everyone who wants reform is in a regrouping mode. Here's some of my current thinking:

1. I hope the legislature passes something. I don't know what kind of a "something" our political process will allow, but it's crucial to show that we the people, through our government, are not totally impotent with regard to managing the health system.
   
   Experienced psychiatrists know that when we work with demoralized patients with chronic ailments who've given up hope that change is possible, an early success, however trivial, builds momentum for achieving more substantial goals. That's where we are with health reform. A baby step is better than no step.
   
   
2. It appears that the mandate for each individual to be insured has elicited an especially strong backlash. Here's what s 55 year old New Hampshire resident said about the mandate - “I won’t pay it! And I’ll shoot the first person that tries to make me go to jail because I will not buy health insurance.”
   
   As I said last spring in "The Ethics of an Individual Mandate," there are only two ways to get to universal insurance coverage - tax that pays for everyone or a requirement that individuals get coverage (with financial support for those who need it). Now that the federal mandate is going down the tubes it's just a matter of time until a state creates its own single payer system. The California legislature has given CPR to a universal coverage bill that was tabled last year (see here). If a Democrat is elected governor in November a single payer plan for the state could have traction. I hope that happens somewhere - it will be a crucial experiment, just as Massachusetts is.
   
   
3. Small business owners have also been vociferous in opposing the expectation that they would provide health insurance for their employees. If I ran a small business I'd feel the same. The cost is ridiculous, and the services provided by the purchase don't feel worthwhile. It's hard to find a primary care doctor with time for new patients, visits feel rushed, and the system itself is best described as "high tech/low touch." Small business owners feel they're not getting value for money, and they're right!
   
   I have the privilege of co-leading a "patient-doctor" seminar in a superb primary care residency (see here to learn about the program). We've just finished interviewing candidates for the 2010 - 2011 internship. The applicants were brilliant, accomplished and idealistic. But their passion for providing care was focused almost exclusively on underserved populations in the U.S. and abroad. Virtually none were contemplating a career in the mainstream U.S. system. I connect their lack of enthusiasm for the mainstream system with the small business owners' lack of enthusiasm for buying insurance. Paying huge premiums is bad enough. But if it feels as if the expenditure isn't providing comparable value, it's worse.
   
   
4. Even the tea party folks don't think things are hunky dory in the health system. But it's looking as if we're not prepared to allow the government to launch a large makeover. As the bills progressed through the Senate and the House, the scope of reform kept getting whittled down. "Health system reform," which is what we need, turned into "health insurance reform," which is just one piece. And now it looks as if even these whittled down efforts are too much for the populace to swallow.
   
   In Massachusetts, where many of the elements of the Senate and House bills have been in force for three years, support for the reform process remains strong. It looks as if we're more prepared to trust our state governments than the federal government. Since scuttling the federal effort doesn't put out the health system fire, we should expect to see heightened reform activity at the level of states, self-insured employers, and organized medical groups.

For the foreseeable future I think the mantra for those, including myself, who believe our system requires radical reform, should be - "think globally, act locally."