I spent much of yesterday thinking about the past, present, and future of the American health care system. I've largely chosen classes with an international or methodological focus so this was a bit of a departure from my normal fare. In one day I finished up some readings on health reform, wrote a brief paper speculating on what US healthcare will look like in 2030, attended a talk by Uwe Reinhardt largely based on this paper (PDF), and went to a three hour lecture on US health care (part of a class on the economics of the US welfare state). It's a mammoth subject, and there are many bloggers who write exclusively about domestic health policy -- the guys at the Incidental Economist have smart stuff to say on it every day. There's so much to be said and done even on the somewhat narrowed subject of the Affordable Care Act (ie, "ObamaCare").
But that's not what keeps popping into my head.What keeps getting reinforced is how our system really isn't a system at all, but a weird conglomeration of lots of different approaches for various fragments of our society that emerged for quirky historical and political reasons. I found this description -- from a report comparing various industrialized countries' systems -- humorously understated: "The U.S. does not have a 'health system,' but rather a variety of private and public institutions and programs that regulate, finance, and deliver care." (source)
Paul Starr's classic Social Transformation of American Medicine is a good start for trying to understand how we got to the 'variety' we have today. The end result is that it doesn't serve very many people well at all. The US is a great place to get the most advanced care if you can afford it, but even then you're going to pay a lot more for it. For the non-wealthy the expenses are amplified and we end up rationing care by ability to pay. By pretty much every standard other than innovation (ie, including the delivery of that innovation to those who really need it, not just those who can pay) the US falls dreadfully short. We get poor life expectancy, magnified inequalities, and spending that's roughly twice as much per person as in any other wealthy country.
Ironically, whether the Affordable Care Act goes into effect in 2014 depends largely on whether Obama gets reelected, and whether Obama gets reelected or not depends largely on what the unemployment rate does between now and November. So the future of the US health system depends in a very real way on fluctuations in the economy over the next eight months, and no one really understand that well at all.
If you're just looking at the trajectory of the American health system the ACA is a major reform, even a fundamental one. It will do (and has already started to do) a lot of good things, but I'm skeptical that it will do all that much to fix costs or shift our focus to public health ---prevention over treatment. There are a lot of good small fixes in there, but nothing revolutionary when you compare us to other countries.
And this is why I find domestic health policy profoundly depressing. It's why I've chosen to focus more on international health than domestic politics. In international health I think the prospects for witnessing and contributing to massive, heartening, orders-of-magnitude positive change in my professional lifetime are quite real. On US health policy, I'm less optimistic. My friend and classmate Jesse Singal wrote a description of the US health system -- in the context of astonishingly ridiculous remarks by some conservatives on contraception -- that I think about sums it up: "...our medical system is an octopus riding a donkey riding a skateboard into a sadness quarry."