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Part Three - further comments by Dr. Uwe Reinhardt

I feel like a heel beating up on people like you, for whom I have a great deal of admiration and affection. I would assume that you are physicians who, in their medical school days, were members of AMSA and who do not see themselves, as so many other American physicians do, as "the last bastion of free enterprise." On the other hand, I have despaired of ever seeing in this country a health system that balances the dignity and freedom sought by doctors and their patients with society's desire to have the health system operate within some larger budget constraint. You cannot ever have such a system, my friends. You cannot ever have it, not under our system of governance.

The US is, in many ways, a lovely and often graceful country--one blessed beyond belief. But some higher power seems to have saddled it also with sundry curses, among them a system of "justice" that is anything but just and a health system that is the strangest mixture of unbridled compassion and unbridled isolated Social Darwinism, with many shades in between. All systems of human services in the US always bracket the best and the worst everywhere else: we always have the best and the worst in the OECD, all within one system.

I give a talk with colored PPT slides in which I show that any nation's health system actually balances two "qualities of life": the quality of life of patients, and the quality of life of those who derive their incomes from surrendering real resources to patients (directly, as, for example, doctors, or indirectly, as, for example, researchers at Pfizer). In most other nations, the trade-off between these two qualities of life seems to be heavily weighted in favor of patients. In this country, on the other hand, the quality of life of providers always has been and always will be the overarching goal, to which all others are subordinated. That is why patients will always come second (unless they can pay their way to first place here and there).

There is nothing you or your patients can do about it, because under our system of governance your voice simply does not count. We do have representative government, but it does not represent you: it represents whoever can purchase that representation. Do you have the money to do that buying?

The upshot of this sermon is that your choice in America is not, as you seem to believe, between (a) 1990s style "managed care" and (b) a dreamlike, comprehensive, universal health-insurance coverage with a simple, humane administrative structure and a reasonably adequate budget. That is what you are talking about, I think, but you cannot ever have it. In fact, even your beloved Medicare may soon be dismantled to be rendered a lot more complicated and, I believe, frustrating to you all. And you cannot stop that either, because you are powerless. After all, how much money could you ever concentrate on state and federal legislators to be properly "represented"?

Instead, your choice in health care will be between one rather flawed system (the current one) and other possibly even more flawed systems. You simply must get used to it. And here is where I may possibly shock you. In a talk entitled "Would Jesus have loved 'managed care'?", delivered about two years ago at the Palo Alto Medical Foundation's conference, I tried to convince the audience--and I believe I even convinced physicians in the audience--that the managed care system of the 1990s probably would have pleased Jesus more than would have the unmanaged American health system of the 1980s, mainly because his Mom would have been treated better in the 1990s than she would have been in the 1980s. Furthermore, during the 1990s, America's medical establishment- physicians, alas, in the lead-- was busily helping to price kindness out of America's soul, and Jesus would not have liked that either. I recall making a Xmas card about this pricing-kindness-out-of-peoples'-soul business that at the time.

If anyone would like to take me on in a debate "RESOLVED: THAT U.S. HEALTH CARE OF THE 1980s WAS BETTER THAN US HEALTH CARE OF THE 1990s," I'll gladly take the negative of the debate, because I love to win debates, and this one I would win hands down. My opponents would not even have a fighting chance. Any takers? Try me and make my day!

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