New Yorker on Health Reform, and Difficult Choices. . . .

This one comes to us from The New Yorker, by Atul Gawande, M.D. [Hat Tip: Marilyn Mann] -- the article opens with a review of history -- and the cogent observation that unspeakble cruelties have long-been the impetus and engine for meaningful health care reform, throughout the Western world. That is accurate, in so far as it goes.

I mention it here, though, simply to note that some form of cruelty will permeate every health care delivery system (and certainly, each non-system, like ours). So, it seems, the setting up of a "no-cruely" goal may be the proverbial "bridge too far".

Someone will always, always, get a little less than the very best care (especially if "best" is taken to mean most-expensive), in any setting where -- as here -- resources are constrained. I think the best we can hope for, and thus aim toward, is to be fully-aware of the trade-offs we are accepting, when we embrace any series of approaches to health-care reform, over any given other. In any event, here is the snippet -- but do go read the whole five-page article:

Getting There from Here: How should Obama reform health care?

In every industrialized nation, the movement to reform health care has begun with stories about cruelty. . . .

. . . .The current discussion between the Obama Administration and congressional leaders seems to center on opening up the federal workers’ insurance options and Medicare (or the equivalent) this way, with subsidized premiums for those with low incomes. The costs have to be dealt with. The leading proposals would try to hold down health-care spending in various ways (by, for example, requiring better management of patients with expensive chronic diseases); employers would have to pay some additional amount in taxes if they didn’t provide health insurance for their employees. There’s nothing easy about any of this. But, if we accept it, we’ll all have a lifeboat when we need one. . . .

It won’t necessarily be clear what the final system will look like. Maybe employers will continue to slough off benefits, and that lifeboat will grow to become the entire system. Or maybe employers will decide to strengthen their benefits programs to attract employees, and American health care will emerge as a mixture of the new and the old. We could have Medicare for retirees, the V.A. for veterans, employer-organized insurance for some workers, federally organized insurance for others. The system will undoubtedly be messier than anything an idealist would devise. But the results would almost certainly be better. . . .

So -- let us face it -- and face it, now: some form of rationing is inevitable. Either we can continue to allow this non-system to ration solely based on ability to pay (or to procure adequate insurance coverage), or we can begin to make more thoughtful, meaningful, but no less difficult decisions -- about "how much" each person is allowed to consume.

No one really wants to talk about it -- but that is exactly why me must: sometimes the hardest thing -- and the right one -- are the same.

That is the nut of it. And the sooner we get down to really cracking the shell, and making tough, resource-constrained choices as the foundations of our conscious policies -- the better it will be for all of us.