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Thanks Scott for your well thought out rejoinder to my post (as usual!). I wouldn’t disagree with you much on the critique of American health care. My arguments, however, have to do with the benefits to America’s image that could result from a national policy of an expanded thoughtful engagement on health care with other nations. In my experience in China and elsewhere, there is an excitement about American health care that cannot be denied, one that other countries want deeply to tap into. The heat of debate, experimentation, and innovation here is very hot right now. The typically American values embedded in this panoply of activity are also very attractive. And relative to most nations in the world, we do have a lot to offer and a certain responsibility that goes with it as well. But it is a two-way street and this is only to the good. We interrogate, we learn, we incorporate, we innovate and we give back. It’s a good deal if we can only get our people to sit at the international table.

I agree with so much of what you’ve said in your posting and would add that the American system creates (as opposed ot having been “created by”) an identity crisis that makes matters worse. Citizens of other developed countries identify their health and healthcare in a single context. That is, as a resident of Canada, France or the UK, one’s health and healthcare is simply a function of being a person-citizen and obtaining what is needed to alleviate symptoms or cure disease.

In America, healthcare issues are compounded by the fact that seeking healthcare has to be initiated, percieved and navigated through a prism that requires citizens identify with one sub-population or another.

A person-citizen in America may belong to an employer-sponsored HMO, PPO, POS, indemnity, self-funded, fully-insured or MSA plan. A person-citizen may qualify for Medicare, Medicaid or both. They may also qualify for SSI. Their children may qualify for S-CHIP. A US citizen may qualify for Workers Compensation, STD, LTD, and perhaps even benefits like those offered by Aflac. Someone may qualify for benefits entiteld to pregnant women who cannot afford pre-natal care, temporary assistance to families that includes healthcare, criminal justice healthcare (probationers and parollees and prisoner re-entry) and so on. Cities, counties and states offer coverage of various sorts….if only we knew which sub-population we belonged to!

The degree to which we have fragmented and stratified our society and healthcare delivery system has - in turn - fragmented the delivery system and the doors through which people enter. While our intentions have been good (offering as many people access to healthcare as possible), the net-effect of stratifying the delivery system to match population-type is that people get confused, marginalized and disaffected. I think this has had an impact on the degree to which we have allowed our own systems to stratify. In short, we are exhausted and mystified by all of the complexity and when we don’t understand something, we experience fatigue and back off.

Subsequent to the fatigue and confusion is a reluctance to engage with the healthcare system and we know what impact that has: Americans, I suspect (and verify when I read Commonwealth Fund and IOM reports) are slow to engage their disease process with appropriate healthcare. I want to suggest that our chronic disease, poor self-care and costly care will be positively impacted by a change in terms of identification. When Americans begin to see themselves as one population caring for itself in one healthcare system, they will seek care earlier in a preventive fashion and remain compliant with healthy behaviors and treatment plans over the course of their lives. One lifetime, one person, one healthcare system. The quality and cost of other countries’ healthcare systems has an individual citizen dimension. They use and engage their systems for effectively and efficiently than do Americans because they aren’t hypnotized by them.

Fragmentation and stratification - however well-intentioned - leads to fragmented healthcare-seeking, fragmented treatment plan compliance and disaffection with the system to the extent that disease worsens and cost of care rises.

Patrick Gauthier

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