Schlesinger describes four main themes relating to the notion of a shared household. These are:
Collective responsibility for medical care or cost-
Family members have collective responsibility and commitment in regard to certain burdens (such as paying the rent or household chores). In a similar way, politicians first argued at the end of the Progressive era that the American nation -- qua family -- owed special responsibility in regard to its duty: medical services. Responsibility in regard to the nation providing social insurance reappeared during the Great Depression era where Roosevelt argued that "Americans were ready, in the Depression and after, to abandon individual responsibility for the costs of sickness during and after the Depression" (Schlesinger, 973).
Shared institutions for health care and finance
Just as the household may collectively sit down to meals and share other common experiences, so is the household expected to collectively share in providing for their insurance and support of medical care and related expenses. When translated and applied to a societal / national level, with the nation seen as 'family', these societal responsibilities coalesce into shared financing of care (such as a national health insurance plan) and delivery of medical services (such as a national health service).
3. Norms of equity that emphasize need
Families adjust their notion of merit to individual family members according to basis of need. Similarly, too, the American nation, as a larger 'family', needs to adjust its distribution of health care costs according to the needs and merits of individuals -with some deserving more relaxed costs than others. Concern about need strengthened in the mid-20th century where Medicare was initiated because the elderly were perceived as being "both needy and deserving" (Schlesinger, 974). This concern continued into the late 1960s and early 1970s.
4. Collective protection against threats to health
Families are ideally seen as pockets of shelter against harmful influences or circumstances of the external world. In a similar way, America, qua family, should protect its citizens from threats to health. The Pure Food and Drug Act (1906) was one of the first of its kind to address this need. It protected consumers' from possibly exaggerated and deceptive marketing by medicine companies. Protection from the government against medical deception increased in the 1970s where proliferated spending, insensitive medical performance, and incompetent judgment by consumers almost became the norm. The government decided to intervene out of concern for its 'family' members.
Obama's intentions for change of the health care profession are ambitious and controversial. Goldhill argues that Obama's reforms actually exacerbate, if not overlook the real problem and that the massive national bill of health care costs is spiraling out of control. The Brookings Institution, for instance, calculates that U.S. health care costs exceeds national costs on Social Security and national defense combined (Brooking Institute, 2008), whilst 40% of U.S. citizens, ages 18-64, lack adequate health insurance (Consumer Affairs, 2007).
Goldhill's points include the following:
1. Price of health care is disproportionate to other areas - The government is spending more on healthcare than on anything else. Compared to the housing bubble in a business sense: policy makers have defined housing as an undersupplied social good and have therefore worked to make it more affordable. Result: people are more willing to borrow and spend than they otherwise would have thus causing the housing bubble. A similar scenario has occurred with the medical field with social resources disproportionately allocated to the medical field at the expense of other systems, distorting the demand, raising the price and making us poorer by crowding out other necessities.
2. Health insurance is not health care -- Insurance is usually employed only for funding rare, unexpected and large costs since its burden can be exorbitant and massive. In the field of health care, it is overlooked that healthcare insurance is perpetrated as a regularity (something like paying the grocer weekly with insurance). The uncommonly high bills are a huge drain and headache on the nation's coffers. "For every two doctors in the U.S., there is not one health-insurance employee -- more than 47,000 in total." Goldhill argues that the enormous cost of health care would disappear if we paid for routine and predictable health expenditures by ourselves. This leads to the hazardous situation of health care becoming an integrated industry of consumption where new treatments and drugs arise all the time, and people -- particularly insured patients -- demand the more expensive and newer products on consumption. Often the cost that goes to cover these expenses comes from other people's pockets; this is morally hazardous. In a similar way, we feel smug and anesthetized at the notion that someone else is paying for our treatment. Goldhill argues that there is 'noone else'. "Our nation's health-care bill is too big to be paid by anyone other than all of us."
3. Government efforts to control costs have failed since the government is focused on prices rather than costs. As a result, some areas of the medical field are overloaded, whilst some are deficient in practitioners (such as the geriatric field where geriatricians make less money than other practitioners), and the tax on Medicare keeps on rising.
4. An uncompetitive system -- endless layers of healthcare regulation stifle competition in the health care system in the classic economic sense. As a result, hospitals remain under-motivated and practice remains at status quo levels. Private and government institutions negotiate services and reimbursements, and the hospitals have no reason or motive to excel. In a similar way, the patient is not the customer; it is the health insurance (e.g. Medicare) that is, therefore, causing the exaggerated investment in IT (particularly billing) rather than medical equipment. As a consequence, there are hidden costs and a lack of transparency of cost and billing to the consumer.
The root of the problem, argues Goldhill, is enormous health care costs that should be shouldered by individuals rather than the government. It is these economic and business matters that are leading to the collapse of the medical system in so many ways and Obama's suggested reform will do little, if anything, to ameliorate the situation.
In short, Goldhill advocates a consumer-driven health care system rather than a government-driven one. This can be achieved by implementing a catastrophic-based illness insurance policy that may cover any expense above a certain threshold. One could pay annual rates, but the objective would be to restrict medical coverage to true catastrophes.
Health care should be paid out of income and savings, with every American required to have a Health saving account and borrowing, if necessary, to maintain it. In the case of lower-income Americans, the government should fund the gap. Likewise, to encourage check-ups (that people, to save money, may be reluctant to have), the government can fund free checkups every two years.
Technological innovation would begin to concern itself with value not quality. Hospitals would be focused more on making profit and attracting consumers, hence increasing their level of care and competitiveness. Congress should obligate maximum transparency on services, prices, and outcome with safety and efficacy remaining the cornerstones of government licensing. It is in this way that health care will serve us more, and, paradoxically, cost us less.
Goldhill's ideas are interesting. Numerous strategies have been posited to address the fumbles of the Medicare systems and its inability, due to rising costs, to provide all with insurance and equal quality care. In fact, exorbitant costs of the system lie at the heart of America's bumbling medical performance in comparison to other countries. Goldhill indicates one solution. Some may see his recommendations as being too harsh, and problems exist in how to define' poor' and in how to distribute a nationally accepted merit-based scheme. Nonetheless, certain of his points have merit, and competition may certainly inspire the hospital to improve its service.
Parenti's stance takes the overall question of what it is that we seek in the healthcare system and then applies the sub-question, what can we do right now to achieve that.
She protests that we are using the wrong framing -- that of Wall Street capitalists to perceive the medical insurance / economics of health care template -- whereas we should really be revising our frame to that of 'whole system design'.
The system should not be run like a corporation with levels of hierarchy and organizational cultures as well as perspectives of leadership, managerial control and so forth; neither should it be under the control of corporations and moneyed-people. One has nothing to do with the other and only ruins the objective and reputation of the medical profession. At the end of the day, too, capitalists seek for the status quo of the system and do not wish reform; reform is too expensive for them. In short, what should be achieved is transformation of the system where those who care most about the healthcare system and are most qualified to assess it should be brought in to design its delivery systems.