Last week I was traveling in Spain, Italy and France, where my novel is being released in translation. Inevitably, I was asked about the health care drama in America. It's such a compelling story to me, and I was delighted to find it being closely followed in Europe.
In general, the Europeans I met, ranging from drivers, to publicists and editors could see the pros and cons of what President Obama is proposing. They live in countries where it is unimaginable that breaking an ankle can render you bankrupt and homeless, which can happen in the U.S. They freely admit that the health care in their countries is nothing to brag about: there can be delays, and things get done quicker in the private sector. But even so, the best care is in the public sector. Health care is not a deciding factor in moving jobs or taking a plunge to create their own start up. Overall, I found a sophisticated understanding of the debate: no "death panel" kind of hyperbole, just facts. They are watching closely in Europe, very curious about how this comes out with a vote on Sunday.
Since coming back to the States a few days ago, I have jumped right back into being the attending physician on the wards of my teaching hospital, a busy tertiary care setting. It has been busy, but it has also been grounding and humbling. Strangely, amidst suffering and illness, and while watching families struggling to care for their loved ones outside the hospital, the drama of the health care debate recedes. It has simply not come up with my team, with nurses or with patients; indeed, I hardly think about it until I am away from the hospital. It's because, for the longest time, all of us in American health care have had no consciousness about costs -- we practice as my colleague Alan Garber says -- as though we are ordering off a menu with no prices.
But now is the moment of reckoning. I find myself quite caught up in the excitement leading up to Sunday: the Congressional Budget Office (to everyone's surprise) seems to say the money is there; the American College of Physicians and even the AMA have given their blessing to the latest proposal -- who would have predicted that? The abortion issue is in reality a non-issue: the sole physician I know who provides this service for all of west Texas and New Mexico tells me no one ever uses insurance or federal funding for elective abortion. It is a mystery to this physician why abortion is a sticking point for the debate.
There is great drama watching elected representatives deciding if they want to "do the right thing" (that's a direct quote) . . . I guess the alternative would be "do what might keep your seat safe or what the people who raised your campaign money paid you to do"? Tell me it's not thrilling!
We might look back to this Sunday the way we remember the moon shot. Perhaps that's what makes this so tough for politicians: there is potential to make great history -- or not. A vote could indicate you were a part of making history, or you were wise. It might indicate you were a visionary or else your vision was too narrow, too self serving. The danger in the latter instance is that even if you voted the way you thought your constituents wanted you to vote, they may paradoxically later see you as lacking courage, as being on the wrong side.
The package is far from perfect. I still say that without true payment reform, as long as we have fee-for-service, it is inevitable that we will have more service than we need and more people providing lucrative services (that inevitably involve procedures), because the income incentives are huge. But what happens tomorrow (or not) will be a great first step. I will be watching closely. And I know they will be watching us closely in Europe. How could they not? It's showtime in the United States.