Remember Harry and Louise? Sitting at their kitchen table, the nondescript couple burst onto the national stage in a 1993 television commercial that deftly attacked Bill Clinton’s proposed health care plan and made even those of us committed to universal health insurance afraid of its consequences.
I can’t recall the lines Harry and Louise used, but 15 years later I remember the message: America is built on choice, health reform will take away that choice, and if we pursue the proposed reforms we’ll deeply regret it. Then a medical student, I was convinced (albeit naively) that we should have a healthcare system like those of our European counterparts. I was seeing many, many patients who had waited too long to visit the emergency room because they didn’t have insurance – and the accompanying detritus of medical neglect. But I was moved by Harry and Louise. I am not a person who is easily swayed, and yet their message made sense to me. It put a chink in the ideological armor of the left that persists even now.
Today, as we think about how to pursue smart and sustainable healthcare reform, we would do well to remember that Americans – myself included – like to get something in return for their money. And we like to have meaningful choices. As we try to make the system better, let’s not sacrifice choice. In fact, expanding choice is actually the best rationale for reform. We like to think they have choice in our current system, but there are a myriad of choices that are made for us before we even walk into the doctor’s office or taken away from us after a decision is made.
Take advance directives. Americans cling to the false hope that we have the power to decide how we will die. That we can refuse unnecessary care, die with dignity, have the needs and the questions of our family members answered, and opt for extraordinary measures if we choose. This image of death on our own terms is a fallacy.
Last year, when my grandmother lay dying in a California hospital, I saw firsthand how little say a family has in the care a loved one receives at the end of life. Private insurance, a willingness to pay out of pocket, and two doctors in our family did nothing to give us choice. One morning, I came into her ICU room to discover that even though her care providers had observed an unexplained drop in the urine flow from her catheter, no one had checked it. No one had laid hands – or eyes – on the patient. The simple solution was the right one. Her catheter had slipped out of place. And this simple oversight meant she had been sitting in her own urine long enough to break down the skin and cause what would turn out to be a life threatening bed sore – if you can imagine that. As a family we chose to have her be turned regularly to heal the resulting bed sores. Yet despite dividing up the duties so there was a family member with her in the hospital 24 hours a day for months, we couldn’t always get hospital staff to change diapers or assist with turning her even though the evidence shows that these steps are essential.
Despite differences in opinion on her need for dialysis, we found we were at the mercy of the renal physician on duty that week. Just as we chose the follow the advice of one insistent physician to take the more aggressive step to undergo dialysis, that physician would go off service and we would be faced with a new doctor who adamantly refused that same course of action.
And even though she had proactively chosen her physician and her physician had attending privileges in the hospital in which she lay, we found this same doctor who had known her for decades had very little say in the care she received. Instead she was left at the mercy of a new hospitalist every week, each with no knowledge of her case and wildly varying approaches and expertise. I had no choice but to explain the nuances of her case to a new doctor each week. Years of working in medicine and policy were meaningless (in that way alone it was the ultimate democratizing experience). I was totally unable to protect the choices she had made for the end of her life. They willfully ignored her advance directives and the wishes of her family. And they blithely dismissed our choice to have accepted standards of care. What she did want she couldn’t have and what she didn’t want was forced upon her.
When the Aspen Institute polled Americans last summer, they overwhelmingly agreed that health span was more important than life span (91% to 9%). We want a system that helps us stay healthy, and living healthy years is more important to us than living more years. But this is not a choice we are given in our current system. We cannot choose our own definition of a healthy life in the current system.
So the next time you think you have a choice about the health care you receive – think twice. Do you have more reproductive choices than you did 15 years ago? Do you have more preventive health care choices within your insurance than you had 15 years ago? Do you have more choice to vote with your feet when you are treated with disrespect and callousness in a health care encounter than you did 15 years ago?
Harry and Louise were right. We do need choice. But Harry and Louise were also wrong. We will only protect and expand choice through change. And if you watch the latest (2008) installment of the Harry and Louise ads you will see that they too would take their words back.
