Engagement in Democratic Health Reform
SCOTT C.RATZAN
The ideal for democracy to be a just form of governance
is well-founded in Western thought. While twenty-first century democracies
envelop leadership and decision making for millions, health care has
grown at differing rates with variable forms of governance and engagement.
Today, all of us are engaged in some health care ‘‘system’’
activities as a patient, professional, caregiver, or policymaker. It
appears that systems at every level are engaging in health ‘‘reform’’
in the quest for the best approach.
The words health and reform are inextricably linked and
ongoing. A Google search yields 136 million hits.Today, in most major
developed countries, health is at center stage as it commands a growing
amount of the gross domestic product (GDP), currently as high as 16%in
the United States. Furthermore, with an aging population and projected
use of resources to sustain health, the costs will rise.
Today, as we live in a communication and interconnected
world with innovation in many different forms — from gene level
predictors, diagnostic devices, tailor-made medicines, to name a few
— the questions are broad: How much do we need and want, and what
will we be able to afford as both an individual and society? What is
the appropriate amount of GDP to spend on health care? How much is a
disability adjusted life year (DALY) or health active life expectancy
(HALE) worth? What value should we place on emotional medicine advances
(e.g., pain and palliative), incremental innovations, and experimental
approaches?
There is an overarching question that is related to fundamental
approaches and innovation: Are we (as individuals or society or both)
satisfied with the knowledge and tools we have today in health care?
If so, we should work on increasing productivity in the system, mass
marketing all that we have, and penetrating the psyche of our current
knowledge base. If the answer is no — that is, I want to have more
clear preventive measures, the ability to detect disease more accurately
and earlier, and have better and newer medicines and treatments for
disease —then we need to embody a health system that values democracy
and progress, promulgating individual engagement in garnering the best
care and treatments.
On a system level scale this would translate into morals
and values that respect human dignity;promote ethics at professional
levels with equity and nondiscrimination; target public health improvement;
focus on patients and citizens sharing responsibility and participating
in decisions for their own health; focus on improvement in accessibility,
quality, and cost-effectiveness;improve regulation and promote decision
making based on sound science, evidence, and moral values;and enhance
the ethical and science-based research environment thereby orienting
a system for primary health care valuing primary, secondary, and tertiary
prevention.
The evidence in this journal that advances ways we engage
as health communicators demonstrates how actions ‘‘outside’’
the health care system, such as education, nutrition, entertainment,
and prevention of risk behaviors such as unsafe sex (see article by
Noar and colleagues) and obesity (see article by Hoek and Gendall),
have an important effect on health.
Yet, despite the great contribution of health communication
outside the system, we need to develop ways to advance principles within
the system in support of ethical standards for health reform within
the system.As health economists are most often in the lead with policymakers
in health reform development, their literature and conclusions are also
important to consider.
For example, the ‘‘market ’’in health
care that is subject to ‘‘reform ’’is particularly
complex — health insurance and health care services are subject
to uncertainty, adverse selection, asymmetry of information, plus the
implications of value judgments.
Economists remind us that the market in health care is
inefficient: The interests of employers, workers, and providers are
paramount and center on preserving the status quo and are resistant
to any change that would disadvantage them.To overcome positions of
the key players in the U.S.system requires a great deal of understanding
and commitment to change by the rest of society. This has great implications
for health communicators who often promulgate spending outside the system
on environmental elements or suggest investment in prevention or both.Similarly,
gatekeepers in other ‘‘democracies’’ are government
officials or payers who often protect silo budgets or microsystems focused
on cost rather than on value.
Economic evidence also suggests that everything that sounds
like ‘‘competition ’’ or ‘‘markets ’’or
‘‘private sector’’ will not necessarily improve
economic performance. The fact that something is done in the private
sector does not mean that rational economic incentives necessarily apply.The
fact that something is in the public sector does not necessarily mean
that they do not apply.Yet, supporting competitive markets to stimulate
innovation would be an evidence-based approach to health reform.
In health care, people (patients, carers, and citizens)respond
to differing incentives other than economic ones, especially in health
care. Hence, a focus on economic resources hinders efficiency and is
not promulgating ‘‘evidence-based medicine.’’Yet
it is important to get the economic incentives right for resources to
be spent on those people and institutions that do the best job.
Finally, what this all means is that an ideal health system
should have main elements: information for patients to make the ideal
(read, not always rational) decision; information on innovation, quality,
and cost; payers with incentives to seek value and provide value-based
(read, equitable) care; reforms to support innovation in health care
delivery from home to hospital; providers capable of enhanced productivity
and communication (both to patients and using information technology
[IT ]); and a proinnovation and speedy regulatory framework that describes
and diffuses risk, benefit, safety, and value.
As health will continue to be the common fabric of humankind,
it is incumbent upon us to help develop ethical and moral ideals in
the health reform arena. Ideally, health communicators should advocate
a role alongside economists and other professionals to advance the future
systems of health care.
_____
Scott C. Ratzan MD, MPA, MA is Editor-in-Chief of the Journal of
Health Communication: International Perspectives. He also is Vice
President, Government Affairs, Europe for Johnson & Johnson with
academic appointments at George Washington University School of Public
Health, Tufts University School of Medicine, Yale University School
of Medicine, The College of Europe, and University of Cambridge.
