Framing The Health Care Reform Debate

When carpenters frame a new building's walls, the building takes a recognizable shape. Passers-by get a sense of structure, a release of anxiety, the assurance that the process is reasonable and guided by established principles of physics, mechanics, truth and responsibility.

Unfortunately for his investors, Bernard Madoff's framing process provided his investors with a sense of structure, freedom from anxiety, and assurance - echoed by respected financial experts - that his structure was reasonable, in accordance with the principles of the financial industry of which he was an noted executive, responsible and truthful. A Ponzi scheme is an exercise in framing for deceit.

Framing is not restricted to buildings and financial structures: it is also part of our daily political exposure. Arguments are carefully framed and discussed by health care "experts" representing entrenched vested personal and business financial interests in advocating or opposing health care reform. We hear the expert-of-the day on television proclaiming that he or she has a solution or a reason not to solve, our health care problems and we hear our Congresspeople in high dudgeon about the foolishness of some of the proposals.

What does the "frame" look like? How does it compare to the truth?

The Norman Rockwell painting showing a doctor by the bedside, indelibly etched into our psyche, is a good place to start. It is part of the mythology of American medicine: each person should have his or her own honest and competent personal physician who is completely dedicated to him or her, and can marshall all necessary care without any intervention by an outside force. Unfortunately, the physician that one sees when really sick is not likely to be the physician who might know you; the hospitalist may never have met you before admitting you to the hospital and probably will not know you after discharge. The specialists who undertake your care come and go, often unfamiliar faces appearing at odd hours. Medicine has changed from Rockwell's days when the doctor sat by the bedside, waiting for the patient to die because the doctor had no antibiotics, little technology, and scientific knowledge which was woefully deficient. And today's family practice physicians have the impossible task of being knowledgeable in many complex fields requiring their attention today.

Another myth grew from the non-profit operation of early health insurers such as Blue Cross and Blue Shield and non-profit HMOs, the latter established in response to Richard Nixon's actions supporting a new system of care. Insurers and HMOs have perpetuated an image of providing service and valuable expertise to health care, rather than acknowledging that they are essentially system integrators which primarily contract with networks of providers and themselves provide little or no health care, but lots of resource-draining bureaucratic intervention and political contributions.

Another frame issue is the concept that, as scientifically and technologically advanced Americans, we now provide high-quality and efficient health care to all who need it and that health care reform will exponentially increase health care expense. This is a dubious position: overflowing hospital emergency departments (many roadblocked by the uninsured) are many times more expensive than a doctor's office for providing episodic non-critical care. With health reform, why shouldn't we develop money and life-saving efficiency rather than perpetuating the wasteful system that perpetuates income flow to selected self-serving segments of the health care industry and poor quality inefficient care to many Americans?