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Grand Rounds

Health-care security

By Vijay Thadani, M.D., Ph.D.

Amid the hysteria of left-wing and right-wing commentators arguing over health care, it is rare to find a discussion that points out the essential differences between the two outlooks. The well-known columnist Charles Krauthammer did just that in a recent article describing what he called President Barack Obama's "real agenda: his holy trinity of health care, education, and energy." Obama's goal, observed Krauthammer, is "to narrow the nation's income and anxiety gaps. . . . He's here to warranty your life."

Krauthammer went on to criticize this goal because it involves an increase in government intervention. I claim no expertise in education or energy, but given my background, and some knowledge of medical issues, I wholeheartedly embrace Obama's plans with regard to health care.

I was born in India and lived there until the age of 15. Growing up, I saw what the absence of a social safety net can do. A sudden illness or bad weather that destroyed crops could lead directly to starvation and death. It was quite common to see in the streets seriously ill people who had no realistic prospect of finding medical treatment. Improving economic conditions in India have ameliorated the problem, but it persists to this day.

The Grand Rounds essay covers a topic of interest to the Dartmouth medical faculty. Thadani is an associate professor of neurology at Dartmouth Medical School; in his clinical practice at DHMC, he specializes in the treatment of epilepsy.

Good fortune: As one of the privileged few, I was acutely aware of my good fortune, in terms of both wealth and security. Since that time, one of my goals has been to support policies that will extend to all people the security that in the past only the wealthy have known.

When I was 15, my father's employment with the World Bank brought my family to Washington, D.C. After that, my education was entirely American. However, through my parents' careers and my own visits to India and Europe, I became acquainted with the evolution of health-care systems in other parts of the world.

In Europe, where class barriers were, and still are, much sharper than in the United States, the misery of two world wars was one factor that led to the development of socialized health care. Governmental systems have many drawbacks, but no one doubts that they have alleviated anxiety across the entire spectrum of society.

In the United States, the essential issue is this: Do we value unfettered enterprise regardless of unequal outcomes and disaster for some, or do we redistribute resources in order to give security to all? The issue is not black and white. The most ardent advocate of free enterprise will support police and fire departments, yet those are clearly collectivized security arrangements. And on the other hand, the most ardent socialist will concede that progress will be stifled if there is no individual initiative, and that free enterprise in the U.S. has produced the world's most technologically sophisticated health-care system.

How then are we to choose between these two outlooks? At present, the U.S. health-care system is clearly failing, except in emergencies, to provide care for large numbers of citizens. In homeless shelters and on the streets of New York and New Haven, I have seen untreated disease almost as shocking as what one can find on the streets of New Delhi. To oppose collectivist measures now is to condemn millions to poverty, insecurity, and illness neglected until it becomes catastrophic.

The issue is not black and white. The most ardent advocate of free enterprise will support police and fire departments, yet those are clearly collectivized security arrangements.

Cooperation: I am proud to work for an organization, Dartmouth-Hitchcock, that through an elaborate system of cross-subsidies gives equal and high-level care to all those who live in our community. We have here an almost complete monopoly on expensive, high-quality, specialized care. We also provide a lot of subsidized primary and specialty care that is of equally good quality. This has been achieved by cooperation, not coercion, and DHMC providers retain considerable opportunity for individual initiative.

It is clear from the fact that the Medical Center is solvent that there is enough money to go around. The care provided by DHMC is more than adequate, as is my salary, yet our expenditures per capita are not high by national standards. It follows that with no more expenditure than the U.S. already incurs, the entire country could be medically insured and cared for.

Skeptics may argue that with approximately 20% of the nation's population uninsured or underinsured, many are not getting the care they need and that it will cost more to fill that gap. At present, however, even the uninsured are not entirely bereft of services; as President George W. Bush once said, "You just go to an emergency room." Many do, often for minor problems that could be better addressed, at a fraction of the cost, in a doctor's office.

The United States already spends about 50% more per capita on health care than any other country. In the future, rising costs will need to be controlled, but today the net deficit of care cannot be greater than 10%. If I am right in that estimate, all that needs to be done to keep costs level while expanding care is to reduce reimbursements by 10%. I will grant that doctors and other providers already work hard, but I have seen enough in 20 years of practice to know that we could work 10% harder for the same compensation.

Choices: It is for all Americans to decide whether choices regarding health coverage will be made by employers and insurance companies, a policy that leaves many without care, or through representative government. The latter may realize medical care for everyone, and a redistribution of costs and benefits across the whole nation.


The Grand Rounds essay covers a topic of interest to the Dartmouth medical faculty. Thadani is an associate professor of neurology at Dartmouth Medical School; in his clinical practice at DHMC, he specializes in the treatment of epilepsy.

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