Revolution, not reform: a comprehensive proposal for healthcare

The current problems with healthcare in the United States--lack of access and ever-rising costs--are largely due to a societal crisis, rather than a healthcare crisis. However, the majority of suggestions for corrective action deal with only a limited aspect of the healthcare system focusing on costs and ignoring the root causes. The problems with healthcare are multifactorial and include entrepreneurism; excessive technology; an emphasis on specialists; and the broader issues of poverty, abuse, violence, homelessness, and other social ills. Among the proposals for healthcare reform are the free-market model, improved management, implicit rationing, explicit rationing, and system reform. I advocate a final approach: accepting limits and the appropriateness of setting priorities in a healthcare system. This is feasible only with fundamental changes that include major attitudinal modifications in society, in the healthcare profession, in business, and in government. My proposal integrates but modifies concepts presented by Daniel Callahan in What Kind of Life? Four basic levels of care would be delivered in the community setting by personnel of varying levels of training. It is unclear on what moral grounds commitment of additional resources to the highest level of care--"highly advanced technological medical therapy"--can be justified at present. Central to acceptance of this idea is an attitude of sharing based not on self-interest but on caring. It involves action rooted in a community-based concern rather than traditional family, intergroup, or intergenerational reciprocity.