President Bill Clinton's health-care proposal was only one among a continuing string of reform initiatives doomed to failure because of the metaphors and myths our nation uses to conceptualize the health-care system.
The fact that metaphors define the manner in which we view the world is well known. Furthermore, these perceptions of reality play a central role in shaping our behavior.
In particular, our country's understanding of its health-care system is shaped by the mythical and metaphorical presumptions that fashion our thinking. Three of these act to block really useful reforms because they pervert reforms at their very conception and deflect meaningful debate. These are (1) equating insurance with good access, (2) perceiving health care as a singular product and (3) representing health care as a slice of a fixed economic pie.
Perhaps because of the insurance industry's political clout and physicians' long aversion to socialized medicine, our nation equates insurance with access to health-care services. According to this myth, good insurance implies good access to health-care services and good access is most effectively provided by good insurance.
Although 35 million to 40 million Americans are uninsured, it is a misconception to equate the lack of health insurance with the lack of access to health care. Hospital emergency rooms are required to stabilize every patient; public hospitals are required to admit without regard to finances; and public clinics are widely available, at least in urban areas. Lest we forget, large numbers of immigrants enter our country illegally, in part to gain access to the care we provide our uninsured. Moreover, many insurance policies have benefit restrictions that limit access.
Americans' acceptance of a second myth, that health care is a singular product, is suggested by the new word "healthcare" as in the American College of Healthcare Executives. Almost every reform discussion refers to health care as if it were both a single and stagnant product and as much of an absolute necessity for life as bread.
But health care is a diverse and changing industry. For example, managed-care reforms, which might be appropriate for Medicaid hospitalizations, are unlikely to improve the quality of treatments for chronic illnesses or long-term care. Similarly, reforms that reduce health-care expenditures in the short term jeopardize the stream of new technologies such as those that have improved the longevity of low-birthweight infants, burn and trauma patients and individuals with liver or kidney failure.
Moreover, health-care services have both investment and consumption components. Investment means spending money for future benefits such as an increased longevity. Consumption means spending money for current satisfaction.
Criticisms of excessive expenditures typically focus only on the investment component. …