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
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
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. …