We're cattle, not cowboys

By Kelsey Schuette

On Wednesday, Oct. 14, the Senate Finance Committee passed S. 1796, or “America’s Healthy Future Act of 2009,” by a vote of 14 to 9. This much-anticipated vote passed the last committee draft of healthcare reform to the floor, once again evidencing that this current healthcare reform effort has legislatively progressed farther than preceding efforts. My favorite part, however, came (as always) when Kansas Republican Sen. Pat Roberts got a hold of the microphone. “We,” Sen. Roberts declared, “are riding hell for leather into a health care box canyon.”While I’m sure Roberts intended his cowboy metaphor simply to convey an overwhelming sense of doom, his figurative language unintentionally captured a major trend in the current American healthcare debate: we think we are cowboys. We talk about health and healthcare in terms of the autonomous, lone individual-“You’re the decision-maker.” “No one should stand between a patient and his or her doctor.” “How will reform affect me?” Unfortunately for both our macho American egos and the accuracy of our policy discussions on healthcare, however, we are not the cowboys in Robert’s metaphorical scenario. We are the cattle.

Health is intrinsically population-based. And I’m not just talking about the fact that the person sitting next to you on the bus can give you measles. I’m talking about how your chance of getting measles depends upon what percentage of the human population living in your vicinity has gotten their MMR vaccine. You see, epidemiologists realized that we weren’t cowboys a long time ago. They even use appropriately cattle-reminiscent terms like “herd immunity” to describe how disease operates on the macro level. Funnily enough, this also happens to be the level at which public policy, such as health care reform, takes place. “America’s Healthy Future Act of 2009” aims “to provide affordable, quality healthcare for all Americans.” That’s one heck of a herd. So why are we still talking like cowboys?

You might say it’s because this particular healthcare reform bill is about insurance, not health-and you would, at least in part, be right. S. 1796 is certainly about regulating the healthcare insurance industry in this country: who gets coverage, for what cost and for whose remuneration. Discussions about insurance and discussions about health, however, are not as separate or dissimilar as you might think. Multiple studies have documented that insurance can drastically affect the healthcare a person receives and the health outcomes they experience. Furthermore, population level analysis is just as inherent within the logic of insurance as it is in health and healthcare. Insurance is about spreading risk over a large pool of people; it’s about how much money each person has to pay in to cover the rare but large costs that may (or statistically speaking, will) befall members of that group. As Roberts might say, it’s about how many head of cattle you need to sustain the ranch, accepting the fact that one or two are going to bite the dust (or wander out of the box canyon). Economists fretting about healthcare and the federal budget, or insurance companies concerned with pharmaceutical bargaining power, will tell you the same thing: when examining America’s health and healthcare from a public policy level, it’s the macro level that matters.

So why do books, newspaper articles, television programming, documentary film and even presidential addresses regarding this issue focus upon the stories of individuals? Why is the impetus for reform framed within sob stories and predicted outcomes articulated in terms of “how will this affect me?”

These are not trivial stories or invalid questions. Healthcare narratives can help Americans feel connected to an otherwise rather intimidating amount of legislative jargon. The dominance of such individualistic discourse, however, ultimately obscures the real questions Americans should be asking about this healthcare reform. Questions like, does this reform safeguard the health of our population-by ensuring access to accurate health information, to vaccinations, to the treatment of infectious diseases, to programs addressing the epidemics of tobacco use, obesity and alcohol abuse in this nation? Are we maximizing the insurance industry’s ability to spread risk over a large number of people, and increasing their bargaining power with pharmaceutical companies for lower drug costs? Are we optimizing our labor workforce by effectively managing chronic conditions? Are we creating a system that will incentivize safer drugs? Food? Environment?

Would we be designing a different reform bill if we were asking these questions? I hope so.

Thus, Sen. Roberts, I commend you for unintentionally pointing out a major flaw in current American discourse surrounding our healthcare reform. We are stubbornly holding onto the comfortable, familiar, individual level of analysis at the cost of designing effective legislation based upon a population approach because we cannot accept that our health (as well as our health insurance, our health industry and the solvency of our nation) operate at a level far bigger than ourselves. To all you cowboys out there, I suggest you steer your steeds in the direction of Olin Rice 270 at 9:40 a.m. on MWF for Community and Global Health. Or, if Tuesdays and Thursdays work better for you, gallop on over to room 241 at 1:20 p.m. for a little Epidemiology. But most importantly, please stop privileging the individual at the expense of the population when talking about healthcare reform, because it’s obscuring the real issues at hand even more than bad cowboy metaphors.

Kelsey Schuette ’10 can be reached at [email protected]