Our Choices, Our Ethics for Healthcare, Honoring the Contributions of Uwe Reinhardt

Uwe Reinhardt, the great political economist died earlier this week.

Professor Reinhardt famously asked audiences:  “who are the most important people in our lives?  The answer he gave that always received universal affirmation was:  “mothers and teachers”.  He would conclude his talks by reminding us all that
“until and unless we build our society around our “mothers and our teachers” the downward trajectory of our ethics will continue, and with it any sense of justice or social peace.” (my recollection of his remarks, but attributed to him).

Some economists tend to lose sight of the point of it all.  Not Reinhardt.  Instead he helped make clear that political economy is what we must pay attention to: the choices that powerful private and public actors make.  Economic trends are determined by choices, and most are value based, though usually, as he constantly reminded us, based in code words.

We spend a great deal of time debating who is to blame for our dysfunctional health care system. For example we know that insurance, physicians, even high salaries for executives, mergers and acquisitions,  high costs of drugs, all contribute to the out of balance spending and health outcomes we suffer from in the U.S. All of these elements should be looked at for savings to be sure.

Yet, Professor Reinhardt goes further, beyond the code words of blame:

“And when critics complained that doctors were overpaid, he countered that their collective take-home pay amounted to only 10 percent of national health spending. Slicing it by 20 percent (percent healthcare represents of annual GDP) he wrote, “would reduce total national health spending by only 2 percent, in return for a wholly demoralized medical profession to which we so often look to save our lives.“It strikes me as a poor strategy,” he added. (from NY Times obituary)

 I fear that all that energy to reform those  high cost elements will  largely be wasted (and will not likely happen) until and unless we as a people grapple with the ethical core of the problem:  in a democracy, how is it possible that so many suffer poor health and poor access to health care?  Without that ethical core, systems will continue to flounder and waste lives and resources for lack of an ethical center.

Reinhardt reminds us that social solidarity is the path to effective and value based spending. “His ideal model was the German system in which insurers negotiate with health care providers to set common binding prices in a specific region.

“I believe it is still the best model there is, because it blends a private health care delivery system with universal coverage and social solidarity,” he told The Times in 2009. “It’s inexpensive and equitable. Coverage is portable. You’re never uninsured in Germany. No family goes broke over health care bills.” (New York Times obituary)

 I learned a great deal from Uwe Reinhardt, and  continue to try to influence change through engagement of all stakeholders with his principles in mind.  Patient centered,  value based work by all workers, all executives, all physicians, and all managers in healthcare every day can produce not just better outcomes, but the consciousness necessary to create an environment of solidarity, a global kind that creates a true north for all to truly be inspired by with goals tied to ethics, not just performance.

Here is the content of one of Professor Reinhardt’s slides from a presentation I had the honor of hearing in 2011:

“Increasingly, thoughtful policy analysts and politicians think of the following definition of “value”in health care:
1.)  Gross Value Added by Health Care to Patients
2.)  Net Social Value Added by the Health System
3.) The Opportunity Costs of that Care for Society
Neglecting the education of our young • Neglecting science and R&D • Neglecting the nation’s public infrastructure • Neglecting national security and safety of our warriors • Giving up other things households enjoy”

Professor Reinhardt’s contributions to our understanding of what an ethical system of healthcare remains and will remain at the center of our on-going discussion on healthcare.  Ultimately he argues for a model of care that is quite specific, not theoretical.  It is a system delivered largely through private means but with social solidarity at its core.

It is less complicated than we think.  What is much more complicated is continuing to live under our current disaggregated, unjust, expensive, wasteful, discriminatory, and frankly mean-spirited system.





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