Health Reform - Madison expects many steps forward

When I was about 26 years old and just out of my pediatrics internship, I joined the U.S. Public Health Service and was stationed with the Medical Care Administration in Washington, D.C. My first boss was Don Madison. Don came from Lincoln, Nebraska, and was a Seventh-day Adventist and a vegetarian. He was a great fan of the Broadway musical, and great fan of basketball, and was a disciple of some of the leading lights in American pubic health, including Cecil Sheps, who became Director of the Health Services Research Center at the University of North Carolina, whose faculty Don later joined, and whose basketball games he faithfully and enthusiastically attended. Even though he was a Seventh-day Adventist from the Midwest who then attended Loma Linda University Medical School, Don was a great liberal thinker, worked with USC med students Mick McGarvey and Bill Brontson, whose wife was an airline attendant and who could thus fly anywhere for free in his organizing, to start the liberal-radical Student Health Organization (SHO), and then worked at the Beth Israel Medical Center in Manhattan and Montefiore Hospital in the Bronx studying how to organize to deliver health care. He will, as is his way, correct me in these details, which I am never good at, but I'm aiming to get to the flavor of Don. Don was the greatest, nicest, smartest, and most inspiring boss a guy could have. When my unit was splitting into two divisions, "systems" and "action," he asked me which one I wanted to join. I said, "Whichever one you are going with." That's how smart I was. I never learned more from anyone.

Don has been my lifelong friend. As you can tell, I love Don. He says that he is retired, and he is leaving health care behind, where he was a brilliant teacher and wonderful writer. But I won't let him do it. I keep sending him papers, and asking his opinion, etc. It's like the mob - "They keep bringing me back in."

So with his permission I'm posting what Don says about the current health reform movement. I observed to him that Medicare has been so stagnant — I compared it to the Titanic — that it might not be reasonable to suppose that a Public Option in health care would be able to adapt and make progress. Here is his response, which I agree with. His basic point -- just get the best bill you can out now, and trust that there will be lots of adjustment to follow.

"Of course only the passengers on its maiden voyage had the opportunity
> to really appreciate the Titanic! You don't believe Medicare is
> salvageable?
>
> "I think that the fiscal pressure (starting with that from
> Peter Orszag) is going to be so overwhelming in the next couple of
> years that Medicare will have to undergo a major shift in its
> behavior.
>
> "The important thing now is to pass a bill, the best bill we can get
> but one that gets us substantially closer to a "health care for all"
> situation. Then comes the long, hard part. Because it is going to be
> a decade-long, maybe decades-long, process of improving whatever is in
> that first bill. I don't think that the rule of precedents (Medicare
> is the main such precedent, but several out-of-country systems fit
> this model, too) will guide what will happen. What I mean is that
> whatever program passes will not be set in stone — like Medicare seems
> to have been, except for a few changes around the edges — but will
> instead undergo major but step-wise changes (more like Bismarck's
> original program did over the next 40 to 50 years). The changes needed
> will be so complex and difficult, given the recent history of medical
> care in this country (especially The Coming of the Corporation), that
> everything will necessarily move incrementally, once the big bill has
> passed. But that has to happen first."
>
> Don

Budd Shenkin