insure-18_0I recently wrote a story for the state wide news website opinion page (published today) about 3 simple things Alabamians could do to raise our health ranking as a state from just above Mississippi to near Missouri. The solutions, from a set of policy recommendations put forward in the  Global Burden of Diseases, Injuries, and Risk Factors Study 2010 (GBD 2010) were, I thought, motherhood and apple pie. They included: Prevention of road injuries through enhanced enforcement; Implement diabetes treatment programs through expansion of primary care coverage and improvement in care delivery; and Reducing sexually risky behavior through targeting those most at risk (teenagers, not politicians).

To do this we will need to think about illness differently. We will need to focus on fixing a broken system. We will have to exhibit a collective resolve, state agencies will need to partner with other care providers and community leaders, and we will have a slight reduction in individual freedom. I don’t know if Alabama is ready for this, yet. I suspect that many Alabamians would prefer to see other’s personal responsibility  amped up instead. Why collectively try to fix a problem when we can blame the individual next door.

In Remedy and Reaction, Paul Starr describes our system as it exists until 2014

The United States took the critical steps in the formation of its health care financing system in the two post-World War II decades, when it turned decisively towards private, employer-based insurance and created separate programs for the elderly and for the poor. These were the years when the United States ensnared itself in a policy trap—a costly, extraordinarily complicated system which nonetheless protected enough of the public to make the system resistant to change.

Today, for those lucky enough to have a job that provides “good” insurance their illness care involves a lot of invasive testing and “machines that go ping.” For people who are uninsured, if they are lucky enough to roll their care, they will be rapidly transport via EMS to the nearest trauma center where they will, in addition to getting their wounds treated, get tested for diabetes. The motivation is not to keep the car from rolling or to prevent the diabetes.

In 2014, theoretically,the world (at least for Americans) change and everyone gets skin in the game. That is the crux of the Affordable Care Act. Health insurance will be “guaranteed issue” meaning that everyone gets it no matter what their “pre-existing condition” status is. The policy will be based on number of people covered, age, and smoking status. importantly for this discussion, it will also include a “geographic rating.” This will reflect, it seems, the cost of care and the number of sick people in the Metropolitan Service Area (MSA). The more uncontrolled diabetics, costly car accidents, or preterm births we have in our town, the more we will have to pay.

It appears to me that we will be required to take individual responsibility (the individual mandate). We are also going to have to take collective responsibility for our regional costs as well. Maybe we will become our brother’s keeper after all.