Think nationally, act locally

Our favorite description of the United State Health Care system was one given by Dr. Terry Cullen in a lecture to a class of medical students in a Masters of Public Health (MPH) Program. Dr. Cullen described the US Health Care system as a patchwork quilt with a lot of big holes in it (Cullen 2008). Approaching the question of what can be done to provide quality, lower cost, and accessible health care to the entire US population, the patchwork quilt is an apt metaphor. There are pieces of the quilt that are of excellent quality, pieces that do the job more than adequately, other pieces that are old and falling apart, and gaping holes that leave large sections of the bed uncovered. So what can one do with an old quilt? Commit to re-covering the entire structure? Patch the holes as best as one can? Throw it away and start again? Such is the dilemma that confronts the remodeling of the American Health Care System. What is not lacking is a wide spectrum of strong opinions about how it should be done. It is not likely that the health care system will be made anew. An essay by Atul Gawande in the New Yorker (2009) does a wonderful job in outlining how most countries, when they have implemented national health care systems, have designed the system based upon the history, politics, policies, and institutions that were already in existence in that country. This is one reason why there is such a diversity of national health systems in countries across the world: government-run, employer-funded, private insurance based, separate national taxes for health care, etc.; each country's system reflects the political environment of that country at the time of the implementation of their national health care system.