Illustrations by Peter Steiner

I am an obstetrician-gynecologist who is completing his 33rd year with what I consider to be the best health-care organization in the country, Kaiser-Permanente. From our beginning we have provided prepaid health care to our members and still do today. I am responding to the article “A Healthy Decision?” in your October issue. There is little in that article with which I disagree. But no one quoted in the article gets to the essence of the problem.

The problem is fee-for-service medicine. As long as we believe that medicine is a 19th-century piecework cottage industry, we will continue to have the most expensive health-care system in the world with, at best, mediocre quality of care. Most practicing physicians are not dummies. If the system rewards those doctors according to the number of procedures they perform or the number of patients they see, then that is what they will do to maximize their incomes. So what is the alternative? A system that has these three characteristics:

• Prepaid—There is no incentive for us to do extra procedures or make extra appointments since we have already been paid the full amount for that patient’s care. Instead our incentive is to keep our patients healthy. But this is not just a dollars-and-cents decision. It is simply the right thing to do.
• Fully integrated—Our doctors, our hospitals, and our insurance company are all under the same roof. We all benefit if our patients are healthy. We all lose if our patients get sick.
• Fully Electronic—I have immediate access to the charts of any of our 3 million-plus members whenever and wherever I need it.

I do not disagree with the idea of a single-payer system. But it is beside the point. The change needed is not “Who pays?” but “What do we pay for?” Do we pay for more stents, more dialysis, and more transplants? Or do we pay for preventing hypertension, diabetes, and obesity? We may have made our first step toward a proper health-care system, depending on the results of the upcoming election. But we have several more steps to go.

Peter Coffin ’71
Berkeley, Calif.

As a nurse practitioner, the director of Swarthmore’s student health service, and an educator, I was struck by the depth of the debate going on right here at Swarthmore about health-care reform.

One point I wanted to make is that The American Academy of Nurse Practitioners (AANP) has been at the forefront of virtually every point discussed in the article, and I found myself wanting to share the integral part that the AANP played in the development of the ACA. I wonder if academia doesn’t readily acknowledge the many scholarly contributions that the profession of nursing provides in social inquiries such as these. I can’t help but feel that if we continue to perpetuate the image of the nurse as one of a droll, clipboard-toting handmaid (October’s cover), we miss the opportunity to engage the most critical people in our scholarly debates.

Beth Kotarski
West Chester, Pa.

As an acupuncturist and herbalist, I enjoyed the health-care focus of the October Bulletin, including hearing about the medical and political work of Josh Green ’92. From my perspective, shaped both from my clinical practice of Chinese medicine and the critical thinking I learned at Swarthmore, most commonly proposed changes to our health-care system are actually quite small. While the questions about who has access to health care and who pays for it are important, the bigger and deeper question is: What is health and how do we promote it?

Western medicine, for the most part, is structured to strongly emphasize the treatment of sickness after it has already appeared. While this is an important part of any medical system, Chinese medicine historically describes this as being analogous to waiting until your well has run dry before digging the next one. Using more modern imagery, waiting until sickness appears before seeing your practitioner is like waiting for your car engine to seize before changing the oil.

A fundamental reason our health-care system is becoming dramatically more expensive is that it is none of these things—it’s clearly not a system, and, unfortunately, it does not care for health. Instead, what we emphasize is the suppression of symptoms.

Without a more person-specific understanding of health, it’s likely we’ll continue down the path we are on, which is toward an increasingly expensive, high-tech and invasive form of medicine that treats sickness without understanding what keeps us well.

Brendan Kelly ’92
Burlington, Vt.

As a Swarthmore alum who has resided in the United Kingdom for nearly 30 years, I was shocked to see the cover cartoon on the October Bulletin and disappointed to see so much coverage given to Diana Furchtgott-Roth ’79’s personal opinions, though there was balance from other articles in the issue. Furchtgott-Roth sets great store by her experiences from some unspecified time in the past, while it is clear she currently lives in the USA and is influenced by the nonsense constantly expressed by Republicans about national health coverage.

I just visited the USA in October, my first return to the beautiful Swarthmore campus in more than 20 years, a visit only slightly marred by the sight of a Romney/Ryan poster in a dorm window, and the opinions of some Pa. locals who expressed bizarre views about U.K. health care. Having raised two children here and worked in social care for decades, I can testify personally and professionally that health and social care here is better than in the USA. It is not a conveyor-belt system—people have choice, they all have coverage, and if the wealthy wish to pay more to be seen by “private” MDs, of course they can.

Don’t take my word for it—check World Health Organization surveys and other independent indicators to see that health outcomes and life expectancy are much better in the U.K. than in the USA. Compulsory national health insurance is best for everyone.

Laura Wilson Porter ’83
Sandbank, Scotland, U.K.