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When Greed Runs the System...

Is America’s Health Care Crisis Fixable?

by THOMAS H. NAYLOR

Trying to fix America’s health care problem is a lot like trying to confront the null set in abstract mathematics.  There may be no national fix to America’s health care problems.

Claims that the American health care system is broken are by no means exaggerated.  We have by far the most expensive health care delivery system in the world.  We spend over $2.5 trillion (17.3 percent of GDP) annually on health care or an average of over $8,000 per person.

Unfortunately, the problem lies neither with President Barack Obama’s Patient Protection and Affordable Care Act nor with free-market options proposed by Congressional Republicans. Rather the problem lies with the complexity, scale, and perverse nature of the American health care scene itself.

The fundamental problem underlying America’s health care system is a philosophical problem.  Our health care system rests perilously on two principles—fear of death and greed.

The demand for health care services in America is driven by our obsessive compulsive fear of death.  We neither know when to die nor how to die, and few physicians are very helpful to us in dealing with either of these questions.  The supply of health care services, on the other hand, is driven by the greed of providers, hospitals, pharmaceutical companies, and health insurance companies.  When human greed exploits the fear of death, there is no limit as to how high health care prices can rise.  For those who are fortunate enough to have good health insurance, the message is “You deserve the best medical care money can buy, because you are entitled to live forever,” so say physicians and pharmaceutical company television advertisements.

Those with good health insurance have access to a plethora of very expensive, high-tech medical services including magnetic resonance imaging, ultrasound, nuclear diagnostics, complex multi-organ transplants, coronary bypass surgery, artificial kidney machines, death-defying prenatal procedures, genetic enhancements, and gene splicing.  Anti-aging clinics offer everything from yoga, meditation, and mind-body medicine to growth hormones, sex hormones, melatonin, herbs, potions and elixirs to delay the aging process, but to little avail.  Joel Garreau’s book Radical Evolution reports on a new breed of scientists who believe that advances in genetics, robotics, information technology, and nano technology will allow us to improve our intelligence, reinvent our bodies, and even become immortal.  This new field of medicine is known as transhumanism.

There are dozens of drugs and high-tech medical devices and procedures claiming to prolong life.  We have become accustomed to an endless series of announcements on the evening television news reporting major breakthroughs in the cure of this ailment or that, only to be followed by a retraction six months later warning of risky side effects or questions on the efficacy of the drug or procedure.

By widening the boundaries of illness and lowering the threshold for treatment, pharmaceutical companies have created millions of new patients and billions of dollars in profits.  By exploiting our fear of disease and death, pharmaceutical companies have redefined mild problems and common complaints to serious illness and medical conditions requiring drug treatments.

So strong is the fear of death that it’s not unusual for the wealthy who are terminally ill to spend their last months either on the Internet or flying from one medical center to another in search of a physician, a medical school, an unproven drug or medical procedure, or a high-tech silver bullet which will forestall the grim reaper for a few more months.  The problem is that the number of options available to the terminally ill patient is often completely overwhelming.  How does one cope with so many alternatives?  Is this any way to live or die?  Vermont writer Garret Keizer refers to this phenomenon as “physician-assisted eternal life: the desire of the old to avoid death at any cost, especially if the cost can be passed on to another generation.”  But at the lower end of the income level, it’s quite a different story.

The problem with national health insurance is what I call the “I’ve got mine, Jack” syndrome.  Elderly patients who have paid their monthly premiums feel they are entitled to the best health care money can buy.  They never think about the effect which a $100,000 hospital stay will have on other people’s premiums.  What it’s all about is looking out for number one.  Indeed, it’s not uncommon for a senior citizen to boast after receiving notice of a large hospital bill paid by Medicare, “I’m really getting my money’s worth.”  No wonder Medicare is almost broke.

To promote its cause the Alzheimer’s Association recently issued a press release with the provocative headline, “10 Million U.S. Baby Boomers Will Develop Alzheimer’s Disease.”  Virtually all of the attention bestowed on AD by the medical profession, academic researchers, and the National Institute of Health treats the problem as though it were purely a medical problem.  All we need do to cure AD is identify the gene causing the problem and then find a chemical compound to allay the effects of the troublemaking gene.  Apparently it has never occurred to anyone that AD may simply be the body’s way of protecting those whose lives have become meaningless from the despair associated with prolonged life.  AD may, in fact, be a way of taking them out of their misery.  Not only may there be no cure for AD, but even if there were a cure, what would be the psychological, social, and moral consequences of administering it?

Notwithstanding the predominance of Christianity in America with its adherence to the belief in life after death, our culture promotes a Darwinian, survival of the fittest attitude with regard to the extremes to which we are prepared to go to prolong our own individual lives.  A kind of macho, Old West attitude seems to come over us as death approaches.  It matters not how much of society’s scarce health care resources are consumed by prolonging my life for a few more months or years.  I am the center of the universe.  The rest of the world be damned!

Regardless of whether a national health care system is publicly financed or privately financed, if it is driven by the confluence of greed and the denial of death, it will be unstable and financially unsustainable.  Any health care system which does not confront the moral, ethical, economic, and political implications of fear of death and greed represents an exercise in utter futility.

Obamacare is no exception to the rule.  Not only is it too big, too complex, and too high-tech, but it tries to be all things to all people.  Even if the Republicans in Congress do not bring it down, it’s only a matter of time before it implodes.  In a similar vein is the so-called single payer health care system endorsed by the Vermont Legislature – a health care system which will probably never see the light of day.  Neither the Governor nor the members of the Legislature have a clue as to how much it will cost or how it will be financed.  It’s pure pie in the sky.  No one in Montpelier ever mentions fear of death or greed.

For any health care system to stand a chance of working it must be highly decentralized so that patients, physicians, clinics, hospitals, and insurance providers are in community with one another.  To be quite blunt, if I decide to have a nice $100,000 open-heart surgery performed on me, I must be prepared to face the other citizens in my community, who know I have spent $100,000 of the community’s health care resources on myself.  There must be a feeling of, “We are all in this together.”  My life may be important to me, but I am a part of a community in which others want to share in the pool of health care resources.  Resources are finite and must be rationed by the community.

The Swiss health care system, unknown to most Americans, comes close to this ideal.  The Swiss government requires everyone to purchase health insurance with their own money from one of four hundred Swiss health insurance funds, some of which are private, others public.  If individuals cannot afford to pay for health insurance, then most cantons transfer funds to them.  Ninety-five percent of the population is insured against illness.  The delivery of health care services is decentralized to the canton or town level.  But the Swiss health care system works, and it works very well, as evidenced by Switzerland’s high life expectancy and low infant mortality rate.

My favorite hospital is the tiny 19-bed Grace Cottage Hospital located in Townshend, Vermont.  Thanks to a very generous and supportive community, which includes devoted patients, committed volunteers, an amazingly talented, compassionate and hardworking staff, and wonderful benefactors, Vermont’s smallest hospital recently celebrated six decades of saving lives, caring for the sick, helping those who are dying, and encouraging those who are well to stay that way.

There will be no fix to America’s health care problems until the American people and our political leaders come to terms with the importance of fear of death and greed as the driving forces underlying the demand and supply respectively of health care in America.  Furthermore, they must accept the fact that the financing and delivery of health care services must be highly decentralized whether provided by the government or the market.

Thomas H. Naylor is Founder of the Second Vermont Republic and Professor Emeritus of Economics at Duke University; co-author of AffluenzaDownsizing the U.S.A., and The Search for Meaning.