The Healthcare Delivery Con
Innocent enough at first blush, the term healthcare delivery abets a clever linguistic ploy. It serves as the cognitive launch-point for a debate about the broken healthcare delivery systemand how best to fix it. The phraseology fosters the (mis)impression that the American healthcare industry is earnestly engaged, brothers-in-arms with consumers, in an effort to optimize a broadly acknowledged, dysfunctional delivery mechanism. Though remedies may vary, brokenness is surely agnostic. All parties should want to fix a flat tire. This is the intended inference. False consciousness manufactures false consensus.
You know something’s afoot when an industry diagnosis gets bandied about in equal measure by the chronically congested uninsured and their profit-driven, germaphobic overlords. We’re all familiar with the delivery sequence in the movie Modern Times(1936) wherein Charlie Chaplin struggles against a factory conveyor belt whose widgets shuttle towards him at an inhuman velocity. There’s broad consensus among movie-watchers that the machine is not properly calibrated to human scale and capacity. If only the foreman was not such a relentless bully and the factory owner was not the personification of pathologic greed. Today’s healthcare industry is savvier than the old captains of heavy industry. It joins the broken chorus but exerts no great political will to alter the system. This is a sort of have-your-cake-and-eat-it-too strategy. In time, the most vocal advocates for change die or have a coronary. In the healthcare business, time is always on the side of industry. Remember, corporations are people now. Their lifespans are theoretically limitless. Their voices never wear thin.
So, the man on TV calls it a healthcare delivery system because Frank Luntz tested ‘healthcare embargo system’ in a focus group and it went over like a bad flu vaccine. Instead, they stuck with delivery and hoped nobody would notice the doctor was no longer in the house. By the way, we’re on about more than merely words here. One purpose of linguistically structured cognitive frames is to divert the central debate away from its natural point of origin. By jump-cutting to scene two, scene one’s opening gambits remain safely unexamined. Let’s rewind the movie for a moment (as someone swore they saw a gray puff of smoke on the grassy knoll). We know healthcare services in America, universally sought, are not universally accessible. We know this because thousands of Americans routinely die of preventable illnesses and disease. If we really think about it, we also know that the healthcare industry’s first order of business is erecting barriers to customer entry and market rationing. Healthcare delivery is the industry’s service of last resort. In this upside-down delivery paradigm (really an insurance, cost-containment model), the customer is far from king. Instead he is a steaming hot potato, a blemish on an otherwise beautiful premium stream. Each patient constitutes a failure of the vetting and denial process.
Unlike the Tramp, Americans are not awash in healthcare product. The healthcare conveyor belt is parsimonious by design, hardly an orgy of service provisioning. Delivery is delimited by supply side profitability. So yes, healthcare delivery is in the business of delivery alright—the delivery of profits. Counterintuitive though it may sound, the American healthcare industry is in actuality a death merchant cartel that expends huge sums of promotional dollars to perpetuate the veneer of medicinal resolve and Hippocratic rectitude.
What demand the industry deigns to address, it is handsomely compensated for. A 2011 Organization for Economic Cooperation (OECD) study found that the United States spends two-and-a-half times more on health care per person than the OECD average. On The Huffington Post, Wendell Potter of The Center for Public Integrity notes some key disparities: “The average expenditure per person in the U.S. is $7,960, a third more than in Norway, the second highest. The OECD average, by comparison, is just $3,233. (It is $3,873 in France.)”
In short, America has the most expensive health care delivery system in the world, and by a long shot. This might be okay if America could boast the best healthcare system in the world, but it can’t. Nor is expense some inexplicable evaporation. It is a quantifiable wealth transfer from one group to another. Thus the system is working like a charm, though perhaps with asynchronous abandon, for certain supply side participants. Profit is being delivered handsomely; health, not so much. Delivery is a zero-sum exchange. Mass and energy are conserved, never destroyed. Where else can ‘costliness’ go Mr. Einstein but into the pockets of someone else?
So the system works for what it is designed to do. (Just as our porous, broken border works to destroy an American living wage and our broken education works to sustain a malleable and manipulable underclass). Most people, in their naiveté (or is it innate decency) fail to grasp the inherent paradox of a healthcare delivery system that loathes delivering healthcare. That’s not what the term implies. Cognitively at least, the word care boasts a number of warm, cozy cousins: concern, heartfelt ministrations, human compassion. This cognitive web is a boon to many less-than-cozy profiteers.
Delivery hogs have no place at this inhospitable table. The sick and elderly are precluded from the system as much as possible since these groups are unabashed cost centers and profit drains. At least sick people have been known to get better. Some have even gone on to lead productive lives. The ailing elderly though are doubly vexed because everyone knows old people offer diminishing returns and can’t fill the farmer’s strawberry baskets fast enough. Why endeavor to bring them up to speed when their machine is in broad collapse anyway? Old people are slow-motion foregone conclusions, unsafe—certainly nonviable—at any speed. No profit center in its right mind would have anything to do with them. They are being restored for the purpose of, what, getting sick again and dying? Government largesse and mediation notwithstanding, the elderly are inordinately plagued with maladies. Thus they should be avoided like the plague. This is what one might call unassailable market logic.
Fifty per cent of all Medicare costs are incurred in the last six months of life. Seventy-year-olds should not be entering this phase with the hearts of thirty-year-olds. For one thing, it’s a waste of good cardiovascular capacity. For another thing, they might live to be 100. There’s a Nobel Prize waiting for the HMO bean-counter who figures out how to preclude or curtail this costly final episode with a finesse that doesn’t unleash serious PR repercussions. People are funny about euthanasia even in its more disguised permutations. Untimely death, say at age 55, would flatten the cost bulge nicely. But it will have to be a palatable extermination program. (You cannot tell me there isn’t a Soylent Green exploratory committee convening somewhere in our ghoulish health industrial complex. Look for olive-tinged Twinkies in a restored Hostess shelf near you.) Perhaps such a soft extermination campaign is already underway. It would be niave in the extreme to expect a ribbon-cutting ceremony or a PSA. According to a 2011 Commonwealth Fund study, the U.S. is at the bottom of the Fund’s 16 countries in the terms of preventable deaths due to untimely or ineffective medical care. Let the cull begin.
Death by a million paper-cuts offers one socially acceptable extermination option. In an effort to further besmirch their delivery moniker, the industry employs numerous passive-aggressive mechanisms with the twofold aim of thwarting the cost side of the wealth transfer mechanism and killing us softly with omnipresent, low-grade stress: byzantine forms, 800-number gulags, bewildering plan coverages, etc. Complexity becomes a rationing tool even before ability to pay rears its well-heeled head. People tire. Even better, sick people tire faster. Indeed they are ‘better tirers’ than the larger population. Tired people become weak advocates for delivery. Thus we find an attritional strategy at play as interminable delay and tactically-deployed complexity boost profitability in a macabre, opportunity-cost sort of way. Frankly, if by age 85 you are not wealthy enough to employ an attractive 25-year-old personal assistant to administer your medical files, then you should be dead. What the hell were you doing all your life anyway?
Healthcare is perhaps the most keenly sought, and yet most vexing, product on the marketplace’s shelf. For one thing, health is a condition intrinsic to the individual. Some people are blessed with good health. Others aren’t. Health, certainly the lack thereof, can be propped up with external healthcare measures. However, good health (and attendant healthcare measures) can elude extremely wealthy people. As the adage goes, you can’t buy health. But by Jove you sure can ration attempts to restore it in the event of illness. The return to health can be a costly proposition. In the final analysis, health runs out for all people. This injects a powerful emotional current into the healthcare debate. Near the end when the prospects for continued good health appeared slim, Richard III was prepared to trade everything for a horse to save his ass. Issues of mortality tend to hit people where they live, until they die of course. The complete cessation of health is fatal in all cases.
The American healthcare system does have a healthcare mandate. It is to preserve its own financial health and profitability against the incursion of human malady and disease. Thus it sort of dabs fecklessly at illness much as a Band-Aid might dress an arterial wound. You might say everyman illness in America (its mere existence if not its active ministration) serves as a wonderful pretense for constructing a fearsome money machine called ‘healthcare delivery’.
Consider for a moment the grave implications of broad-based good health and general welfare for the plutocrats. A mass outbreak of well-being in America would be catastrophic to the powers-that-be. A healthier, robust population might offer up a more spirited challenge to wealth disparities, for example. Studies have shown that morbid obesity and diabetes among the poor act as inhibitors on bricks thrown at gilded structures. One way to maintain docility and compliance is to embargo healthcare for the privileged few. Sick people can’t fight back.
Of course under the current rubric a ninety-year-old millionaire becomes more ‘deserving’ of a new kidney than does an inner-city ten-year-old. Wherever demand exceeds supply, there will always be a rationing protocol. Society must settle upon the most viable or just protocol. Nonetheless, to the extent someone is too far back in line, he or she becomes a distant and remote standing reserve, not unlike toothpaste at the bottom of the tube. Yes, your sickness can simply lurk too far away. Rob a bank and you move closer.
The justness of the prevailing protocol will always lie to some extent in the eye of the beholder. You, me we all want ice cream. So we clamor for it. No one wants to die although everybody does. In the midst of this human, all too human ego parade, the medical complex is exhibiting a drive towards increased dehumanization. Surely it’s not an unreasonable industry stance that not everyone can be kept alive for one more day, no matter the cost? The dilemma becomes one of reasonableness and social calculus.
Except, some will say, we’re not toothpaste. We are subjects not objects. Moreover every soul is of inestimable value. (Far better that one’s personal God negotiates this theological mire than an HMO finance department. It pays to remember even many gods employ a form of rationing, reserving hell for the sickest souls in their Plan.) Fritz Lang’s Metropolis got the heavy industry and big Molochian furnace part wrong (our ‘industrialists’ have long since moved into the ether-real realm of information peddling). He was dead-on though about the stark two-tier nature of future society. Looming authoritarianism is the great American no-brainer. A corollary of this is subject-status, the privilege of claiming a soul, which is fast becoming subordinated to financial wherewithal. Decent healthcare will be but one entitlement befitting soul status.
In life, nobody gets out alive. Thanks to the healthcare embargo, the poor will be getting out faster. As for a soul, if you really want one, go out and earn it. That’s what the rich did. Judging by Donald Trump and Sheldon Adelson, they never looked back.
Norman Ball can be reached at firstname.lastname@example.org.