The Health Care System, Industry and Morality

Dr. Andrew Duxbury will explore some of the subtext behind our current health care headlines, how we got to this point, and what it means for those of us who believe in Unitarian Universalist Principles.

Dr. Duxbury’s Message:

Many long years ago, when I was in college, I took a course in modern philosophy.  It was full of rather incomprehensible readings by authors such as Buckminster Fuller and Noam Chomsky, most of which I forgot soon after the final.  The one piece that has always stuck with me was a unit on what is known as moral reasoning.  In it, we were posed with questions regarding what was right or wrong in various scenarios.  Our answers were supposed to show how developed we were but probably proved that we were thinking as college sophomores, with all that entails.

One scenario we were presented with was something like this.  You are a parent with an only child.  Not a situation most of us could easily identify with being in our late teens and early twenties and Stanford students who weren’t thinking about reproducing yet.  Heck, we weren’t even thinking about sex all that much.  School was pretty overwhelming.  Anyway, back to being a parent with an only child.  One day, we were told, our child becomes ill with a dread disease.  It’s OK though; there is a medicine that can cure them.  Off we go to the druggist to obtain this miracle medicine.  The druggist tells us that he indeed has the medicine we seek.  He created it himself, patented it and is the sole source -no other druggist is allowed to sell it.  In casual conversation, he mentions that it costs him about two hundred dollars to produce a course that will cure an afflicted child.  However, because he is a good capitalist and has his own expenses, he sells it for two thousand dollars for a course of treatment.  We now find ourselves in a quandary.  We can only raise a thousand dollars to save the life of our child.  No amount of pleading will make him lower his price.  We are not about to let our child die so that night, under cover of darkness, we break into the druggist’s shop and steal the medication we need to save our child.  The question we were asked at the end of the exercise is who is in the wrong?  Is it the druggist for using his monopoly power to deny a dying child access to life saving treatment?  Is it us, as a desperate parent, who commits a burglary to save our child?  Perhaps it’s our child who has the effrontery to create this situation by falling ill.  Maybe it’s society as a whole for creating these impossible moral dilemmas in the first place.

I don’t remember how the class navigated the ethics of the problem.  I think our solution was something along the lines of stealing the medication but repaying the druggist anonymously on the installment plan, it’s the kind of moral reasoning you find in college students.   However, the whole thing came up to me again as I watch our society grapple with the impossible moral dilemmas we have created within our health care system.   We, as a people, have spent decades allowing our health care system transform itself from a traditional service to a population into a behemoth of a big money industry and, with this transformation, we have created a whole series of problems that have been buried for far too long and which, like a cancer, continue to metastasize and sicken us all.

Every society that has ever existed, from Ancient Egypt, to medieval Europe, to the primitive tribes of the Amazonian jungle, has created a health care system.  It’s part of our social DNA.  As we gather in groups and form bonds of caring and community, some of us have always specialized as healers.  Sickness, pain, injury, and other dis-eases are bound to strike and healers are those charged with interceding with the gods in order to restore balance to the body and harmony to the universe.  Modern medicine retains vestiges of this priestly origin.  Modern American doctors still wear ceremonial robes.  We also carry ceremonial instruments of dubious utility.  Those stethoscopes we carry are nowhere near as helpful as a chest x-ray and an echocardiogram.  We also proffer healing magic in the form of a little slip of paper covered with incomprehensible script written in Medieval Latin known as a “prescription.”

I’ve always wondered about this god power myself.  Over the third of a century that I’ve been in medicine I’ve had patients and their families look at me as if I’ve been imbued with some sort of supernatural substance when I have made a correct diagnosis or adjusted the medications in just the right way.  I don’t get it.  I know myself relatively well and I’m more Clark Kent than Superman.  I struggled with this for a while until I fell back upon what I learned in high school and college about theater.  When I understood that the white coat is a costume and ‘doctor’ is a role you inhabit, it got a bit easier.  Some of us, however, forget to take the role off when we take the coat off and start to assume that we are something more.  It can become a real problem when that attitude slops over into areas for which we were not trained… like politics.

The goal of these health care systems, no matter where you find them, has always been roughly the same, no matter the means they use to achieve them:  get rid of dis-eases and by dis-ease I mean a whole plethora of things from infections to injuries to the physiologic changes of aging to the biological hazards of a normal condition such as pregnancy.  The patterns are similar from Abyssinia to Zimbabwe.  A previously healthy person becomes dis-eased and, when they reach the limit of their knowledge base or patience with the process, they turn to the healer to remove the problematic agent and restore balance and health.  It’s been going on for the whole six thousand years of recorded human history and there is archeological evidence that it’s been going on for thousands of years before this.  It leads to what we now call the acute care model of medicine.  Something happens to me, I feel acutely ill and I depend upon the system to cure me, or at least make me better in some way.

For most of American history, the American health care system worked the same way.  Actually, in the early years it wasn’t much of a system and didn’t work terribly well for anyone.  In the colonial period and into the early republic, most health care was provided at home through family lore.  A few physicians existed in cities for the treatment and comfort of the well heeled.  The 19th century didn’t fare much better, with the majority of doctors self-styled through apprenticeships and dubious educational institutions.

The health care system, as we understand it now, started to coalesce in the period between the two world wars.  For the most part, those with dis-eases were still cared for at home.  The majority of physicians were general practitioners who cared for the community in which they lived.  They had a consulting room, usually at their home and then made the rounds to check up on their patients in their Model T or mule cart, pulling up to mansions and hovels to do what was possible for the ill, instruct the families of the afflicted in proper nursing care and be a presence for comfort while nature took its course, one way or another.  You could find some specialists in larger urban centers, gathered around money and the multispecialty clinic began to take form under models pioneered by the brothers Mayo in Rochester, Minnesota.

There were hospitals, but as medicine was a pay as you go cash business, most people tried to avoid them.  In rural areas, especially during the depression when money was hard to come by, barter systems existed and the old trope of paying the doctor in chickens or a bushel of potatoes was born.  This worked fine in communities where everyone knew everyone else but could not work in larger urban settings or with the local hospital board.  Therefore, most hospitals had very narrowly defined mission.  They were places capable of doing aseptic surgery, usually performed for life saving reasons such as the removal of a gangrenous gall bladder.  They were places that could take care of people who did not have an intact family structure to provide nursing care during a period of dis-ease.  They would protect communities by separating those who could be dangerous due to their potentially infectious state (the TB sanitarium) or because of erratic behavior (the asylum).  They were small by current standards.  Usually consisted of large open wards with minimal privacy, and were generally underfunded.

Medicine was a not for profit sector of the economy.  Health care was regarded as a market good, but not one that people in general were interested in selling, as there wasn’t much money in it.  Hospitals, descended from medieval religious institutions that tried to provide humane care for the poor and dis-eased following the example of Christ, were frequently chartered and run by religious organizations, especially Catholic, to provide a particular social good to the community.  Those not run by religious organizations were usually publically financed by cities, counties, states, and other governmental entities.  Again, not for profit entities with specific social mission.  The system here wasn’t that different than the system in the rest of the developed world.  In fact, during the first third of the 20th century, it was far behind some of the great European centers of learning.

The first inklings of change, which would transform the US health system from its backward and bucolic roots, occurred in Dallas, Texas in 1929.  At the time, Baylor hospital noted that the majority of their hospital beds were empty more often than not.  The overhead of a nearly empty hospital was causing financial strain on the institution.  At the time, the average American spent more on cosmetics than on health care (you tended to doctor yourself and your family with inexpensive over the counter remedies) and almost no families could afford a large hospital bill, so they were places to be avoided except in extreme circumstances.  The fine folk who ran Baylor wanted to get their beds occupied by people who weren’t already at death’s door so they came up with the idea of having people buy health care in the same way they bought other consumer goods, a little bit at a time.  They approached the Dallas teachers union with this idea.  For an ongoing charge of fifty cents a month, members of the union could go to Baylor hospital for free.  Without necessarily intending to, they invented the modern concept of health insurance.   Other hospitals saw value in this idea and started to offer similar deals, mainly to large groups of organized individuals such as unions and large employers.  Eventually, these plans developed a new name, Blue Cross.

They spread throughout the country but most people didn’t buy into them until World War II upended the American economy.  Wage and price controls left over from the Depression remained in place in the early 1940s just when the war fueled industrial machine required more and more workers to meet demand.  Unable to offer higher salaries, large employers turned to fringe benefits to attract and retain workers.  A court decision in 1943 declaring health benefits to be tax-free made medical insurance especially attractive to industry and this was further codified in the mid 50s at the behest of big business.  By 1955, an employer based health system was here to stay.  The rest of the industrialized world, recovering from the depredations of the war and the destruction of their infrastructures, did not move this direction.  They needed a more cooperative model of health care leading to what Americans were decrying by the mid 1950s as socialized medicine.    McCarthyism took a toll on American health care.

Many of us came of age during the period 1955-1980.  We all remember health care as easy to obtain, Blue Cross being welcome everywhere, a stable family doctor who knew us well and who would both see us in the office or in the hospital if we happened to get ill.  We carry that ideal around in our head as if that’s the way health care always was and always should be, rather than a unique time in a unique economy. At that time, our health care was the envy of the world, and we still carry the idea of American exceptionalism in medicine with us.  Our hospitals were better, our doctors more knowledgeable, our research universities making exciting discoveries.  The sparing of our society from the physical damage of World War II, our industrial capabilities allowing pharmaceuticals, especially antibiotics, to be mass produced, and our welcoming of the great medical scientists of Europe fleeing Nazi persecution, all led to us being the envy of the world.

Of course, this employer based system left certain groups out in the cold.  Predominantly those who were post-employment, or retired.  The Roosevelt administration toyed with adding health care to its New Deal social programs such as Social Security but there was a feeling that this was a bridge too far and with an increasing need to focus on the looming crisis of World War II, buried the idea.  The Truman administration resurrected the idea of publicly funded health insurance for non-employed persons in the late 1940s but the rising tide of McCarthyism made any such social experiments suspect at best and communist at worst.  The legislative language of the 1940s remained in draft form, and, when the political moment became right a generation later, the Johnson administration passed the Great Society programs including Medicare for elders, the disabled, and retirees and Medicaid for the impoverished, transforming the health care landscape in ways the original authors could not foresee.

Medicare and Medicaid were created to solve a particular problem.  Non-employed populations had no access to hospital care.  They couldn’t afford it.  When they did turn up at a hospital, which was predominantly a not for profit institution established to provide a specific social good for either civic or religious reasons, it was the mission of the hospital to provide care first and ask questions about finances later.  A generation of medical progress had taught the American population the ideal of American exceptionalism in medicine all too well and hospitals were rapidly transforming from the backwater of the health system to the shining centerpiece.  It was also the hospitals that provided the muscle to push Medicare and Medicaid through a semi-recalcitrant congress, a battle reminiscent of today’s battles over health care legislation.  Like all such battles, there was an equal and opposite reaction lobbying to maintain the status quo.  In those days, that was represented by the AMA which viewed the programs as socialized medicine in another form and inherently bad for American Health.  A massive propaganda campaign, led by an out of work B movie actor named Ronald Reagan, tried to change the path of the country and defeat the proposal but did not succeed.

The passage of Medicare, especially, was a huge success and there has rarely been a more popular social policy in American history.  The elimination of large hospital bills through Medicare A and the significant reduction of outpatient expenses from Medicare B rapidly lifted the older generation out of medically induced poverty.  It also opened the floodgates for federal dollars to start rushing through the health care sector of the economy, changing it within another generation from a relative backwater to a big business.  The rules of the game in the immediate post war era, which defined health care as a social good that should be open to all, began to change.

The first major change was the introduction of the for profit company into health care.  The profit motive was not new.  Even in the good old days, doctors and hospitals tried to make money, but, having developed out of religious orders and civic institutions, nearly every organized piece of the system was not for profit.  Moneys made were rolled back into the system in the form of improvements to facilities, new discoveries, or improved salaries for workers, not to pay dividends to shareholders.  Laws required health insurance to be not for profit and all of the original Blue Cross companies of our youth were structured this way.

More and more money in the sector, however, did not go unnoticed by the financial sectors of our economic system.  There had never been a lot of interest from Wall Street in health care in the past.  The money was too small and the profits too slim, but billions from the federal government were a different matter and the system began to evolve.  Bit by bit our country transformed our health care system into a health care industry.  It began in earnest in 1973 when the Nixon administration allowed health insurance companies and other health entities to operate as for profit businesses.  Wall Street was ready and slowly, but steadily, the health economy moved from local control under a small business model to larger and larger corporations, often regional or national in nature.  With these changes, a business mentality took over.  Medicine stopped being about the individual and idiosyncratic dyad of healer and patient and became about the delivery of standardized product in the most efficient manner.  With typical American ingenuity, our health care industry became more and more adept at this task in a for profit model.

As the health economy has grown and evolved over the last forty years, this process has accelerated and perfected itself.  The healers are no longer in charge, the administrators are.  They are the ones who speak the language of finance and big data sets and deliverables in an increasingly complex health care world and that’s what it’s all about.  Like any mature industry, health care is now functioning in the United States exactly as designed.  We still want to believe that it’s all about caring and compassion and making the lame to walk and the blind to see.  It’s not.  Our present health care industry is about what all modern industry is about – transferring the profits of that industry to the owners of that industry and it does that very, very well.  So well in fact that it has become nigh on impossible to change the industry in any fundamental way.  Any major change is likely to negatively impact the bottom line of various industry players and that cannot be allowed to happen despite the catastrophic fall of American health standards when ranked by the World Health Organization.  Among developed nations, we’re dead last.  Among all nations, we’re 37th, right between Costa Rica and Slovenia.  In some places, our child and maternal mortality statistics are worse than sub Saharan Africa.  It’s not that American doctors are rotten or that we’ve lost knowledge and ability.  People still flock from all over the world to our hospitals and to study in or medical research institutions.  It’s just that we’ve changed the fundamental purpose of why we have health care from health to wealth and that no longer keeps wellness at the top of the reasons for it to exist, unlike nearly every other advanced world system.

Now I could go on for another half hour or so on specific flaws in our health care system and thinking such as our siloing of care by specialty, our overdependence on specialists, our refusal to accept death as a natural consequence of life, our training of the population to become creatures of pharmaceutical habit, and all the rest of the issues that many of us are familiar with but I’d rather bring this back closer to home and to who we are as UUs and why we spend our time with this religious community rather than one of the many other fine religious establishments in town.

Our first principle states that we affirm and promote the inherent dignity and worth of every person.  The Universalist tradition comes from the idea of universal salvation.  No one, but no one gets left out.  To me, a church that ascribes to this worthy ideal must, by its very nature, ascribe to a health system that is similarly universal or it is vacating one of its core reasons for existence.  We don’t have an everyone in system in this country but we have been cautiously moving that direction in recent decades and over the course of the last eight years, since the adoption of the Patient Protection and Affordable Care Act, a couple of very valuable things have happened.  First, the number of people with access to the system increased enormously, more or less cutting the uninsured rate in half.  Second, with access to health insurance, fewer health costs had to be borne by families and the rate of personal bankruptcy in the country has also fallen by half.

However, we now live in a different time.  As a society, at least as far as our electoral choices reflect, we have firmly come down on the side of health care not being a right, but a privilege which should only be available to those with means.  Our representatives in congress have been busy crafting legislation designed to enable the market forces behind health care to succeed at the expense of the people health care is supposed to serve.  It doesn’t really matter whether you believe the congressional budget office, the department of health services, or industry trade groups regarding the projected outcomes.  No one is predicting that any of the effects will do anything to make access to health care more just and equitable. At the moment, the ACHA in the house, the BRCA and the so-called skinny repeal in the senate appear to be dead, but with a political party having staked its reputation on changing a flawed system, I don’t believe for a minute that they’re going to stay dead.  Especially in the reality television circus of current DC politics.  The calculus of the Senate, in particular, is likely to change in markedly in 2018 and John McCain’s decisive no vote is subject to the vagaries of his own health needs.

The thing that bothers me the most about the current debate over health care is that it spends all of its time looking at how to cost shift from public sources of funding to individual and private sources of funding while spending no time at all looking at the reasons why our health care system is the most expensive in the world.  The American health care system consumes 17% of our gross domestic product.  In no other industrialized country is it more than 11% of GDP.  With an American GDP of 18.5 trillion dollars, reducing our spending in line with other economies would give us about 1.1 trillion more dollars a year to spend on other needs. Or to improve and rebuild our health system until it is once again, the envy of the world.

The other thing that bothers me is a rather insidious change in the language and framing of the discussion of health care.  It’s no longer a discussion of how can we help people, it’s now a discussion of who deserves to be helped.  Every time I look at the news, I see an elected public official musing about the other, often in terms of ‘the cheaters’ or ‘the entitled’, especially when it comes to people on the lower end of the socioeconomic spectrum.  I thought we had gotten rid of differentiating the deserving poor from the undeserving poor during the Victorian era when economists started to recognize that poverty was usually the result of macroeconomic forces and not due to personal choices.   Sober minded individuals, usually affluent white men, proffer rhetoric of ‘three strikes and you’re out’ in terms of life saving treatments, suggest that no access to health insurance is fine because there are always emergency rooms (showing a fundamental misunderstanding of how the health system works), or speak of millions of children and elderly being thrown off of Medicaid rolls as a good thing.  In most states between a third and a half of children rely on Medicaid for health care.  With major cuts, some of those children will die.  Let’s call it what it is.  Human sacrifice.

The idea of asking Americans to take responsibility for their own health rather than just assume that the health system will care for them is a laudable one but it’s not as easy as it seems.  Imposing it from the top in a punitive way through fines or increased costs is only likely to drive people away from the system leading to disease being found later, at a more advanced stage and ultimately driving up costs.  For it to work, we have to attack health literacy on a societal level.  Starting early in life, people have to be taught how their bodies work and have to be taught that health is a partnership with a healer, not something that is done to them.  This, of course will require a much more robust primary care system than we have in this country.  We know how to build such a system but to do so, you have to have about three quarters of your physicians in primary care and one quarter in specialty care.  The United States has the opposite proportions.  It will also require more scrupulous honesty in American society about the naturalness and necessity of death (a whole sermon unto itself) and an understanding that a system that tries to cover all possible treatments for all people all of the time is doomed to failure and that certain types of choices must be made and should be approached with science and rationality – both qualities currently missing from the American political system.

There is a huge problem with placing personal value judgments on health care and patients.  It’s a lesson I learned early on in my medical training.  I was a medical student in the mid 1980s at the height of the HIV epidemic.  People were dying of a preventable disease due to our society and government’s unwillingness to understand marginalized populations.  One day while on the internal medicine service, our team was caring for two HIV patients.  One was a young man in his late teens or early twenties, the other a grandmotherly woman of sixty or so.  The young man was about as fey as they come.  You could have seen the flames coming off him from space.  His effeminate mannerisms were a kind of psychic armor helping him cope with the fact that he was unlikely to live to twenty-five.  The older woman was the sort of woman you expected to bring you milk and cookies and tell you about your day while she knitted you some new wooly socks.  My attending physician, a well-known internist in his fifties ended our rounds and walked away with the comment. “You know, it’s too bad that poor woman is an innocent victim of AIDS but that guy deserves it”.  I was a little more familiar with the patients than he was.  The young man was a hemophiliac who contracted it through his need for transfusions.  He had never had a sexual relationship in his life and probably never would.  The older woman was a swinger.  Value judgments are a very slippery slope, which is why the Hippocratic Oath has read as it does for three thousand years.   And, no matter how you slice it, no one ‘deserves’ disease.

Where does this leave us?  To tell you the truth, I don’t know.  I’m just one small individual in a stormy sea of a system that’s gone somewhat off the rails.  I don’t have the power to fix it. All I can do is what I have always done, save the world one patient as a time.  There’s an old Chinese proverb, some say a curse.  ‘May you live in interesting times’.  Well, these are interesting times and the health care system, which has always been a bit of a wild ride, is bound to get wilder.  Hang on and fasten your seat belts.

 

Thank you.