Sickness Unto Death: An American Dilemma

Part I

By John MacWillie, Ph.D.

Murphys, CA…Introduction: The United States is alone among industrialized nations in using wealth as a gatekeeper for access to health care. The wealthier you are, the more and better health care you get. The national debate that is now taking place focuses on whether every individual, irrespective of their income, should have access to great health care.

This is a series of eight articles on a single theme to be released once a week. Copyright license granted under ©Creative Commons.

The United States is alone among industrialized nations in using wealth as a gatekeeper for access to health care. The wealthier you are, the more and better health care you get. The issue isn’t about efficiency (keeping costs down) or efficacy (performance), it is about whether you have the financial wherewithal to be able to see a doctor, have surgery, visit a mental health professional, or afford prescriptions. The national debate that is now taking place focuses on whether every individual, irrespective of their income, should have access to great health care.

From Medicare to Obamacare

Before 1965 and the creation of Medicare and Medicaid, if you were elderly or very poor, the answer was definitively no. In 2003, President George W Bush signed legislation to expand coverage to include prescription drugs. But the working poor, those working for small companies, individuals with pre-existing conditions, students, and those seeking employment — a population in the tens of millions — were still not covered by these programs. The Affordable Care Act (ACA) of 2010, more popularly known as Obamacare, sought to address these concerns by mandating increased coverage for those with pre-existing coverage and a host of other changes.

Trumpcare

The House of Representatives recently voted by the narrowest of margins (217-213) to radically alter Obamacare. While the primary associations of doctors, nurses, hospitals, and mental health professionals have been quick to criticize what is becoming known as Trumpcare, most Americans are confused by the bewildering debate and changes in insurance plans. Over the next several months, while the Senate and the Congressional Budget Office weigh in on what House Republicans have adopted, it is time to consider why coming up with a good health care system is so contentious.

The Republican plan, known as the American Health Care Act (AHCA), would provide tax credits in lieu of subsidies for insurance premiums, eliminate Federal mandates for insurance coverage, establish high risk insurance pools for those with pre-existing conditions, provide limited underwriting of these pools for a short period of time, and authorize health care savings plans. In its original form, the AHCA flamed out when the non-partisan Congressional Budget Office (CBO) forecasted that 24 million people would lose health coverage by 2024. (CBO March 13, 2017). That does not include the 28 million citizens without insurance today. Even with this projection, the most conservative wing of the Republican party known as the Freedom Caucus rebelled against any protection for citizens with pre-existing conditions. Because the House rushed the adoption of the latest version of the AHCA, we will have to wait for a revised CBO analysis. But, even an early reading of the bill reveals that the numbers of those who will lose their health insurance will be substantially higher. The AHCA is opposed by the American Medical Association, The American Hospital Association, and the Catholic Health Association. Republican Senate leaders have already indicated they will ignore the House bill and write their own.

California’s Single Payer Proposal

In California, legislators are moving forward with an alternative to all of these programs with a proposal to create a single payer health care system for all residents of California. (CA Senate Bill 562).

The Great Question

The difference in these programs and proposals mirror the divisive debate in America on how (and whether) everyone in our society can (or should) have the opportunity to live longer, healthier, and satisfying lives without creating a burdensome regulatory environment and bureaucracy to administer this opportunity.

What We Need to Know

The challenge of health care governance for policy-makers and politicians, as well as the general public, arises from: a.) a lack of knowledge about how the health care system works; b.) the lack of consensus over goals and objectives for health care; and c.) fundamental differences in what role the government should play in health care delivery. For something so vital to all Americans, these are big problems.

How Little We Know

First of all, most of us do not appreciate just how complicated health care is and how little we know about its cost and performance. Consider the fact that the United States spends $600 billion for defense (armed forces, civilians, equipment, operations), while, at the same time, we spend nearly 8x more — $4.6 trillion — for health care services (doctors, hospitals, drugs, long-term care). Ironically, there is more publicly available information about the fire and flight control problems of the Pentagon’s F-35 Joint Strike Force Fighter than about the effectiveness of cancer treatments.

Healthcare is a Question of Ethics

Second, the goals and objectives of health care services are not only economic (how much) and political (who controls) questions, but emotional and ethical ones as well. Consider the decision process about a patient with catastrophic anoxic brain injury (i.e., persistent vegetative state). Whether the doctor (for reasons of viability), the patient’s family (for hope), the government (for policy), or the insurance company (for cost containment) makes the decision to terminate life support, it is still an ethical choice. This decision matrix complicates many, if not most, health care related decisions.

Who Makes the Decisions

Third, this leads to the question of who makes this kind of decision. Most people, if asked, would assert it should be the patient or his or her family. But in many cases, the final decision is made by those paying for the care: the hospital, insurance company, or the government. From its inception until the end of 2016, half of the country opposed Obamacare largely around concerns about the insertion of the Federal government into healthcare decision-making. By the beginning of 2017, twenty-five million Americans had been given access to health insurance through Medicaid expansion, insurance subsidies, or direct purchase and the latest Gallup poll now shows that 55% of Americans support Obamacare, while 41% oppose it. (Gallup April 4, 2017). Opinions shift relative to perceived value.

In the Coming Weeks

In this series of columns over the next month, I will examine why health care, as policy and as practice is so complicated, why we as Americans are sicker and die earlier than residents of other countries, why our health care is so expensive, why the answers to these questions have a particularly grave importance for rural America, why the system that Obamacare tried to fix was so broken, and finally, the political question of whether health care is a right or responsibility.

Part II: Who Knew It Could Be So Complicated?

Murphys, CA…Ever been to a hospital? Apparently, not President Trump. How else to explain his apology for not initially getting a “repeal and replace” bill through Congress, by incredulously asking of healthcare, “who knew it was so complicated?” 

Ever been to a hospital? Apparently, not President Trump. How else to explain his apology for not initially getting a “repeal and replace” bill through Congress, by incredulously asking of healthcare, “who knew it was so complicated?” Nevertheless, I want to give the President credit for illustrating what most professional health care workers know, and is largely unobserved by the general public — health care is complicated.

What Do Americans Want?

Take the commonly accepted primary goal of health care — to help people live healthier and longer lives — which turns out to be an enormously complicated objective. Do we, for example, take all measures to sustain someone’s life even if they have no cognition of what is going on around them? Do we provide expensive chemotherapy treatments to someone with lung cancer who insists on smoking cigarettes? Do we emphasize preventative care to reduce pathologies? When do providers intervene when they observe someone hurting themselves? When does the government get involved when there is a determination that a workplace environment is hazardous to workers? Every question provokes a surplus of contradictory responses. How do we sort this out without asking our Congress to prescribe our health care. Health care is not trivial — and being a Democrat or a Republican does not simplify any decision we make about it. It’s a fundamental human problem.

At the risk of losing my readers, let’s consider some numbers.

Poor Use of Resources

In 2012, 130 million patients visited emergency rooms for a variety of reasons, only ten percent of which required admission to the hospital for inpatient care. (CDC 2016). Most of the reported problems included headache, fever, bad cough, etc. In 2013, private practitioners recorded 70 million scheduled patients. (Physician Foundation 2017). Thus, there were twice as many visits to an emergency room than to a doctor — the emergency room was the family doctor. Given that emergency room visits cost nearly twenty times a comparable visit to a private physician and thirty times the cost of a family clinic, something is clearly wrong with how we provide health care in this country.

Size of Healthcare Industry with Other National Priorities 

The U.S. health care system has over 900,000 professionally active physicians and surgeons and more than 4 million professional nurses. In addition, there are lab technicians, pharmacists, physical therapists, nursing aides, nutritionists, psychotherapists and a host of other direct service professionals, as well as all employees of the broader health care eco-system like the information technologists, insurance representatives, administrators, pharmaceutical representatives, researchers, community health educators, for a total of 12 million health care workers (Kaiser Family Foundation 2017). By contrast, the U.S. Defense Department has 2.9 million employees (active forces, civilians, and National Guard). The health care industry is four times the size of the Pentagon and that doesn’t count research and development in the pharmaceutical and medical device industry.

In the U.S., there are 5,500 hospitals with nearly 900,000 attended beds in the U.S. for those patients with more serious conditions or for inpatient surgery. (American Hospital Association 2017). The U.S. Department of Defense maintains some 800 bases around the world — including training, active combat, command, storage, and intelligence bases.

Thousands of Bad Guys

Let’s not forget, however, why we even need a health care system to begin with — diseases and injuries. Our bodies are susceptible to all sorts of dysfunction — pathogens (viruses, bacteria), genetic malformations, bio-chemical imbalances, developmental disorders, and environmental (ecological as well as social). According to the World Health Organization, there are 30,000 categories of diseases in the world (of which 7,000 are considered rare). Having once inadvertently ingested a rare parasite while travelling overseas, I can attest to just how many laboratory tests were required to identity the pathogen. As the little critter had not been seen in the U.S. before, it took substantial experimentation to find an effective antibiotic.

Fortunately, the number of serious diseases in the United States is much smaller. In 2014, for example, the most prevalent causes of death in the U.S. were forty-two different forms of heart disease (23% of all deaths) and ninety-seven types of malignant neoplasms (cancer) which caused another 23% of deaths. Emphysema, accidents, Alzheimer’s disease, strokes, suicides, and diabetes account in toto for 27% of all deaths. Even this subset of common ailments requires a large number of technicians, techniques, physicians, nurses, and resources to identify and treat the cause and symptoms.

Can You Afford to Get Sick?

Planning for and providing health care is complicated and the President is right to call it out. The elephant in the room, when speaking of the complexities of health care in America, is not just who gets covered, or why they get covered, or even how they get covered. It is if they get covered and the gatekeepers for that complex topic are the insurance companies, to which I will return in Part VI.

Part III: Why Katsu is Healthier Than Carl? ~ By John MacWillie, Ph.D.

Murphys, CA…Americans like to think of themselves as the wealthiest, healthiest, and luckiest country in the world. I won’t debate the first and last points here, but, the United States is decidedly not the healthiest. How do we know that?

How Long Will You Live?

One answer is measuring lifespan — how long is the average person likely to live? In the United States, that probability is 79.8 years (longer for white women, less for black men). But when compared to the rest of the world, the United States ranks 42nd. Really? The U.S. lags behind Japan (3), Israel (11), Italy (14), Sweden (16), Canada (19), United Kingdom (33), Germany (34), and even bankrupt Greece (35). (CIA 2017). If you are young enough and you want to live longer, move to Canada.

It is not that simple, though, as this difference is partially explained by three important variables: diet, lifestyle, and access to health care itself. Compare the health status of residents of Japan who live longer than Americans.

Prevention

Americans eat substantially more calories than residents of other countries. Americans consume, on average, 3,754 calories. The Japanese consume 2,768 calories. But when you look at the components of what is eaten, it is more striking. Americans eat 126 grams of sugar everyday; in Japan it is 56 grams. Americans consume 65 grams of fat every day, while the Japanese, with a diet more reliant on fish, only consume 45 grams. (Euromonitor 2017). The difference in obesity rates couldn’t be starker — 36% of Americans over the age of 15 are considered obese, while only 3.5% of Japanese are similarly categorized. (OECD 2017).

“Obesity raises the risk of morbidity from hypertension, dyslipidemia, type 2 diabetes mellitus (diabetes), coronary heart disease, stroke, gall bladder disease, osteoarthritis, sleep apnea and respiratory problems, and some cancers.” (Jensen, et. al., American Heart Association 2013). Comparing data from the United States and Japan for deaths due to cardiovascular disease finds that Americans die at a rate more than 70% higher than Japanese. The data may not establish causality, but if you are betting person, those are not great odds for Americans.

It Helps to be Rich

Second, this data suggests that health is related to lifestyle and one of the principle drivers for lifestyle is income. In a study just published by the American Medical Association, the data shows the wealthier lived much longer than those who are poor — males with the top 1% in income in the U.S. live fifteen years longer than males in the lowest 1%. (JAMA 2017). Lifespan is directly related to lifestyle and the economically poor are much more likely to have poorer nutrition, at much higher risk of being the victims of homicides, and be more susceptible to environmental risks.

This raises the question of the relationship between lifespan and income inequality. Here the numbers are particularly striking. The World Bank calculates the difference between a theoretically equal society (in terms of income) and the actual distribution of income in a nation (what economists call a Lorenz curve). The United States ranks 63rd among 167 nations such as El Salvador, Russia, Uruguay, Gabon, Turkmenistan, and Madagascar — in other words, the U.S. is very unequal in income distribution. Japan ranks 122nd, where the higher ranking represents less income inequality along with the United Kingdom, Ireland, Switzerland, and South Korea. (World Bank 2013, 2008). This raises a political (and ethical) question, which I will address in Part VII of this series.

I am Sorry, the Doctor is Unavailable

Third, lifestyle may account for a large part of a healthy life, but access to health care providers is important too. In the United States, the average adult visits a doctor four times a year. In Japan, the average number of visits is thirteen — or three times more often. (Commonwealth Fund 2010). The health care system in Japan is a mix of public and private control. The government mandates universal health care insurance with fees set by the government, while hospitals and clinics are controlled by doctors in not-for-profit corporations. Policy consistently demonstrates an effect on behavior — and given longer life spans in Japan, it suggests that that just might entail a positive effect.

Of course, there are limits to comparing Japan with the United States. Among other things, Japan is a nearly homogeneous society that has less than half the population of the U.S., yet lives in a territory the size of California. These are very important differences that should caution any argument that America should adopt the Japanese approach to lifestyle and health care.

Healthcare as an eco-system

But, health care is part of an eco-system — biological, social, economic, and technical. Eco-systems are, by definition, complex. Some complex systems maintain self-governing stability. Other complex systems exhibit a high degree of indeterminateness — the so-called butterfly effect. And yet other complex systems are inherently unstable, bordering on catastrophic decay. Before you start radically altering a complex system, we ought to know its current state — a two week debate in Congress would not seem to qualify for the kind of deliberation we should expect for something so important to our collective lives.

Part IV: Dollars and Sense – In Sickness and Health

Murphys, CA…We pay more for our health care — in some cases, twice as much as countries like France. Is it worth it? There can be no argument, however you want to analyze health care delivery and the value of outcomes, the American health care system is significantly more expensive than any other comparable system in the world. The US spends $9451 per person on health care. That is 121% more than citizens of Japan spend on health care. (OECD 2015). The next nearest country to the United States, in terms of health care spending, is Norway which spends $6567 per capita. In other words, the U.S. spends far, far more than other nations — and on a few very important measures is performing nowhere as well.

A Mixed Bag

Having said this, the United States is doing very well in some specific disease treatments. A massive study of 26 million patient records in 67 countries from 1995 to 2009 which was published in the highly regarded medical journal, The Lancet, showed that the United States, France, and Sweden had scored the highest remission rates among women with breast cancer. But for other types of cancer, the United States did not do as well. In the case of cervical cancer for the period 2005-2009, U.S. remission rates were below more than half of all European countries, as well as Nigeria, Cuba, and many Asian countries. (Allemani, et. al. The Lancet 2015).

A World Leader in Medical Research

There is no doubt that the United States is formidable in its pursuit of research of diseases and the basic sciences, but the execution of these competencies appears to fail when we apply them to those actually in need. An in-depth study by the Commonwealth Fund in 2010 concluded, “the U.S. fails to achieve better health outcomes than [six] other countries, and as shown in the earlier editions, the U.S. is last on dimensions of access, patient safety, coordination, efficiency, and equity. ” (Davis, et. al., Commonwealth Fund 2010).

But at What Price?

Is it for lack of effort? In 2006, Americans spent $2.1 trillion on health care products and services — a value equal to 16% of our national Gross Domestic Product. In 2017, we are expected to spend $4.6 trillion or 19.5% of GDP. (Kaiser Family Foundation). Even in constant dollars, that is a stunning number. But what is perhaps more shocking is that fully 50% of that increase is not due to more patients, better procedures, or even improved delivery — it is due from the rapid investment in and adoption of advanced technology — from proton beam radiation to future-edge genetic surgery.

Technology for Life

Americans love technology.”After all, that innovation has given us vaccines, antibiotics, advanced heart disease care, splendid surgical advances, and fine cancer treatments. And many diseases and crippling medical conditions remain that call for yet more innovation. The opposition to imposing controls on costs is politically more intransigent than the opposition to providing universal coverage.” (Daniel Callahan, Hastings Center Briefing, 2008).

We have more MRI machines per person than any other country except Japan — and we do far more (expensive) MRI exams and computed tomography scans than any other country at substantially higher prices per exam. And more revealing is that Americans take nearly 50% more prescription drugs than the French, at a cost double that of the U.K., Canada, and Australia. Poignantly, following the United States, Germany and Switzerland have the next highest cost per person for drug costs. These three countries account for having the headquarters of the pharmaceutical companies with the largest market share of drug sales in the world. (Commonweath Fund 2015).

Part V: Why Rural America is So Sick

Murphys, CA…The health of rural Americans is worse than those who live in cities, in part because rural health care systems are collapsing. This is a problem that has been long in the making. America shifted from a predominantly rural population to one that was more urban in 1920. This pattern continues today. In 1990, 25% of Americans still lived in rural counties. Today that proportion is closer to 17%. A more important characteristic is the difference between urban and rural areas in terms of income, poverty rates, and unemployment. According to research from the US Department of Agriculture, urban residents make nearly 30% more per year than do rural residents and the difference between these regions is growing. (USDA 2015). The rate of urban employment is 112% above what it was in 2000, while rural employment is at 97%. (USDA 2017). Consequently young people in rural areas are migrating to cities for employment and other opportunities, leaving the social fabric of rural areas older, fragmented, and less resilient. At the same time, the proportion of rural residents that are older or are veterans has substantially increased — populations that need more not less health care.

Cities are Where the Opportunities Are

The reasons for this economic transition arise from the advantages of cities over rural areas in the new economy. Cities offer economies of scale (greater density makes it easier to communicate and interact), larger pools of well-educated potential employees (the new economy requires technical training not available in rural areas), requisite infrastructure (very high speed Internet broadband, mass transit, and airports are generally not available), and access to capital. Venture capital firms are more likely to only invest in local economies — where “local” means urban areas. Some rural areas, particularly those offering recreational amenities are attracting new residents — mostly retired.

Disappearing Rural Healthcare

With a declining economic base and a health care model which presumes community hospitals will deliver care, rural areas of this country are in trouble. Since 2010, more than 80 rural hospitals have closed and literally hundreds are on the verge of bankruptcy. In California alone, nearly a hundred hospitals, mostly small and rural, have closed since 1996. (California Health Line 2014). Losing a hospital not only creates a loss for health care, it costs the community economically. Rural areas that lose a hospital see a fall in income and an increase in unemployment. (National Institute of Health 2006).

But the Need is Increasing

Males living in rural areas are 38% more likely to have chronic arthritis than their urban counterparts; 20% more likely to have diabetes; and are diagnosed with asthma 50% more frequently than city dwellers. (Georgetown University Health Policy Institute 2003). And the rural population is older — much older.

But it isn’t just the loss of health care that makes this problem so critical. There is a social crisis in rural America — unemployment, mental illness, drugs, and alcoholism are plaguing rural America. For example, opioid use is increasing at a faster rate in rural areas than in cities, particularly among white working-class people. (Keyes, et. al., National Institute of Health 2014). Suicide rates among rural youth is now double that of the urban young, with far less access to mental health care than in cities. (Fontanella, JAMA Pediatrics, 2015). As researchers put it, “Our research validates the hypothesis that rural healthcare providers serve populations which are not only socioeconomically disadvantaged but also suffer from numerous health disparities and poorer outcomes than non-rural communities.” (Chartis 2017).

Numerous studies have shown that Obamacare strengthened the financial health of rural hospitals by stabilizing payments, particularly for populations without health insurance. This is a conundrum that Republicans seeking to repeal Obamacare must confront. In fact, the highest proportion of rural hospitals most likely to close are in those states (Georgia, Texas, Louisiana, Mississippi) that chose not to expand Medicaid under Obamacare.

Part VI: Free Market Health Care that Isn’t Free

Murphys, CA…If you draw a graph of the American health care system, it looks like a home-stitched quilt made by someone that cannot see. Nothing fits together — not the colors, the design, or the function. There are a lot of reasons for this picture, but how we fund health care is the single biggest problem.

By almost any measure, the American version of health care is bizarre: one health care system for seniors (Medicare); another for veterans (Veterans Health Administration); yet another for the poor (Medicaid); and for a majority of Americans employed by medium and large companies, there is a network of possibilities offered by a mix of not-for-profit and profit-making insurance firms; finally, there is a stop-gap measure for employees that lose their jobs (COBRA). That leaves a large percentage of Americans with no insurance coverage at all — perhaps of because of pre-existing conditions, lack of financial resources to purchase private health insurance, or works for a small business doesn’t offer any health insurance.

As one moves from one plan to another, those lucky enough to be insured may have to change doctors, dentists, clinics, laboratories, and therapists. And along with clinicians, the quality of insurance coverage changes, as do patients’ payments for premiums and deductibles.

How It All Began

How did we get such a patchwork quilt of services and insurance? Surprisingly, the adoption of health insurance in the United States is relatively new. Before World II, health insurance programs were spotty at best and were primarily run by hospitals — the first one was in Dallas — to help fill empty beds. This concept became what we know today as Blue Cross. During the war, U.S. employers, desperate to find workers, began to offer health insurance as a benefit of employment. In 1943, the Internal Revenue Service ruled that employer-sponsored health care benefits would be tax deductible as an expense of doing business. By the early 1950’s, more than two-thirds of adults were covered by health plans.

Research and development, as well as research on the battlefield, led to major innovations in health care technology (medicines, procedures, training, and facilities). Not only did this R&D lead to much better health outcomes, it was also more expensive. In 1900, the average household spent $100 a year (in dollars equivalent to 2009) mostly on quack remedies like “snake oil”. By 1950, Americans were spending $407 per person for health care services. By 1980, that per person rate jumped to $2050 per year and by 2009, the cost increased to $6807 per year (all dollars in current 2009 dollars). Today, the cost is $7847 in 2009 dollars (or, for those keeping track with earlier columns $9451 in today’s dollars).

Somebody is Paying More

What is most striking in this data is the proportion of this cost paid out of pocket by consumers and how much is paid by insurance companies and government agencies. In 1900, all costs were borne by the consumer. In 1950, fifty-six percent of health care costs were paid out of pocket. But by 2009, only fourteen percent of costs were paid by consumers and eighty-six percent of costs were paid by third parties. (All data except 2015 from Fuchs, New England Journal of Medicine, 2013. Data for 2015 is from OECD 2017).

Why?

The principle reasons for this increased cost are complicated, but there is no doubt that there are three very significant reasons.

First, as mentioned in an earlier column, Americans love technology. Technology promises better health care and better health care promises a longer life. The problem with this syllogism is that it isn’t working for Americans — we invest more in technology than any other country and we live substantially shorter lives than those living in comparable systems.

Second, attempts to contain these costs by eliminating duplicative purchases and redundant capital investments have never made it out of Congress. At least twice in the past fifteen years, legislators responding to the pleas of pharmaceutical and medical device manufacturers have buried these reforms.

The third major reason for cost increases is the rise of the for-profit insurance companies in the market, collusion, and market consolidation (acquisitions). In 1981, 12% of the health insurance market was supplied by for-profit insurance. By 1997, that proportion increased to 65%. (Jonathan Cohn 2007). Today that percentage is estimated at more than 70%. It is estimated that the cost to consumers for for-profit insurance companies as intermediaries is between 7-15% of their annual premiums.

Insurance Monopolies

In 2015, Aetna (2016 revenue = $60 billion) and Humana (2016 revenue = $54 billion) announced their intention to merge. If permitted, the two firms would control 25% of the Medicare market. It isn’t as though Obamacare hasn’t been good for business. Aetna shares were trading at $42.09 per share and Humana’s at $79.52 on Jan 1, 2008 before President Obama took office. On October 1, 2016 (when most forecasters thought Hillary Clinton was going to win the Presidency and there was no expectation of “repeal and replace”), Aetna’s shares traded at $124.01 (+194%) and Humana’s were traded at $171.53 (+115%). A Federal judge blocked the proposed merger in 2017 citing the consequences of monopolization. Another merger by Anthem and CIGNA has also been blocked for the same reasons.

Many Congressmen refer to the importance of a free and open health care market. But the data strongly suggests that what we have isn’t a market, but a monopoly of insurance interests in which sicker citizens are abandoned while Aetna’s CEO pockets $17 million in annual compensation.

Part VII: Health Care — Right or Responsibility? 

Murphys, CA…The United States Declaration of Independence declares “We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness.” Without good health, where is the possibility for the pursuit of happiness? As the Declaration’s primary author, Thomas Jefferson, would later write, “The care of human life and happiness, and not their destruction, is the first and only legitimate object of good government.” (Jefferson 1809). 

For the past six weeks, we have examined the issue of health care in terms of its delivery, effectiveness, and cost. This week we turn to a much more contentious question — the political status of health care. Is health care a fundamental right, or is it simply a privilege granted to some in society? Under what basis could health care be considered a right?

There are two categories of rights: legal rights and natural rights.

We are all familiar with legal rights. They are rights established by law. Laws passed by Congress and business contracts set forth certain kinds of rights. These kinds of rights are presumed to be valid as long as the statutory provisions remain valid or until a contract expires. For example, under the Affordable Care Act (Obamacare), the right to health care is assured by statute that simultaneously enables these rights through the provision of insurance contracts between insurance companies and their customers. A customer with a pre-existing condition is guaranteed by legal rights that he or she will not be treated differently than any other customer of that insurance provider. It does not establish a rightful guarantee that insurance rates among customers in California and Alabama will be the same.

By contrast, there are natural rights. Originally, natural rights were assumed to be those rights guaranteed by a divine power, as it was assumed that everything in nature is derived from God. For example, the U.S. Declaration of Independence refers to self-evident truths that human beings are “endowed by their Creator with certain unalienable Rights”. In this secular age, natural rights are more likely to be referred to as “universal rights” and are asserted by consensus in a common compact and in an appeal to common interest. The right of free speech is an example of a claim to a universal right. Universal rights, by their very name, are asserted to apply to all that are a member of a common compact and, without exception, unlimited in scope or time. Thus, the claim that there exists a right to universal health care is much stronger assertion than a contractual or statutory right and one that all persons have a right to exercise.

Is there any basis for saying that American citizens have a universal right to health care?

Consider the following interpretation.

Thomas Jefferson stated in the United States Declaration of Independence that “all men….[have natural rights including] the pursuit of happiness.” Curious word, “happiness”. Whatever did he mean? Surely not that everyone has the right to “feel” happy or “giddy”? Hardly.

Jefferson was a child of the Enlightenment — the age of Reason — when philosophers such as Locke, Rousseau, Diderot, and Montesquieu took their inspiration from the ancient world and relied on Reason as the best guide to a better, freer life. In their turn to the ancients, Jefferson, like Madison, Adams, and Hamilton observed that happiness was interpreted as the highest satisfaction one could derive from the highest goal — virtue. For the ancients, happiness referred to the Greek word “eudaimonia” (u-dy-moh-nee-ah) which means “living well” or “flourishing”.

Any examination of this nation’s founding documents, including the Federalist Papers, as well as Jefferson’s phrasing of the Declaration of Independence, will highlight the degree to which the founding fathers saw the kind of happiness the ancients called “flourishing” as the ultimate goal of a new nation. As George Mason, the author of Virginia’s Declaration of Rights wrote, stated “All men are created equally free and independent and have certain inherent and natural rights . . . among which are the enjoyment of life and liberty, with the means of acquiring and possessing property, and pursuing and obtaining happiness and safety.”

But if happiness was so important to the early leaders of this country, why is there no mention of health, doctors, or medicine? First of all, health care in the eighteenth century was not much more than superstition and experimentation. To be treated by a “doctor”

The first vaccine was not discovered until 1796 by Edward Jenner; a general anesthetic (ether) was not developed until 1837; Joseph Lister didn’t demonstrate antiseptics to reduce infections until the 1860’s; while it wasn’t until the 1870’s that Louis Pasteur and Robert Koch identified bacteria as a major source of pathogens; a decade later a number of biologists isolated and grew viruses. It was not until 1928 that Alexander Fleming developed the antibiotic, penicillin. Only in the second half of the twentieth century, did biologists, pathologists, geneticists, and molecular scientists begin to unravel the enigma we call biological life. In other words, for most of this nation’s history there wasn’t a health care practice about which anyone would care to claim a right. It is only in this century that we have the knowledge, the capacity, and the will to offer health care for all.

So the question has to be asked: if something didn’t even exist as a conceptual possibility in the eighteenth century are we limited to those concepts as the basis for asserting political rights or do we re-evaluate what the founders meant when they said the foundations of our social compact included social flourishing? Given the capacities of modern medicine to give everyone a more flourishing life, can we not begin to consider the possibilities of what happiness means in the twenty-first century?

There is a very strong argument that equal access to flourishing (which does not mean everyone will flourish) justifies the claim that healthcare is a universal right. And if it is a universal right, it is something far more exhaustive and extensive than the legal right to health care which is the standard of Obamacare.

What such an assertion that implies is taken up in next week’s final article.

Part VIII: No One Dies From the Lack of Health Care?

Murphys, CA…On May 7, 2017, Congressman Raul Labrador (R-ID) spoke at a town hall meeting with his constituents. He exemplifies the chutzpah of many in Congress: “No one dies because they don’t have access to health care”. Then there is the case of Chris Collins (R-NY). Just after the House of Representatives voted to “repeal” Obamacare and potentially cause tens of millions of Americans to lose their healthcare coverage, Collins was interviewed by CNN’s Wolf Blitzer. Collins, who voted to “repeal”, acknowledged he never read the bill upon which he voted. It brings to mind Aldous Huxley’s dictum, “Facts do not cease to exist because they are ignored.” (1926). 

Over the past seven weeks, this series has offered an overview of the state of healthcare in America. In this last article, I summarize some of the key observations from this series and a few of the more important implications:

• We all want good healthcare.
  • We are all fragile organisms that are going to die, but we are self-conscious organisms that want to live.
  • There are thousands upon thousands of pathogens that can kill us, millions of possible genetic mutations that can do us grave harm, and even more accidents that could do either.
  • Good healthcare gives us the substantial possibility of improving our odds of living longer.

• Access to quality healthcare is critical.
  • Emergency rooms and doctor’s offices have more than 200 million visits a year.
  • There are 900,000 beds in hospitals for individuals that need more than an emergency room.
  • More than 38 percent of Americans will be diagnosed with cancer sometime in their lifetime. (National Cancer Institute).
  • Cardiovascular disease kills 800,000 persons a year and another 92 million are at risk or are recovering from a stroke. (American Heart Association).

• Healthcare is crucial to our economy.
  • Healthcare is the largest sector of our economy and accounts for 19% of our Gross Domestic Product.
  • It generates nearly twice as much revenue ($4.6 trillion) as all manufacturing ($2.4 trillion).
  • More than 12 million Americans are employed in healthcare, or 10% of the entire U.S. workforce.

• Healthcare delivery is complicated.
  • There are 900,000 doctors and surgeons organized into nearly 230,000 practices. Increasingly doctors are joining hospital (e.g., Stanford) or not-for-profit practices (e.g., Sutter). The complexities of multiple insurance and payment systems, regulatory reporting, and increasing specialization and technology, doctors are finding it advantageous to “go corporate”.
  • There are 5,500 hospitals in the U.S. and over half belong to a health system network. For example, Dignity Health runs 39 hospitals, while Adventist Health operates 20 hospitals. Moreover, the number of independent hospitals is declining dramatically as the result of merger, acquisitions, and bankruptcies.
  • With increasing specialization, laboratories, clinics, pharmacies, diagnosticians, medical equipment, anesthesia services, etc. are provided by different providers who have different billing systems, insurance coverage, and liability coverage.

• Healthcare funding is fractured.
  • One of the most unique features of the American model of healthcare is the reliance on market-based funding. Healthcare services are priced by the originating provider (doctor, hospital, etc.), but what fee that provider actually receives is set either by an agreed-upon contract amount the provider makes with an insurance company covering a specific patient or by a fee established by the government for covered classes of patients (seniors, the poor, disabled, etc.). A patient with no insurance will be billed for the original (and usually much higher) amount set by the provider. A patient covered by insurance plan A may pay a different amount from a patient covered by insurance plan B, which in turn is likely to be quite different from the price charged to a government covered patient.
  • Some patients discover that being covered for services in one part of a hospital network (e.g., an emergency room visit) may not be covered in another part of the same network (e.g., outpatient laboratory tests).
  • A majority of individuals over 18 and less than 65 years of age are traditionally covered through their place of employment, but this proportion has fallen from 65% in 2000 to 52% in 2015.
  • If you change from one job to another, it is highly likely the insurance coverage will also change, and along with it, the providers which you can use.
  • If you are unemployed, self-employed, or a low-wage employee and do not receive health insurance, you can show up at a hospital emergency room and get “charity care”, which is reimbursed from public funds.
  • If you become unemployed, you may stay on your former employer’s insurance plan for a set period of time (COBRA) by paying the full cost of insurance. But if you do not find employment with coverage at the end of the COBRA period, you lose all health insurance coverage.

• American healthcare is outrageously expensive.
  • Americans spend more for healthcare than any other country — $9,451 per person. The second highest expenditure per person is Norway with $6,567. Japan, with one of the best health systems in the world, spends $4,951 per person.
  • Perhaps even more shocking is that the U.S. uses 19% of its Gross Domestic Product (total national income) for healthcare, while Norway only invests 9% and Japan 10%.

• People do die from poor healthcare.
  • What we get from that steep investment in healthcare is surprisingly not all that much. Our expected lifespan ranks only 42nd in the world. While some Americans love to criticize the Canadian healthcare system, Canadians live longer than us.
  • Because we have traditionally run our medical system as a factory that responds to symptoms rather than a value-based service emphasizing prevention, many of our performance numbers have been getting worse rather than better.
  • Healthcare performance is also related to economic health. “A large segment of white middle-aged Americans has suffered a startling rise in its death rate since 1999, according to a review of statistics…that shows a sharp reversal in decades of progress toward longer lives. The mortality rate for white men and women ages 45-54 with less than a college education increased markedly between 1999 and 2013, most likely because of problems with legal and illegal drugs, alcohol and suicide, the researchers concluded. Before then, death rates for that group dropped steadily, and at a faster pace. An increase in the mortality rate for any large demographic group in an advanced nation has been virtually unheard of in recent decades, with the exception of Russian men after the collapse of the Soviet Union.” (Washington Post Nov. 2 2015).
  • Before Obamacare, it is estimated that 45-50 million Americans did not have health insurance. According to the non-partisan Congressional Budget Office, the so-called Trumpcare plane would result in 24 million losing health insurance. Does it make a difference? According to the American Journal of Public Health, those without insurance have a 40% higher chance of dying from health-related issues in any given year than those with health insurance. So yes, Congressman Labrador, the lack of health insurance can kill you.
  • Healthcare in rural communities is not keeping up with the demand. Rural hospitals are failing and closing at an alarming rate.

• Healthcare policy is brain dead.
  • As this is being written, a small group of Senators have been closeted away trying to draft legislation that would shape the entire healthcare system in the United States. Donald Trump once asked, “who knew it was so complicated?” The American Medical Association and the American Hospital Association have both pleaded with Congress to fix, not replace, Obamacare. Yet, a small group of Senators think they know better.
  • Perhaps more important is the difference between market-based healthcare, universal healthcare, and single-payer health care:
    • Market-based funding — the model of healthcare since World War II — presumes that the employer is the best source of coverage through private insurance. By 1965, it became clear that seniors who no longer work and those who are unemployed do not have access to this form of healthcare financing. As a result Medicare and Medicaid were created to fill the gaps.
    • Universal healthcare — Obamacare — is premised on the fact that additional gaps have been generated in the economy because increasingly the emerging job market does not offer health insurance — retailers, fast food chains — or the large number of self-employed. Fewer than 50% of those employed no receive employer-based health insurance. But universal healthcare is like sticking your fingers in an ever failing dyke. More and more gaps or leaks appear and failure is inevitable.
    • Single-payer healthcare guarantees that if you meet basic, non-discriminatory conditions, you are guaranteed access to healthcare. There are no insurance companies and no middlemen siphoning off life-giving resources. In many countries, even prescription drugs are included in these programs.

• How can we fix it?
  • Our fractured healthcare system is in the state it is primarily for one reason — it meets the business needs of the health insurance industry. Professional medical groups agree that we need major reform that moves towards a more holistic healthcare system. The major source of disequilibrium in this market is largely attributable to the ever larger and dominant, for-profit health insurance companies. They are the primary opponents of healthcare funding reform.
  • The numbers on a single-payer universal healthcare system are still out, but the momentum for such a system is alive and well in California. The State Senate passed SB 562 and moved it on to the Assembly.
  • There are many questions that need to be asked about the implementation of a system — for example, will the Federal government waive the use of the Federal funds for this system? Is the funding model predictably solvent? There is a question as to whether such an entity should be a not-for-profit corporation created by the State or another state agency.
  • We need to reform the healthcare system in this country — a system that makes the value of service as important as its cost.
  • Granted, there is a nearly insatiable demand for healthcare. The question isn’t whether everyone has a right to all the healthcare that is possible, but rather it should be possible everyone has access to healthcare. Perhaps there should be conditions for this access — no cigarette smoking, for example. But people who become ill from exposure to toxic chemicals, like farm workers or miners, or gardeners and lifeguards who get melanoma from increasing exposure to the sun should have ready access to appropriate treatments. Many do not.
  • Rural areas, which are losing their hospitals and doctors, should receive financial support to get quality healthcare.
  • Healthcare is a universal right derived from the promise of our Declaration of Independence — the universal right to pursue happiness. Not a privilege, but a right!

Author: John MacWillie is a native of Calaveras County, California. He graduated from UC Berkeley where he studied European history and bio-engineering. His graduate studies include economics and urban planning at New York University and philosophy at San Francisco State. He received his Ph.D. from the University of Leeds in the U.K. He worked for ten years in law enforcement policy and administration in New York City, spent nearly thirty years as a senior executive in the software industry, primarily in information security, and for the past twelve years has been teaching in undergraduate and graduate programs at California State University — East Bay in multimedia, art history, and criminal justice. He resides with his wife, an attorney, in Murphys CA.

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