North Carolina Society for Ethical Culture

U.S. HEALTHCARE: An Ethical Dilemma
by Enid Handler
January 10, 1999

This topic is so enormous and pervades our daily culture in newspaper arrticles, analyses, TV shows, even pop movies, to such an extent that I'm rather daunted by it. I suspect most of you, if not every one, may be quite tired of hearing and reading about it. I hope not to bore you with repetition of all too familiar cliches and data. I will try instead, to give some very broad brushstrokes in outlining the bases on which society's concern with health care rests, on why it should be an ethical issue; where we, USA approaching the 21 Century, stand now in our efforts to address this concern; and finally, I'd like to close my talk, with a topic that is critically important to this issue, but one that is almost NEVER discussed openly and forthrightly.

Let's explore first the very basic question. Should healthcare for individual citizens be a concern to a society? Is it a right, an entitlement,a privilege? Who should pay for it? These are questions that sound very much in the political mode of today. They reverberate with the same phrasing of welfare reform, benefits vs. entitlements, government programs, the right to a good, free education as the due of every child in America, etc. These are the sorts of questions that make up most of our modern political agendas. What does evolution and history tell us?

Before there were civilizations and organized societies, there were tribes, totems and clans. However primitive these clusters of humans were, they nevertheless each had a class of elevated, respected individuals who performed a special role in the primitive culture. These individuals were the medicine men, shamens, voodoo priests, whatever. They were revered by the group, and their job was to provide health and healing. Why was a class of this type created in all these primitive cultures? What societal need was this attempting to address? The need, quite naturally, was to ensure the survival of the clan. Illness, disease and death deplete a community, may in extreme situations, threaten it with extinction. When a group is struggling to survive, it is crucial to its survival that its members do not succumb too soon or too often to death and disease. So in the very crudest earliest sense, good health and caring for other clan members was a necessity.

By the time of the Old Testament we find biblical injunctions furthering the idea of providing for the survival of weaker members of the group. There are admonitions and practices for providing sustanence for the most vulnerable member. At harvest time, a portion of the bounty was to be set aside for the widows and children. In additional, The Hebrews taught righteousness as a revered quality. A 'tzadak' is a righteous person . This concept of 'tzedakah', 'giving' was for the Hebrews, an offering stemming from a sense of righteousness, not borne of obligation or guilt, but of a desire to do good. This was an act incumbent upon the righteous person, to be done without deliberation, but in a true sense of sharing. Tzedakah also included visits to the sick. We can follow from this the moral beginnings of a societal concern to care for its sick, and to keep its members strong and healthy, to look after the weak.

The New Testament offers us the parable of the Good Samaritan, in the book of Luke. Jesus encounters a travelor who is ill, a Saracee. Not a Christian, nor a Jew, the Saracees were truly outsiders, beyond the tribe, not members of the group. To offer help to a non-member of the clan involved risk, but the parable instructs us that the good samaritan looked after the ailing man, although a stranger. And before going on his way, he offered coins for his continued care of the travelor until he was returned to health. The Christians taught compassion.

Fast forward our search for the foundations of society's interest in health care to more modern times, we can now look to the principles of public health. The first efforts of public health stem from 1798, when a Marine Hospital was established in the US. The public health movement grew out of a concern for public hygiene and communicable diseases. It isn't rocket science to figure out that rampant epidemics of disease are a drag on a modern society. Governments will do well to maintain a healthy populace. High numbers of sickly newborns are not in a society's best interest. A healthy society is one that is economically productive and able to protect and defend its interests inter-nationally. This is self-interest without the benefit of ethical or moral entanglements. But, since the strands of our Judeo-Christian tapestry are interwoven and deeply entrenched in our heritage, we extend this self-interest in a healthy populace, to provide some forms of care to the biblical equivalents of the widows and orphans, the elderly and the needy.

From a variety of sources our present society has generally acknowledged a rationale for providing health care -- to varying degrees, and to certain segments of society -- as a part of civic responsibility. We've seen the basic need to sustain the viability of a tribe or clan; the Old Testament righteousness of caring for the least able and the New Testament compassion extending beyond one's own group to today's modern public health concerns. Thus we have in place a number of ways in which we adhere to the moral mandates and ethical concerns of caring for the ill, the needy and the least able.

But now we face our current dilemma! As a society, late 20th Century America is the premier power on the globe, riding the crest of a very long, robust economic boom and lets take a look at where we stand in healthcare from a world wide perspective.

The US is the only country in the industrialized world that does not offer every citizen some form of subsidized or otherwise affordable healthcare. That's a pretty shocking statement just by itself. Health care in America is paid for primarily through insurance companies, providing the intermediary role, regulated on a state-by state basis. The entry to insurance coverage is linked to jobs. About one half of the population has affordable access to health professionals through this route. BUT here comes the quandary. These are not the people least able to provide for themselves. In fact, these are the ones with good jobs, presumable the better incomes. Ironically, The Pres., VP, Congress and Cabinet have total federally provided health care -- what some politicians scorn as socialized medicine. What about those for whom the bible taught us we must look after:

Well, I mentioned a moment ago that there are specially designed groups of citizens who are taken care of through a maze of different programs. CHAMPUS, VA, MEDICARE, MEDICAID, HEALTH CHOICE, federally funded health clinics, etc These various programs serve military dependents, veterans, the elderly, the indigent, needy children and communities that are 'medically underserved'. But this patchwork still leaves an estimated 15% of Americans who do not have health insurance, do not quality for these programs, and cannot afford healthcare. That familiar number, 43 million Americans. And that number is not one that has reached a plateau, either. About 1 million per year are expected to be added to the 43 m. already uninsured.

Let's take a closer look at who are the uninsured. Over 80% of these adults are working. One third of construction, agricultural, fishing and mining industry workers lack insurance. 50% of the self-employed or workers in businesses of under 10 employees, lack insurance. Not all, but many of these working people comprise the group known as the 'working poor'. This is a population with many other problems, adding to the difficulties of maintaining health: sub-standard housing, crowded living conditions, high stress levels, risk factors leading to higher incidence of disease and injury. These are recipes for poor health statistics, indeed.

Make no mistake, this is not a scenario where lack of funding is the major problem. The system does not need more money! The government estimates the US healthcare system is a $1 trillion dollar business. IN FACT, the US spends more on healthcare than any other country in the western world.

1991 figures per cap spending
..........................................US.....Canada..........UK.....Japan.....Germany
Per Cap Spending...............2.850......1,915.......1,003.....1,310.......1,660
Spending as % ofGDP..........13.2%........10%........6.6%......6.8%..........9%
Life Expectancy...................75.6.......77.2........75.8......78.6........75.6

Why are we getting so little for all the money being spent.? We have the highest per cap, highest GDP, lowest life exp., high infant mortality...it just doesn't make sense.

Problems of our current arrangement: 1. Duplicative adm & overhead of government programs. Each of the programs mentioned above has its own administrators, directors, managers, etc. Each requires its own set of gatekeepers, record keeping, billing clerks. Each program has its own requirements of who is eligible for which, gatekeepers who monitor that only those eligible are served. Quite naturally, this also keeps the public guessing as to which program, if any they are eligible for. Each program has its own application forms, billing forms, clerks to process all these papers. Aside from government programs, we have the largest body of coverage through insurance coverage. 1,500 insurance companies generating 4 billion bills per year!! It is estimated that each claim processed costs $20.

2. Access. Requires having treatment sites reasonably close to where the target population can reach the services. Access also requires eligible recipients to know what they are eligible for. This means outreach is required. Costs are involved in educating the public about available services. A current example here in NC is HealthChoice, a new program for needy children, who are not elibible for medicaid, but cannot afford private healthcare. A recent news report stated that the agency has just established an advertising budget, since they are currently funded to serve 71,000, but have fewer than half that number on the rolls. Here you see underservices and unmet needs, underutilized personnel/equipment, while there are literally thousands of children without adequate health services. Another situation, also very timely, is Durham's Medicaid rolls. These are dropping significantly. As families leave welfare, they retain Medicaid eligibility for a year. Are they aware of this? Most welfare recipients who do enter the workforce are not in jobs that provide medical coverage, nor are they likely to achieve that in just one year. What will happen after the year?

3. Expensive delivery system. The uninsured tend to wait before seeking medical care, leading to more serious illness, which could be treated at less cost if treated earlier. This group also tend to overuse of the ER, which is the most expensive treatment site. An additional factor increasing the expense of service delivery is that little effort is given to prevention. There is no economic incentive for prevention services, resulting in higher costs for preventable illnesses.

4. Encourages competition in service delivery. Competition is often thought of as a solution to high costs in a free market economy. However, all of our previous experience with health economics indicate that a free market in health care does not lead to lower costs. It leads instead to expensive overuse of high tech equipment, more duplications of already duplicative systems. Some other reasons a market system doesn't work in health care are: 1. Aging pop. 2. No cap on demand 3. Technology increasing faster that rational distribution Drives up costs, because competition demands the latest, newest generation of high tech equipment and services.

As you all know, there have been numerous attempts at restructing or bringing down healthcare costs, of 'tinkering with the market': We have tried incremental changes, but they do not address systemic needs. In the 1980's there were national efforts made to limit hospital beds, force closings of superfluous departments, rigidly limit the number of MRI machines, etc. I was a health administrator during those years, and remember the boards of bureaucrats set up to regulate, the elaborate rituals of defending why your hospital needed a piece of equipment, a satellite clinic, a maternity ward, etc. etc. That effort did not have much success. Clinton's plan for managed competition was an attempt at a systemic change, we all know where that went. HMO's are an attempt not at systemic change, but simply an attempt to slow increases in costs. That is not working, as we are seeing it unfold. Elderly in medicare HMO's are being dropped (400,000 according to the latest figures I've seen), access to specialists is being severely curtailed, services severely limited, HMO's are losing money in record amounts, docs not forthcoming with important information about available care. Cancer centers are notorious for competing with one another for cases. (When my son was faced with making a decision about a bone marrow transplant, at the time a highly risky, new procedure only being done in a few places in the country, he had a discussion with his physician. He was being encouraged to opt for the procedure at Sloan-Kettering Hosp. in New York where he had been treated. Evan asked what was their success rate, and was told "it is 50%". Only when he pursued that piece of information and pressed further was the doctor forced to acknowledge that % was based on two cases...one lived, one died. What we are seeing today as a current political issue, the need for a patient's bill of rights, demonstrates the public's insistence on wanting the government to deal with these problems.

Well, that's been the overview of where US healthcare is today. But what about the future and the unspoken reality I alluded to in my opening? There are not many models out there being suggested. I am personally open to hearing about them. Managed competition was too complex, buying cooperatives seems to be a variation on that same theme. The only truly viable option I know of is a single payer health care system, with one entity -- either a single insurance company, or a pool of highly regulated insurers, or a government agency. The US General Accounting Office estimated savings of $80 billion per year, which would adequately cover all the uninsured. One study showed that a quarter of US health care workers do mostly paperwork. Check out the business office of your doctor next time you visit. How many clerks are occupied with forms? This same study estimated that under a single payer plan 1,407,000 few clerks and managers would be required. Private insurance overhead averages 14%-30% in the US, while overhead costs for Canada is about 1%-5%. Advertising costs and commissions for insurance companies now cost 20% of premiums, which would be completely eliminated. Health experts have pointed out ad naseum, that we could cover the expenses of all the uninsured without spending another dime! Let me repeat...the issue is not cost, it is not a system in need of more money, it is a system in need of coherence!

Before going on to the nasty little 'secret' o0f healthcare, I want to mention that I have reluctantly omitted the topic about which I am most familiar. Mental Health care is the field I specialized in in my public health training, and in which I worked for 15 years. Our treatment of the mentally ill as a society is truly shameful, and the issue is so large that I cannot even begin to discuss it in this framework. Let me just add to this mix of unresolved issues, the one of insurance parity for mental health care. Legislation was passed a year ago at the federal level, requiring employers to offer equal mental health coverage to medical coverage for employees. The legislation is weak and contains more loopholes than swiss cheese. 19 states have adopted state legislation; NC was unsuccessful in passing legislation last, and the issue will probably be reintroduced this year. But in terms of cost, think about the two security officers killed in the Capitol this last year by a deranged man, the instance last week when a 32 year old woman was thrown off a NYC train platform in the path of a train, and the public nuisance in Durham who is mentally ill and walks around with a loaded shotgun. This is the price we are paying for not adequately providing mental health treatment. Perhaps another time we can talk about this topic, and the costs to employers of lost time, accidents and addictions.

I want to end our thinking about US healthcare by introducing a very hot, provocative topic. That's the dirty little reality I've been alluding to, the one no one likes to talk about -- rationing health care. It is rarely acknowledged, but by reducing access to healthcare and maintaining the cost beyond the reach of 16% of the public, we are actually practicing a form of rationing -- limiting its availability to 43 million Americans. This rations not the service or type of care, it rations the number and class of people who can use the care. And if you look at some of the specifics of health services, the rationing becomes more stringent, the availability to fewer ie, the latest tecniques and advances in cancer care for example; organ transplants are another instance. Medicaid pays for kidney dialyses and trangsplants, but not bone marrow. When my son needed his bone marrow transplant, I called medicaid and asked would it be approved. "No", said the worker "we only pay for kidney transplants" (This was 1986 or 87) When I asked sy, her answer was flat, matter of fact. "They have a better lobby." Is this the best basis for health care decisions?

In the US there is only one situation where rationing has been attempted on a rational, systematic and totally public basis, that's in the state of Oregon. Their slogan 'rationing care, not people'. Just last Sunday the NY Times ran a large article on the state's system, and the article was picked up in total by the Raleigh N&O. There are many details, many indicating the difficulties the system has encountered in the 5 years of operation. But there are also many poitives, and a great deal to learn from their experiment. Basically, Oregan has reduced the uninsured from 15% to 11% over the 5 year peiod. But to provide coverage to all, their original goal, they must limit services, and they have developed a list of medical priorities.

We as a society do not want to contemplete rationing health care. We do not talk about end of life decisions -- when do we decide not to continue heroic measures to continue life. What about the new medical quadary of fertility drugs -- how many families can face a life of raising 6, 7 or 8 same age children in one household? What costs to the medical system if they survive, but with severe mental/physical handicaps? There are so many other issues begging to be faced and rationally addressed. We need to bring this morning's talk to a close. I do hope we can have a discussion, today and continuing next Sunday.

Thank you.

Last Modified: Sunday, January 15, 2006
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