Every issue confronting us in the health care system dead-ends in a social, political and economic cul-de-sac. All of the rational analysis, looking at the problem from every angle and studying the alternatives, still requires decisions tempered by personal values and beliefs. This is what I call "moral ecology". Moral ecology is the sum total of social, political and economic principles which constitute a "philosophical-core". Whether these values and beliefs are conscious or implied, they drive the system. Therefore, any discussion of health care needs to make explicit the philosophical core as operating assumptions. For example, if we are going to entitle everyone to health care at the best hospital in town and still let them smoke, be obese, drive a motor-cycle without a helmet and not buy insurance, then we can forecast costs accordingly.
A moral ecology and philosophical core.
Core Component #1
A two-party political system has a tendency to reduce all debate to a black and white, left or right, republican or democrat polarization of two extremes. Several decisions need to be made: 1. What is the role of health care in the US economy for the next century? Is it to be "overhead" to be restrained by regulation or an export industry to be encouraged to flourish? 2. What method of disciplining has the greatest chance of success? Should we rely on the forces of supply and demand in the market to set prices and optimize, or; do we turn to government bureaucrats, financial intermediaries and corporate benefit chieftans to act as our loyal agents? 3. Why does the cost behavior and experience of health care, education and other social service systems vary so dramatically from the productivity improvements displayed by industrial organizations? 4. Does government distrust the market players so much that it seeks to regulate and control, or is it willing to empower the players to act out their destinies on a level playing field?
Core Component #2 SOCIAL
It is clear that health care has been transformed socially on a learning curve that extends from the days of the barber-surgeon. Sometime in the 1970s we crossed a great divide where the promise of the technology finally began to pay compound dividends. Health care has risen from an unmeasureable expense in the 1890s to 16% of a muli-trillion dollar economy at the turn of the 21st century. Our founding fathers could not have envisioned this transformation and therefore, health care as a right and entitlement has, like women's suffrage and civil rights been won like a game of Mother-May-I, two steps forward and one step back.
Government and employers have an implied social contract with the citizenry and it is no longer possible to define health care as some kind of discretionary consumer expense the way you would treat the purchase of an i-Pod. But, the organic evolution of the social contract has left out major terms, particularly in the area of personal responsibility. The inability of society to deal with basic issues such as motorcycle helmets, seat-belts, smoking, obesity, failure to buy insurance and all matters of fraud and abuse create a disturbing mosaic.
Dysfunctional social systems tend to cultivate learned helplessness and grease a slippery slope on which it is difficult for an individual to self-arrest even if he wants to. If policy makers, and by this, I include not only government, but big business, the financial intermediaries and the multi-hospital systems, continue to herd society down the path to serfdom, the consequences will be collapse of the system. It is already overshooting its limit to growth and sustainability. A new social contract that includes expectations of the patient as a rational, informed consumer with both rights and responsibilities must be drafted.
Core Component #3 ECONOMIC
Relatively few of the pundits commenting on health care have a grounding in economics. Therefore, it is understandable that the failure of the health care market, due almost entirely to ill-informed public policy and corporate paternalism, is cast as some intrinsic retardation of the intelligence of the market to live up to expectations. The laws of supply and demand, setting of prices, striving for efficiency and satisfaction of the customer and all the characteristics found in excess in the computer, automobile, housing, food and entertainment markets are virtually lacking in health care. Is health care an imbecile? Could such a retard be capable of also discovering miracle drugs, the MRI, advanced heart and cancer treatment, mobile combat hospitals and an array of advanced medical technologies. Can in industry that is comprised of the most intelligent people from our society be so incapable of playing by the everyday rules of disciplined markets that they deserve to be overlorded by an army of lawyers, premium-seekers and apparatchiks to barely function?
The crucible of debate about the economics of health care will, in my mind, seal the fate of the United States economically. For, if we cannot turn health care, education and essential public services into export industries we are left with illegal immigrants and off-shore businesses as our hope for the future. Any anxiety about the melting of the ice-caps should be minor compared to the stress that we should be experiencing about the rapid loss of comparative advantage in a global economy.
Health care must be transformed in a way that it functions as a gifted child, not an imbecile. It must grow up to be a responsible, informed, rational market player who thrills at competition, and doesn't whine in the face of a challenge. The parents who are right now duking it out with the coaches need to get off the playing field and become mature spectators who, if they intervene, it is to empower and encourage, not to regulate and punish.
Core Component #4
RIGHTS AND RESPONSIBILITIES
Take a moment and imagine a health care system with the following attributes: -Every citizen has the right and is entitled to access a publicly financed health system. -The system has limits and therefore it must ration certain services, establish queues and impose restrictions on unproven procedures and brand name drugs. -A large portion of the nurses and doctors are foreign and display a certain hostility. -Every year government bureaucrats set the budget, determine whether facilities will be maintained based on politics. -Tax dollars of people who exercise, eat right and follow a healthy regimen are used to subsidize smokers, alcoholics, the obese and people who refuse to wear protective gear when riding a motorized vehicle. - Each year the system becomes more dumbed down, less innovative, more stifling and yet, it's percentage of the gross national product rises to over 20% and keeps on going. Health care becomes the major employer, but the nation's wealth keeps declining.
Such a script plays out in most political, social and economic systems surrounding the USA. The twin reasons that our country has been a shining city on the hill, has been the moral fiber of the citizenry and our insistence on market-based social and economic systems. Otherwise it is a road to serf-dom. But, any political establishment that caters to a consuming public and offers up rights without responsibilities, benefits and rewards without a price to pay or consequences will be breeding a learned helplessness in its citizenry.
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