We all know that our health care system is in trouble so we listen to and look at all of the alternative ways of fixing it, and argue about how much they will cost our already expensive system. We need to because our current system is really unsustainable; it's already growing faster than the rest of the economy and when the epidemic of diabetes we are now seeing begins to show the effects of this disease it will grow even faster.
Paul Starr, in his new book Remedy and Reaction, calls our situation a policy trap; we are unable to move on because of the unintended consequences of past actions. So what have we done and how do we fix it?
The current proposals for fixing our system have mostly dealt with how the care is delivered. There are best practices and making them universal will save a lot of money as downstream care will be reduced if we do the right things now. And if we can encourage efficient practices with the proper rewards they will spread the efficiency. But these manipulations are kin to managing an economy from the top down, and, as the Soviet Union and China learned two and three decades ago, that is difficult to do. If we can learn anything from their failures it should be that analytical fixes, based on seeing and repairing faulty parts of the system, don't work nearly as well as fixing the roots. The roots are the parts of our health care system that are below the surface so we are less likely to examine them; they are the foundation and they play a large role in how the system grows and how healthy it is. They need to be examined just as much as the rest of the system.
The first roots we see are those just below the surface that pick up all the water needed for the tree to grow;they are how the system gets paid. In the U.S. we have opted for insurance paid by our employers. We like it because it covers everything and our employers get to deduct their contributions from their taxes, but there are downsides. Newt Gingrich, during the first
attempts at reform under the Clintons, pegged it right when he said that our third party payer system was the underlying reason for its expense. Neither he nor anyone else has repeated that since because it's political suicide, but everyone who has spent any time looking knows he is right; it's the elephant in the room that everyone sees, but no one talks about. It's a major policy trap in Starr's terminology.
The Wisconsin Policy Research Institute published their report, "The History of Health Care Costs and Health Insurance" in October 2006 and showed the correlation. And while a temporal correlation does not demonstrate causality, combining the correlation with an understanding of moral hazard strengthens the argument substantially. Moral hazard is related to the opportunity to get a personal benefit at another's expense. Under normal circumstances we hesitate to use someone else for our own good, but when the other is an impersonal third party all bets are off, and opportunities for this permeate our health care system on both sides; everyone seems to game the system for their own benefits.
To be sure some of this gaming has paid off in dividends because the increases in medical technology we have seen since third party payment was begun have brought some benefits, but are they worth the cost? Given the choice most people choose a caring physician over technology. The rise of technology in medicine is part of the tap root and will be considered more there.
The Wisconsin report shows that when people are put back into the mix that health care expenses drop by about 20%. Consumers are a critical part of a free market system that we have chosen to use in our health care system. The role of the invisible hand, conjured up by Adam Smith to explain why a market always led to a better society, is best seen as a result of informed consumers making wise decisions in a transparent marketplace. This is something we ought to be working for. But the choices we are given are between socialized medicine and our brand, and we always turn down the socialized alternative without realizing that ours, thanks to our third party payer system, is neither transparent, nor a market.
The Wisconsin Policy Research group also points to a way to make it more of a market: putting the patient back into the equation. They conclude their executive summary with the statement that, "As Health Savings Account balances will likely build up rapidly for the majority of people who are in good health, they also provide hope for the fiscal Titanic that is Medicare." Health Savings Accounts (HSAs) are options for many. They are most liked by healthy people who can use them to save for retirement. With them a person can obtain a high deductible policy to pay for true emergencies and pay for routine care care from his savings account, which turns into a retirement account when she retires.
There is another, largely ignored, benefit with HSAs that would show itself if they were used more widely, like if they were the basis of Medicare and Medicaid. Aaron Antonovsky studied people who were healthy and found significant differences in how they interacted with their environment: they were more likely to have a sense of congruence with it (they were a part of it, they participated in it), a sense of meaning (that their world was not whimsical), and a sense of control (the middle class value that one's actions can affect events). He called this view salutogenesis because it helps make people healthy. This is one of the things that happen when people are empowered. An example for how this works and its impact comes from right here at home.
Infant mortality is a problem in our country. You would think that an advanced nation like ours with our high tech health care would be able to do better, but International ratings have us well down the list--just below Cuba. Our biggest problem is with African American women whose isolated statistics compare with some of the better countries in Africa. But Madison, Wisconsin saw a dramatic decline in infant mortality in the early part of this decade, due entirely to improvement in this group. The question they are asking is why. One element in the answer that deserves more attention is the South Madison Health & Family Center -- Harambee, that opened in 1995, a mix of several service agencies and a women's clinic. It became a center where women could get help, information, and support. In Antonovsky's view this center (Harambee means pulling together in Swahili) enhanced all of the factors he considered important for salutogenesis. It closed in 2006 and infant mortality has since climbed back up to previous levels. To really see these benefits, and why they occurred, requires a different paradigm than what is the tap root of our health care tree.
Western medicine is built on the foundations of humoral medicine and western science. From humoral medicine we get the idea that good health occurs when the body is in balance, so symptoms are treated to restore the balance. Not so long ago, since the practice was still
recommended in the 1920's, we thought that a person with a fever and a pounding pulse had too much blood. And there was reason for this because when we bled this person and reduced the excess blood those symptoms disappeared; the body was in balance again. Only more of them died, as we found when we looked at the practice in people with pneumonia. So we stopped blood-letting and moved to scientific medicine, but we didn't change our paradigm; we still focus on symptoms and try to balance them. Scientific medicine has helped us define many parts of our physiology in this way, so now we have many more symptoms to balance.
The scientific revolution radically changed how we see the world. In the Ancient Greek world things behaved rationally; you could think about how something should work, as Aristotle did, and you could convince many that it did work that way--so heavy objects obviously fell faster than light objects. Except they didn't, and they still don't. And when Galileo and others started questioning the old system eventually the whole of Aristotle was sent to the recycle bin. The
rational quest was replaced by the analytical and experimental and over the next few centuries this new way of seeing led to the remarkable advances we have seen in the sciences and from which we all benefit.
This model worked in the sciences because we could isolate cause and effect better there. It's not so easy with quantum mechanics and 'uncertainty,' but it works well on the macro level. It worked so
well we tried to use the same principles in other areas. Budding economists like AdamSmith described the workings of the marketplace in mechanical terms--except for the mystical invisible hand that beneficently guided it toward constant improvement (which he could not explain because it's not mechanical). The founders of our country used the mechanical balancing of powers to establish a government that was supposed to be fair, balanced, and long lasting.
Mechanical ideas worked well and they were predictable. They worked so well that other disciplines tried copying them. Economics wants that accuracy; so do sociology and psychology, and the historian Ranke wanted to write history 'as it actually was'. Efforts to attain the predictability of physics in these other areas came up against what is generally called 'the human factor'. Predictability was elusive because humans in some way or another always screwed it up. Medicine has also followed this path, searching for predictability--it's why we have double blind placebo controlled trials--but has been just as frustrated by the human element as the social sciences.
The problem with this is that they are dealing with different orders of complexity and the tools for one don't work for the others. Linear systems are like connect the dots; they can be figured out easily with a pencil and paper. Gravity, introduced by Newton, was simplified to relate only to two elements; the sun and earth, the moon and the earth, a falling body and the earth, etc. If you add
another element, however, you have the three-body-problem in mathematics--a real challenge for the pencil and paper.
As you increase the number of elements and their interactions you have increasingly complex systems that defy the pencil and paper, but, like the three body problem and the weather, can be resolved and predicted with some accuracy using simulation programs that include as many of the elements and their interconnections as are known and understood. But increasing the number of elements and their interconnections rapidly exhausts even the largest computers; "combinatorial numbers," points out Phillip Anderson, "are bigger than cosmic numbers." There is a limit to how well we can deal with complex systems. Many have honored human complexity, and that is a step in the right direction, but not big enough.