“Before you get too exercised over the multiple idiocies and injustices of the current American medical situation just reflect for a moment that the whole creaking system cannot possibly survive no matter what the Supreme Court might have ruled or whatever Obama sought to accomplish. The US economic system is about to blow up. The banking sector has been kept technically alive on the life-support of accounting fraud since 2008, but that artful racket is coming to an end because sooner or later the abstraction called “money” must make truthful representations of itself in relation to reality, or else people cease to accept its claims of value. Without a functioning banking system none of the rackets organized into US health care can continue” (JH Kunstler, July 2, 2012).
Kunstler has succinctly summed up the big picture for American healthcare. We are slapping bandaids on empire’s heart attack. I am revisiting healthcare reform for two reasons. First, healthcare’s complexity creates a good exercise in broadening our scale of view. Secondly, now that healthcare reform is law, the question is, what does this new law mean for individuals at the small scale, and for the country at the larger national scale?
Because my specialty is health policy, this is one topic where I have to fight the tendency to narrow my focus and analyze small bits, as most other specialists do. Indulge me briefly, however, while I wallow in the details, as it is important to describe what the reform actually entails as a whole rather than examining pieces and parts. The new Affordable Care Act (ACA) is 2000 pages long. And no, like many of our legislators, I haven’t read the act either. But McDonough (2011) has. The legislation includes 10 titles:
- Expansion of health insurance to those difficult to cover through mandatory insurance payment or tax/penalty to cover uninsured
- Eligibility of all low income individuals for state Medicaid programs
- Additional Medicare preventive benefits and closure of the drug donut hole
- Inclusion of preventive health strategies in all public and private health plans
- A national workforce commission, with expansions/funding of community health centers and National Health Service Corps
- New centers for fraud control, a Patient Centered Outcomes Research Institute, and The Elder Justice Act
- Mechanisms to promote generics and prevent anticompetitive behaviors from pharmaceutical companies
- A new national, voluntary long term disability program (this title is being repealed by Obama)
- Financing provisions for less than half of the ACA with key taxes on health product manufacturers and Medicare taxes on high income wage earners, among other taxes
- The kitchen sink–a catchall title for amendments and additions resulting from the blind man approach to policy (Medscape, 2012)
Except for title 8, these key provisions appear to generally create more federal cost for healthcare funding. This reform does not change the fundamental nature of our costly healthcare system, while attempting to cover more people (Holtz-Eakin, 2010). If the goal of the reform was to restrain costs, we have failed miserably, at a time when healthcare is already 17% of GDP in the US. We are bankrupt and most likely entering a Depression. We cannot afford this Act, either as a tax or mandated payment to powerful insurance companies that the middle class can’t afford, or as expanded federal debt through money printing.
How blind policy doctors diagnose a heart attack
Like the blind men and the elephant, polarized political parties argue about different aspects of the same problem in American society today–the growth of inter-connected corporate and government power in a bureaucracy in overshoot. Behind the varied stances is the same looming problem–our expectations for healthcare and other sectors are still mired in expectations of future growth without limits, allowing continual expansion. On both the left and the right, that creates a large blindspot as to the abilities and limits of both the federal government and the private sector. One policy doctor puts his stethoscope on a corner of the mess, and hears the power of big government and taxes. Another policy doctor listens at another spot and hears the murmur of corporate power and inequities. Yet at the root of the problem is the idea from both the left and the right that the indulged American empire has no limits. Politics about the details becomes immaterial if we are all mired in arguments for growth that is unsupportable. Our politicians have rediscovered an essential truth about democracies that resurfaces as political systems reliant on fiat currencies age.
“A democracy cannot exist as a permanent form of government. It can only exist until the majority discovers it can vote itself largess out of the public treasury. After that, the majority always votes for the candidate promising the most benefits with the result the democracy collapses because of the loose fiscal policy ensuing . . . ” (Tytler, perhaps).
Our blank check world view adopted by both American political parties emphasizes medical ethics that promote unlimited care. Both parties advocate for and value unlimited growth. It is hard to take a free-market policy stance towards healthcare, for example, when someone you love is being supported by government-supplied healthcare. It is hard to promote universal health care without subtracting from the system that we
now have. People oppose policies on a political level, yet support them in their personal lives, creating cognitive dissonance. Yet personal circumstances will be inexorably overcome by changes at the larger scale, so the energetic processes at the national scale are what ultimately determines what happens to our healthcare system and to us. While the minute details are critically important at the personal scale to individuals and their health, creation of unsustainable policy is futile. That is sad. Eventually, unsustainable systems stop working. We must examine the system at the broadest scale, since we can’t pay for the system we’ve already got now, which does not work.
“Because of the way science has usually been taught, we most often look from the whole inward to the parts in order to find mechanisms of the way the whole works. By doing this, we move to a smaller scale of time and space, one that may be too small for the questions raised. For example, in many environmental affairs, study of the parts of an ecosystem is not as important to understanding and prediction as studying the ecosystem’s interactions as a part of the economy around it. . . . Limiting the scale of view limits understanding, because every scale is part of the scale above and composed of the smaller scaled items below. . . . When emphasis on looking smaller is carried to the extreme, people on one scale deny there is any science at the next larger scale. many people are taught that looking for purpose is not scientific, that teleology is bad. However, what is viewed as purpose of a unit at one scale is its part in mechanisms of the next larger scale. Avoiding purpose is really hiding from the larger scale, which controls the longer scale of events.” (Odum & Odum, 2000, pp. 11, 14).
We can’t fix our problems with the same thinking that caused them. We must chunk up by creating some distance, examining the problem from the larger system within which the American healthcare system resides. Our assumptions are that we can continually improve healthcare quality, costs, and access are wrong if our energy basis is declining.
Broadening our scale of view
We have opted to increasingly privatize our healthcare system; thus it focuses more on cost than quality. We often make the mistake of equating money with healthcare. Money is not healthcare. Health insurance is not healthcare. Healthcare is the work of treating sick patients using goods, services, and energy. The more intermediaries between a money source and the consumer, the less resources get delivered. There is little value added by insurance companies, and administration adds bureaucracy and the cost of siphoned profits and dividends. Insurance companies protect patients from catastrophic costs, but they prevent the operation of free markets in healthcare. Patients are factory products in the health care assembly line; they lack autonomy in the system. We treat the system as a free market and a place to create wealth. Money gets diverted into profits. Our system relies on a global just-in-time system and high production per cost basis, resulting in an efficient system without room for any disaster, crisis, or improvements in quality. Our system is already operating at peak efficiency for the system and expectations that we have. Our intensity of care creates bottlenecks, and any reform that adds patients, complexity, or other features would entail additional energy inputs.
Complexity and an overly crowded “policy arena” (lobbyists!) prevent broad policy reform in many sectors of our American empire. Instead we focus on pieces at the smaller scale and rely on incremental reforms of a broken system, applying tourniquets, salves, bandaids, and ace wraps on the limbs of the mess. What the system needs is a heart transplant, a do over, starting from scratch. We could afford a basic universal health care system like those seen in many other countries, but we would need to develop a complete new system without middlemen and profit-making. We are in a position of zugwang, where any decision or move in our overly complex system will result in the creation of more problems. Policy changes of any sort create unintended consequences.
Money game or energy spectacles?
What is the energetic basis for healthcare? An emergy evaluation has not been done, but simple analysis of the cost, complexity, and growth of the system suggest that Americans have the most advanced, complex, and energy intensive healthcare system in the world. Our new healthcare policy is not sustainable even in a growing system. In a system in descent, I doubt that we will be able to roll out this new plan.
The US has 4% of the world’s population but uses 20% of the world’s fossil fuels, while heavily dependent on inequitable trade of foreign resources and the petrodollar, which provides a very broad energetic footprint, complex hierarchy, and centralized institutions. Failure of our petrodollar currency, with reboot, will mean a very different emergy basis for the US and its institutions, and it will probably mean the failure of many monolithic insurance companies along with many other financial, insurance, and real-estate companies. Most likely when the petrodollar collapses, we will fall back on a simple self-pay system without middlemen. Public health will suffer, and morbidity and mortality will rise considerably. Systems that we privatized and monopolized in the last two decades such as hospitals may either close or return to community ownership. Big Pharma is collapsing already–have you noticed that over the counter drugs are their market leader, marketed to the elderly on the nightly news and in children’s cartoons?
Until our leaders understand where thermodynamics is taking our country regardless of politics, we are trapped in an economic downward spiral of less access for healthcare, more healthcare cost through inflation, and a decline in quality as complexity grows and resources shrink. Our capitalist system values survival of the fittest and profits over fair care treatment for all. There will be less care and more cost in the future no matter what system prevails. And the more we try to maintain our institutions, the more inequities and unintended consequences we will have. And if there’s a crisis, I’m taking care of my own health and not planning on any help from the system. Our healthcare system is designed for just-in-time supply chains for an optimally healthy population. A good part of the treatment we seek is unnecessary, especially if we take care of ourselves. As an intensive care nurse, I see too much. I have never had a personal physician, and I try to avoid the healthcare system like the plague. I’m avoiding national politics, too–there’s no future for any organized political party that places economic growth at the top of its list of values, as Dylan Charles suggests. American politics is just not working for me anymore, along with many other American institutions.
For your own personal health, focus on preventive self care. Kick that habit, lose the weight, get on a bike, or go for a walk. Learn about and avoid environmental toxins, since they are increasing rapidly. Enjoy life, develop lasting relationships and pour yourself wholeheartedly into the type of culture that you can believe in. A great part of your health is in your head and heart.