Thursday, October 22, 2009


I recently participated in an online healthcare reform chat group. I’d expected a passionate discussion, but instead found people drily exchanging statistics and prices. Deflated, I looked up the group’s roster. Of sixty-two members, almost all were administrators or economists. In fact, I was the only one identified as either a patient or medical practitioner.

What can we possibly be thinking when we omit healthcare’s obligate participants from the reform discussion? The current Congressional hearings involved numerous representatives from the insurance, hospital, and pharmaceutical industries, but hardly any patients or practitioners.

Evidently Congress is convinced that the healthcare crisis is purely economic. If policy makers were to ask plain old citizens who are sick and those who treat them, they’d learn that at its core, healthcare isn’t just another business. It’s as subtle as it is complex, a blend of suffering and science, hope and compassion. Seen through the narrow lens of economics, though, doctors and patients are simply agents engaged in the transfer of a product: health has become a commodity like pork bellies and winter wheat, what a “provider” sells to a “consumer.” Shame on us. Hippocrates is spinning in his grave.

It is that gross misperception, not economics, that is the nucleus of our healthcare crisis. Surgeon-writer Atul Gawande explained this incisively in the June 1, 2009 edition of The New Yorker. In an article that’s become required reading for White House staff, Gawande demonstrated that we pay too many bucks for too little bang because we simply overuse medical care.

We demand more than we need, encouraged by the perennial avalanche of press releases about the latest breakthrough, that medical miracle just over the horizon. Most of these wonders don’t pan out, yet relentless publicity persuades us that there is or soon will be a pill or procedure for virtually anything that can go awry. We understandably want to believe this, and genuine advances do occur, but most of what we hear is flat-out sales pitch. Consider the magazine ads and TV commercials you’ve seen by the score: “Nervous? (Insomnic? Depressed? Itchy?) Ask your doctor if this is the right medicine for you.” Sadly, some of these hawkers are physicians who, having noticed the rushing river of healthcare dollars outside their window, lean out to dip their ladles.

Mesmerized by unrealistic but pervasive promises, too many of us don’t take care of ourselves. Assuming doctors will heal us no matter what, we eat processed foods that bestow weight without nutrition, we ingest noxious chemicals, lack tools to handle stress, tolerate abusive relationships, and don’t exercise. When I ask my medical colleagues what fraction of their patients are being treated for self-caused problems, they uniformly answer in the majority. We’re talking here about most cases of obesity, hypertension, type two diabetes, atherosclerosis, accident proneness, emphysema, cirrhosis, and so on, the results of sick-making lifestyles.

Cheaper—and even empowering—approaches are available. More than a decade ago, cardiologist Dr. Dean Ornish and his staff at the University of California San Francisco showed that clogged coronary arteries could be cleared with a simple but intense program combining diet, exercise, meditation and support, the cost of which was a few thousand dollars. Compare this to a four-way coronary bypass operation costing a quarter million dollars. Yet who’s going to push lifestyle change when entire industries, many thousands of jobs, depend on bypass operations? Maybe it’s easier to just get the operation, especially if someone else pays for it.

But sooner or later, we’ll need to rethink that strategy because as costly as healthcare is now, you ain’t seen nothing yet. In 1960, one dollar of every twelve spent for anything in the United States went toward healthcare. By 1980, healthcare’s share was one of every seven dollars. Today it’s close to one in five. At this rate, we’ll eventually buy nothing but healthcare: we’ll live in packing crates and shop in dumpsters, but at least some of us will have access to the most opulent healthcare technology in world history.

No matter what reform scheme emerges from today’s Congressional pipeline—single-payer, government-subsidized private insurance, or something else—we’re headed toward national bankruptcy unless we alter the conversation. Instead of just debating who’ll pay for what, we need to begin discussing personal responsibility, effective health education, and exactly what we as members of a democracy owe one another.

- Jeff


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  2. On the present health care crisis, that Jeff describes so well, there's enough blame to go around: patients who adopt a do for me, I am a victim attitude toward both their sickness and their doctors, and allow themselves to be manipulated by drug company adveritsiements; doctors who often offer treatment options in terms of what pays the most for them, which may also be the easiest thing to do, and in accord with their patient wishes, rather than what is best for the patient; the drug companies and hospitals who view the whole healing enterprise in terms of the bottom line, or as just another business enterprise. Of course we have to add blame on the government, now the creature of lobbyists, who manipulate the public even as they buy off legislators with contributions that is just legalized bribery. Put this all together and indeed, you get the title of Dr. Kane's blog:

    Health care coverage arose in the US through the insurance industy. It didn't come about through a collective realization by voters that universal health care is a right and a service to which citizens are entitled, just as they are entitled to public schools, police and fire services and a national postal system. In the other advanced industrialized countries, health care is perceived in this way, even in countries like Germany, where private insurance companies provide supplemental services but are limited in their fees by government regulation.

    The unceasing expansion by settlers from the East to the West coast of the nation, plus the fact that these were the children of earlier immigrants who crossed oceans to get to this country, feeds into almost ingrainted attitutudes of self-reliance and distrust of the "feds," and big govenment by many Americans. The early conservation movement led by Theodore Roosevelt, was regarded both by big industrialists and local residents in those areas as unjustified government incursion into areas that those groups wanted to leave in private hands. If we consider unregulated private ownership of guns by Americans as the embodiment of this "goverment, leave me alone attitude," then I wonder what the average Texan is feelings, Texas with the highest incidence of gun ownership, along with the largest number of state residents with no health insurance? Maybe they are into holistic medicine? Somehow, I think not, but folk medicine has its wisdom and I could only hope that the Texans are finding wisdom now, as they enter and leave their beds, guns in and out of hand.

    It's important that the larger macro issues get addressed, in dealing with the health care crisis. Part of this approach is to establish or restablish new economic and social forms of relation that involve more meaningful work, proper boundaries between work and leisure, and between places of work and one's residence. Michael Pollan, among other figures, has written important works on food production and distribution in America, and its contrast to more natural methods of this. Natural food is finding its way into supermarkets, but that's just a start.

    Free clinics are admirable but it's not fair that medical professionals, often themselves overworked, should bear the responsibility for the failing health care system in America. America has now dropped to 50th in life expectancy, I believe. One could only hope that as the health care crisis continues to grow, that reason and compassion and right action join hands, and banish manipulation and greed from our midst. May our voices from the blogosphere ring out, in the world, with those of others, to help make this land a better place for all.