The coming serfdom
Monday, December 15 2008
(This one’s been rattling around in my drafts – I figure I might as well publish it.)
This summer the Washington Post ran an article by Kendra Marr that described health care as “the beating heart of America’s economy”. Marr cites projections that health care will account for fully half of U.S. Gross Domestic Product by 2082; she does admit some downside to this trend, specifically the ever-increasing costs of health insurance, but her article is generally positive.
Around the same time, Harper’s Magazine published an excerpt from testimony (paywall) by Jonathan Rowe, calling it “Our Phony Economy”. You can read the full original testimony for free. Rowe was testifying before a Senate subcommittee hearing on “Rethinking the Gross Domestic Product”; his argument was that GDP is a terrible way to measure our economy.
The purpose of an economy is to meet human needs in such a way that life
becomes in some respect richer and better in the process. It is not
simply to produce a lot of stuff. Stuff is a means, not an end. Yet
current modes of economic measurement focus almost entirely on means.
As it happens, nowhere is the disjoint between means and ends more problematic than in health care. The latent premise of Marr’s article – that health care is just another economic sector – depends on the assumption that people buy health care like any other economic good. That’s obviously false: some 75% of current health care spending goes towards people with chronic illness, and this share isn’t likely to diminish.
So what we’re talking about, mostly, is spending by sick people. Yet the idea that sick people are just like any other consumer is deeply flawed, even perverse. For starters, most of these people are compelled by their illness to purchase health care. In my case, my only choice is to take my medicine or get unstoppable diarrhea. When I buy that medicine, it may look like a free choice to the number-crunchers – but I might as well have a gun to my gut. I’m all for free market, but let’s be clear: this ain’t it.
In that same hearing, Karen Davis, President of the Commonwealth Fund, offered her own ideas about health care and GDP:
Simply put, spending on health care does not reflect the value of health care delivered.
What she means is that it’s all too easy to pay a lot, and not get a lot. A lot of the debate on health care reform is focused on “means” – basically, changing how we pay for health care. But just as important – perhaps even more so – is to make sure those means are effective in getting patients the care they need. And by care, I mean whatever it is that sick people need to live fulfilling, productive lives. That should be the “end” of a health care system, by whatever means we decide to fund it.
Granted the means are non-trivial. 50% of GDP is a lot of money. But 75% of half of GDP is about 38% of GDP – that’s still a lot of money being spent by and on sick people. But where is that money going to come from? At present, the portion that doesn’t come from government spending comes from a hideously unjust insurance system that leaves sick people even more vulnerable, marginalized, and powerless.
Health care reform has to address this: it has to pay attention to ends as well as means. If we don’t, there’s a real chance we could create a perfectly solvent system that nonetheless continues to disempower and marginalize the very people on whom it depends. In effect, sick people could become the serfs of our economy – more inputs than actors, with the wealth of this nation built on our suffering.
The problem here is that some ends are not what we want. We don’t want to face mortality, so we put the feeding tube in the Alzheimer’s patient (that is illegal and considered malpractice in nearly every other industrialized democracy). The problem we have is that we do not want to define what treatable and productive are. We ignore the word terminal–the chemo and radical surgery for the stage V cancer patient who will die. The belief that there just might be a miracle, and if we do not pursue these measures, the miracle won’t happen.
And so what happens is that a few cases ended up causing most of our costs. And treatable illnesses get left behind because employers or private individuals can’t afford the insurance premiums. This causes relapses of chronic illnesses, and sometimes severe complications, which add to the cost of the medical system and compound the problem.
But the baby boom generation has punted. They’ve punted on everything. They punted on abortion, they punted on war, they punted on the environment, they punted on the national debt and they punted on health care. Obama is really a Gen Xer. Maybe they’ll move forward instead of constantly punting.
@ The Bag –
I agree – I think a lot of our ideas about appropriate treatment and prevention are mistaken. What I’m advocating in the post is exactly the kind of change you’re looking for; if we reform the means without rethinking the ends, our system will still be screwed up.
Here’s the problem though: you define the end as being “whatever sick people need to live productive and fulfilling lives.” Yet there are points when that is impossible. Those that are still cogent realize it and die peacefully. Those that are not, get decisions made for them by grieving relatives who do not want to accept reality.
Starving to death is regarded as awful by society. It conjures up images of famines from Africa. And the instinctual reaction among many is that “we shouldn’t be like that, he/she shouldn’t die that way.” Leaving aside the fact that we’re all human, and in death there is some equality–the same things cause death here that cause death in poorer foreign countries.
And so what do we get? Feeding tubes in the terminally ill and nursing homes that are already busting at the seams (if we don’t do anything about this, there will be old people dying in the streets in 15 years…it is a looming national disaster that will make Katrina look minor).
So if we accept that things are not always the way we’d like them to be, and accept the word terminal, where do we draw the line? Do we draw it at pureed food? What about thickened liquids? What about pain medication for the terminally ill cancer patient? What about a feeding tube for a Crohn’s patient who can’t eat due to their disease? What about surgery on anyone over 85? What about lung transplants for Cystic Fibrosis Patients?What about radical chemotherapy for stage 4 cancer patients? What about long-term dialysis for kidney disease patients?
What is “fulfilling and productive?” It’s subjective. And the problem is that, in the absence of a federal health care system, patient advocacy groups have popped up. 95% of them are devoted to “cures.” If we can’t change the system so people can get treatment, then maybe we could cure the disease so people don’t need to use the system. And so we have ended up with the worst of all worlds, an inaccessible system that spends too much on research and too little on people who are actually ill.
Yet to change that. To have a frank discussion about end of life issues involves pissing off the advocacy organizations. And no sitting Senator who is running for re-election wants to be on the wrong side of the Breast Cancer movement. They know this, which is why they’re not as supportive as they could be of universal health care. The reason: if we adopt universal care, cost reduction plans will inevitably lead to discussion of mortality. And that will inevitably lead to the conclusion in the public consciousness that somethings–Crohn’s Disease, Breast Cancer, etc–are occasionally fatal, and that there isn’t much we can do about it.