Healthcare Beyond Elections

For the near future, watch out for that very first column on the far left side of the very first page of the New York Times. Whatever appears there from now through November 2 is likely to be a bit of political advertising disguised as protected journalistic speech. And one guess as to whose candidacy it will likely be promoting.

They did it with their lament for Bush’s education program on August 18 (about which I’ve blogged). Now, there’s “Costs of Benefits Cited as Factor in Slump in Jobs” (Thursday, August 19, 2004) -- not really a breaking news story so much as a featured thesis piece, and one most conveniently timed. For it just so happens that, through a creative synoptic reading of various government data and an interestingly selected compilation of interview quotes, the writer mirrors precisely the conclusions of a new economic report commissioned by and for the Kerry presidential campaign, and to be debuted by and spoken about by Mr. Kerry that very same day.

Does the Times really think so ill-concealed a program of shilling for Kerry, writing page-one editorials in the format of news stories, will go unnoticed? And if so – if their readership is actually so gullible – why does the Times bother to continue in its effort to seem written for the intellectually discerning?

Now, none of this is to say that healthcare is a trivial issue or that it doesn't merit discussion during a presidential election season. And, yes, each of the candidates is addressing healthcare, offering in each case proposals consonant with the overall tenets of his party.

There are, thus, important differences in emphasis between their approaches, but neither really examines the issue beyond the parameters dictated by vote-cadging.

Notwithstanding Medicare and Medicaid (passed in 1965 and expected to be relatively modest expansions of New-Deal-style social safety-net programs), free-market dynamics have historically dominated the development and delivery of healthcare in America. The vigor of this free market has, moreover, accounted, more than any other factor, for the breathtaking range, velocity and sophistication of American medical and pharmaceutical advances in modern times.

President Bush’s second-term proposals aim at strengthening the efficiency of free-market forces in moderating healthcare costs and expanding its availability – not least by arresting the metastasis of malpractice suits. The parasitic industry of trolling for liabilities by tort lawyers who assert ever more extravagant liability claims while doctors, hospitals and the health industry pass along the mounting burden of condign legal defenses has obscenely engorged healthcare costs.

Additionally, Bush advocates ways of helping businesses employ economy-of-scale mechanisms in negotiating insurance costs, and measures intended to invigorate the sanitizing powers of competition.

John Kerry, the self-avowed "internationalist," is contemplating something very different.

Internationally, while the American health industry has been developing increasingly efficient and high-tech treatments, medications and technologies, much of the rest of the world has opted into a complex of bureaucratic conspiracies to exploit these advances unfairly. Barriers and controls imposed by foreign governments compromise the fair compensation of (primarily American) medical innovations – political sops to domestic constituencies – represent a hugely distorting factor in raising the cost of modern healthcare, one obviously beyond the power of the United States to rectify directly.

Healthcare in these countries, however, has time and again proven ultimately to be a losing enterprise. Shady practices for circumventing reimbursement protocols, rationing of care, substandard medical personnel and recourse to black markets are among the blights which, to greater or lesser degree, increasingly plague all major examples of socialized, government-subsidized healthcare systems abroad. (Those shady billing practices are instigated all too often here, too, mostly by the inefficiencies and deformations wrought by those American experiments in government controls, the afore-mentioned Medicare and Medicaid.)

But Kerry would actually import and replicate many of these kinds of control. In a manner analogous to the one scripted by Hillary Clinton a decade ago, though with some novel twists of its own, Kerry's plan would effectively make of the American healthcare system a subsidiary of the Canadian and other socialized systems elsewhere in the world. Essentially, Kerry would be domesticating unfair foreign trade practices. Call it, perhaps, policy in-sourcing – just one more ironic inconsistency in the muddle that is the overall Kerry economic philosophy: part gung-ho free-trade-ism, part benign neo-socialism, part populist protectionism.

While the impulse to have a national healthcare agenda in an election year springs mainly from political expediency, the Bush policies are, when all is said, preferable. At the least, in the spirit of the Hippocratic oath, they do no harm.

Unfortunately, however, neither the Bush nor Kerry approach to healthcare – each of which is really pitched to transient domestic economic worries – addresses larger and more global questions.

I want at least to enumerate some of those questions now.

First off, how vigilant are we of the definition of health? What are the politics of its definition? If healthcare is to be a matter for government policy debate, ought we not be fastidious as to who gets to define its object?

Next, if healthcare is indeed some kind of right or entitlement, what are its limits? What does a basic entitlement to healthcare consist in? Is it limitless? If limitless care is (as seems evident) impossible, who sets reasonable limits on it? Are we, for instance, entitled by right to technologies and medications that existed at a certain epoch in time? That cost only so much and no more? That vary from person to person according to age or genetics? That don’t exist yet?

What are the true dialectics of thinking of healthcare as a commodity versus a right?

Does the subsidizing of care insulate a population from a mature conception of its true cost and value? And, if so, what are the consequences of thus infantilizing a public's true understanding?

Naturally, the humane and fraternal instincts always so potent and evident in American history prompt us to recoil from the notion of anyone suffering merely for lack of means. Both common sense and long historical experience, however, have taught us that attempting to reify virtuous impulses via the blunt action of government is counter-productive. If anything, the displacement of humane action to the operations of public bureaucracy robs such action of both efficiency and virtue.

Virtue has a more difficult and more active role to take than mere wishing upon the distant star of federal programming.

First, beyond the thorny economics of medicalized and technological healthcare, we need to revisit the human level of health maintenance, re-examine the seriousness and efficacy with which we inform and promote and value individual action, how we provide incentives for personal responsibility and healthy life choices (exercise, eating, alcohol, tobacco, drugs, sexual prophylaxis).

Next, on a higher level of social organization, just as visionary private sector activism has had success in making social consciousness and corporate responsibility pay dividends for various industries, it is high time for private-sector activism to promote altruism, humane pricing and mutual support as economically viable and rewarding values in healthcare, the most humane of all commercial arenas.

Finally, the infantilized fallacies of socialized care throughout the world should be reversed. But how? In the short term, only concerted diplomatic pressure and aggressive trade negotiation are viable. In the long term, however, success by example holds a higher promise of persuasion. Maintaining a vigorous free market, fostering a continually increased GDP, and evolving a domestic polity with ever more universalized access to healthcare via expanded affluence should be our goals.

Perhaps in the secularized, post-industrial and solipsistic 21st century, health itself has become too personal, too jealous, too solitary a concern. If we continue egoistically and parochially to focus hope and anxiety only on the cost of care to ourselves and our loved ones, we duplicate psychologically the very limits that form the economic and political barriers to meaningful universalization of care.

The first commercial health insurance policies were issued in 1914. In 90 years, such instruments have been elegantly and variously iterated many times but, in essence, remain the chits in a kind of grim lottery, artifacts of a more primitive and now ethically superseded form of capitalism.

The tools can be improved. But not necessarily by government. In fact, government is the wrong workshop. Government mandates are neither the sole nor the best anvil on which to forge together private and collective welfare, consumer and provider needs.

Were government to stand back and the genius of enlightened community to step in instead, insurance in its next iteration might be a product of heightened social morality as much as of neutral actuarial science.

With new tools plied by the richly layered and redundant energies of voluntary association; with webs of enlightened community aggregating both mobilized consumers and humanely responsive providers, resources answerable to the ever-expanding circle of invention could be generated, and an eventual dispensation of universal succor and support naturally achieved.