Healthcare, You Can’t Unstir It

There are many people who like to keep their peas, carrots and tuna casserole carefully separate on their plate; I have always preferred stirring them all together – along with the ambrosia salad.

This seems often to be true of our approach to social, economic and political issues (see, I have just done it). But the lines of effect ultimately jumble together like spaghetti. First, to scoop things into neat little piles.

There are two basically different starting positions: 1) all people have a right to healthcare and 2) people should only have the healthcare (or anything else) that they can afford [1]. Add to these the absolute truism: no good or service can be had without compensation, immediate or eventual. Very quickly the mixing starts.

If we take the view that people should only have the healthcare that they can afford, the argument is greatly simplified. There is no need for much further consideration; a person acquires means by their effort in the economic system and can use that means to compensate those who have acquired medical and related expertise as their way of attain means. Those who have not acquired sufficient means do not get the services and goods of healthcare. We need no agencies, authorities, commissions, etc. to oversee such a design. Providers charge what the market will bear. The number and quality of providers is decided by the people’s ability to pay for service.

If in this design there are other opportunities to create new goods and services in support, these too should be allowed to fully express their creative potential, expanding and contracting in response to the ability to pay. There is no issue in this model with the need for compensation since it is immediate and required. What happens to those who do not have the means to acquire the healthcare goods and services is not a concern of the system, but only a concern for those who are without means. This is how it is for all other goods and services. If one does not have the means to get an Armani suit, then one doesn’t get one, rather perhaps making do with second-hand from Goodwill.

In this model the costs are known to be a personal responsibility; each person must prepare for eventualities by acquiring the means to meet the most likely needs. Those who, by either poor planning or misfortune, are short of the required amounts simply have to do without. The consequences are poor health, reduced vigor and death for such an underclass. Another way to describe the consequences is that people in poor health cannot contribute to the stability of the social order; in fact, the reduced vigor of the unhealthy produce a whole dynamic of effects, among them low productivity, illiteracy, dependency (on productive people), crime and social instability.

Remembering that all goods and services must be compensated, a large underclass creates by their very existence demands that must be compensated, both of their own and from those whose comfort and stability they challenge. And so whole armies of people would be required to supply goods and services to and in response to the unhealthy; they and those that they affect will demand it.

The major origin and consequence of this model is the “every man for himself” mind set; positive feedback quickly sets in and each increment of self-righteous distancing from ‘the other’ feeds the next increment. The adherents of this view will (happily?) pay, in taxes and their own security and other costs, twice as much for police forces, prisons, armies, courts, devices, etc. as would be saved by having a generally healthy population that feels respected and engaged in all the behaviors that support a functioning economy and a stable society; and all for the ‘peas in their own pile’ reason that they can’t stand the idea of “someone getting something for nothing,” especially if they think they are paying for it [2].

If all people have a right to healthcare, the issues swirl in the opposite direction. How are the providers to be compensated becomes the first concern. We know who gets care, just not how it is to be paid for.

This is such a different mind set that often people in the first group’s heads explode when they try to get close to these ideas (requiring medical attention). There are no ‘others’ in this view; we are all our brothers’ and sisters’ keepers; “What is done to the least of these is done to me;” that kind of thing. In fact, all living things are to be respected; harming or allowing harm to any other living thing (plant, animal or other) should only be done in necessity and never gratuitously. Every “brother and sister” is to be supported in the pursuit of a full life and no human is to be the direct or indirect slave of any other person or system. From here it is obvious that, since we are all in this ‘being alive on the earth business’ together, healthcare must be available to everyone.

The first principle of compensation for this model is that it not to be “privately” operated; for this point of view, ‘private’ is code for greed and selfishness (for the other view, ‘greed and selfishness’ is code for success). Therefore, healthcare must be a social good and managed in the commons, i.e., the compensation is made from a pool collected from the economic activities of each person and managed by representatives of the whole for the whole. The thinking is that the managers would be judged on their ability to deliver the most healthcare for the least amount; this would be the mandate from the whole community. Preventable illness and incapacity would be all but eliminated, the sick and injured would be respected in their need, a far smaller fraction of the population would be of reduced capacity in education, work and acts of social responsibility, and all for the ‘carrots in a pile’ cost of a national, publicly owned and funded single-payer health system.

But there are problems. How much is a provider to be compensated? Is it to be based on what the average (modal, median or arithmetic?) income recipient can pay? Should providers get rich delivering these services? How are inherent limits of time and opportunity to be apportioned? How are legitimate medical concerns to be distinguished from the frivolous? How are the amounts of available service to be balanced with amounts of need? Can the selfish and greedy use the system for their needs or can they be excluded?

None of these and many other concerns exist when a capitalist model is used: pricing mechanisms do several of these things more or less automatically. There is no social limit on wealth. Needed services and numbers of providers follow rates of demand as providers try to maximize their income. But this all functions by the pressures from the margins, euphemistic language for the lack of service, and in the case of healthcare, untreated sickness and injury. There are some of us who see this as acceptable and some of us who do not.

What about the costs of medical goods and services that by their very nature – huge numbers of man-hours, rare materials, energy intensive devices and procedures, significant preparation times, significant risk of unsuccessful outcomes – require very large compensations to get people to engage in them? What if people will not deliver the goods and services for the amounts made available?

Clearly goods and services must be compensated, and just as clearly a society that has no sense of community is a hollow shell, a failure and doomed to implosion. What can and must be the common values that underlie a huge polymorphous society like the USA and especially what are the common values that would support a workable healthcare system.

Those who focus on compensation solutions as wealth producing cannot be especially interested in the goal of universal care delivery (unless they can write the rules so that it is not really care delivery so much as it is compensation recovery). Those who focus on universal care delivery cannot be especially focused on goals of economic gain.

So which is it? Are people bunch of sheep to be fleeced by the few wolves and left to their own devices after the fleecing or are human beings valuable in and of themselves and to be made whole in specieshood as well as we can do? Is the goal of economic royalty more important than the health and life of fellow human beings? Do we honestly and in our best most giving spirit say that medical care is just too costly for the masses, that our economic system requires the striving after infinite wealth for it to function and that the attempt to stay healthy is a profit center that is just too good not to exploit?

The healthcare issue brings the divergence of these values into great clarity. But, ultimately it is in the messy mix of self-interest, concern for others, societal quality and equity, pain and suffering, life and death that each of us must make our stand. The vast majority of the Great Many – basically sane people whose self-interest looks first to what is good for family and friends rather than as a wealth engine – would help a person in distress and accept help in return. If we can’t make this a value for the society with a healthcare system that is universally delivered and fairly but not extravagantly compensated, then there is nothing that can be done for the other destructive forces challenging us.

We are in the thrall of the insanely wealthy; all our decision-making processes distorted by the social assumptions required to justify these excess accumulations. If I had to re-sort the wonderful mess on my plate into separate piles, the first one would be that excess wealth is a crime against life itself. Real healthcare must begin there.

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[1]What are the implications of people having only what they can afford? First, there are a number of unspoken concerns: afford in what currency of exchange? Is each and every person to be considered a completely independent unit? Are groups units so that a group might ‘afford’ a thing in one currency and distribute it to group members using a different currency or measure? The simplicity of the statement hides many issues.

What are the implications for social relations and the nature of social systems? Is it rational to expect all people to accept the same arbitrary system of accumulation and exchange? What are the consequences of people accepting systems of exchange that are destructive of both social and environmental order.

If the statement is changed to “all services must be compensated,” then the essential meaning is preserved, but focus is shifted from the accumulation of excess from which to compensate a service to the relationship between the receipt of the service and the returning to the service source of some meaningful value. What makes this significant is that accumulation without an intended object of exchange must be in some generalized form and emotionally is an action supported by some generalized need. Defining the compensation with an object turns the action into seeking the object rather than seeking the arbitrary ‘stuff’ of compensation.

And lastly there are intentionally hidden meanings – intentional in the actions of propagandists. ‘Affording’ becomes a code for social worthiness. There are trains of emotional connections to the idea of being able to afford a thing, with negative connotations to not being able to afford, especially, an important service. This also, partially, removes the social responsibility of others: the person doesn’t have the service, not because it is not available, but because they can’t afford it. Of course, if the cost is more that a person can accumulate, then the service is not available to them. If we are willing to go this far, then we have to look at the conditions that determine the ability to pay; and if the ability to pay is deduced by the actions of the larger society so that the ‘failure to afford’ is a fixed property of the society’s prescription for certain of its members, then the ‘can’t afford’ argument is a sham. That a few people escape this trap is no argument against both its existence and its domination of lives; a few people escape from prison too.

[2] I had a client once who disclosed to me that he literally could not sleep if he felt that someone had gotten the better of him in any economic matter, but slept like a baby when he had, by guile or lie, cheated someone else. It has become clearer to me over the years that this form of madness infects a significant number of people.