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Croat Med J. 2010 June; 51(3): 267–269.
PMCID: PMC2897080

The US Struggles with Health Care (and Other) Issues

There are more than a billion people in India and more than another billion people in China, but we can be certain that each of them is different one from another, some very different. The same can be said for you, your relatives, your neighbors, and each of the world’s citizens. (No one will be offended by what I am about to write because everyone will think I am talking about someone else). Let us be honest: you think the person down the street is just quiet, polite, and possibly shy (or perhaps a mass murderer with bodies in the basement); you think the people of the country next door are horrible because their relatives killed your relatives 1000 years ago and they have not improved since (as though genetics fully explains maliciousness and malevolence); you think that people who dress differently, eat differently, and work differently are uncivilized, diseased, uneducated and probably lazy; you think people who follow different religions are bound for Hell and are to be either avoided or “saved;” your standards are higher than the standards of others, your family, city, country, and continent are more important than other families, cities, countries, and continents. Christians are “better” than Jews or Muslims, Jews are “better” than Muslims or Christians. Muslims are “better” than Christians or Jews. We all knew what was right and what was wrong by the time we were 5 years old, but Einstein likely was correct when he said that “Common sense is the collection of prejudices acquired by age eighteen.”

Prejudice occurs without a person knowing or examining the facts. Preferences occur when a person makes up his or her mind based on facts (or perceived facts). We all have preferences about politicians, sports teams, foods, and our neighbors. It is when we have no facts but have opinions based on rumors that we get into trouble. This person’s color, or religion, or wealth (or lack of wealth) tells us he has a personality flaw. The world (barely) functions based on such nonsense, but the citizens of countries which think of themselves as civilized (that is, of all countries) look down on the rest of the world, satisfied that they are better than everyone else and insulted when shown otherwise by the facts. A person needs not bother to learn anything if s/he already knows everything. Being exposed to facts simply complicates things. If Mr Spock thought that humans were “barbarians” (members of a people considered by those of another nation or group to have a primitive civilization), he probably was correct. Nonetheless, we earthlings do make progress; George Gissing: “It is because nations tend to stupidity and baseness that mankind moves so slowly; it is because individuals have a capacity for better things that it moves at all.” Thank God for individuals. The great American writer Edward Abbey said that “All men are brothers, we like to say, half-wishing sometimes in secret it were not true. But perhaps it is true. And is the evolutionary line from protozoan to Spinoza any less certain? That also may be true. We are obliged, therefore, to spread the news, painful and bitter though it may be for some to hear, that all living things on earth are kindred.” I hope he was right.

What is civilization? Education? Good manners? Emphasis on the arts? Paved streets? Nice clothes? A car in every garage and a chicken in every pot? Seems to me we can survive without these, if survival is the only goal. When my wife and I moved from the city of Fort Collins (population about 140 000 and growing) to the mountains, near a village (population about 200 and not growing), we decided to simplify our lives by ridding ourselves of the accumulated junk of our past 40 years; it took many days to do that. Our heat comes from a wood-burning stove and I cut trees, split them, stack the wood, and haul it to the house in the winter. We miss many things that were available to us when we lived in Fort Collins but, to us, the freedom from all those niceties is worth the price. We have no paved roads here and no traffic lights. The only burglaries are by bears. The coyotes sing outside, not in our shower. The general store serves as a gossip center and maildrop.

We can easily do without many amenities but the principal amenity we cannot do without (other than clean water) is medical care and, if needed, medical assistance (helicopters can be called to pick up a patient here and take him to the hospital in Fort Collins). Many years ago, when my wife and I were here one day, just wandering around trying to find the most appropriate location to place a house, I reminded her of my age and asked her what would happen if I had a heart attack while we were living here. She said, “You will die in a beautiful place.” She was right, of course; possible death is a trade off for marvelous views, moose and elk in the yard, spring wildflowers, solitude, and quiet. The lack of immediate medical care is a price we pay for this freedom; our choice. Some people, many people, perhaps most people, have no choice.

In the US, where most people say they are Christians and others say they are Jews or Muslims or atheists or Buddhists, or whatever they claim, we have a health care system that is somewhat barbaric. If a person, any person, goes to a hospital for an emergency, they are cared for by the most competent staff available there. They are treated as anyone would be treated. For those who have medical insurance, the bills may (more on “may” below) be paid by the insurer. For those who do not have medical insurance, the bills are paid by the local government, the state government, and the federal government, and collection agencies attempt to recover the hospital’s expenses from the patient. Emergency care is very expensive, given that emergency care physicians are paid a great deal of money for their expertise and 24-hour availability and the fact that people who rely on such care defer medical attention until the situation cannot be ignored or is dire. Well then, why would anyone want to pay good money for insurance when they can obtain medical care without cost to them? A good question and a complicated question, one requiring a complex answer.

We Americans like our independence. We do not like to be told what to do. We object to administrators making rules to cover every eventuality in order to protect ourselves and society as a whole from ourselves. We do not like Europeans telling us we should not drink red wine with fish, police telling us at what speed to drive, theater attendants telling us the line should form to the left not the right, physicians telling us what to eat and what to avoid, foresters telling us how far from the house our trees must be removed for fire mitigation, and so on. It does not matter what is good for us; we do not want to be told to do anything or to not do anything.

We (particularly westerners) do not like to depend on others when we can do things for ourselves. People who think like we do would agree that this is good. When governments get involved in our lives we lose some of the independence we cherish; fast cars, open roads, no traffic lights, huge vistas, mountains, and wildlife. The fewer the rules the better. Governments produce nothing, they simply take money (taxes) from those who work and redistribute it as they say is appropriate, with approval from the voters, of course. The money is used to help pay to build and maintain roads and bridges, help fund schools (schools here are locally funded and managed, for the most part), make sure foods meet certain standards, protect our borders, etc (and there are great number of et ceteras). It’s another trade off of freedom for amenities. It is when the loss of freedom outweighs the usefulness of the amenities that a line is crossed and the dreaded socialism (next stop communism?) takes over. The fact is, we have had a mild sort of socialism in the US for hundreds of years. The good of the many rather than the good of the one, as Mr Spock would say. So what is the problem with a bit more socialism? And where is the line that cannot be crossed? Which one more governmental program will carry us over that line? According to a reader of a popular magazine here, from its inception American society has placed a fundamental value on the self-evident truths that “all men are created equal, that they are endowed by their Creator with certain unalienable Rights, (and) that among these are Life, Liberty and the pursuit of Happiness” (1). To secure these rights, “Governments are instituted among Men, deriving their just powers from the consent of the governed, (and) that whenever any Form of Government becomes destructive of these ends, it is the Right of the People to alter or to abolish it, and to institute new Government, laying its foundation on such principles and organizing its powers in such form, as to them shall seem most likely to effect their Safety and Happiness” (1). That is, when a government meddles with those pursuits through supposed superior wisdom the rights of individuals’ freedoms (always) are infringed upon. Therefore, in what we like to call a free society, the right to pursue one’s own ideas of happiness is a sine qua non. We recognize the need for laws and those laws must not infringe upon the rights of other individuals but, other than that, stay out of my face! It is a demanding task to determine how much freedom is acceptable and useful. That shouting “Fire” in a crowded theater as being unacceptable is a classic example.

Let us switch topics for a moment, to discuss ignorance, bigotry, prejudice, and avarice. America is a great country; we have here all the seven deadly sins and more in play at any one time. We think we should have the freedom to do whatever we want to do; otherwise we might as well live in un-free places. Ignorance knows no bounds.

There are sincere and honest people here who are adamantly against revising our health care “system.” They do not want the government to take what they see as that one last step over the line between freedom and dictatorship. One problem is – we do not have a “system.” Another problem is that certain individuals and groups see every action or lack of action as nothing more than a political opportunity. The extant ignorance and the lies that are being told at this time about our President, our political system and, germane to this subject, our health care system, take us down a road most of us do not want to travel, but we will go down that road anyway. In the end, it will take us to a crossroads, where revolution could be an option. Democracy is not easy. Part of the ignorance is the result of not knowing what the new laws actually indicate, depending rather on what people have heard they indicate; hearsay. I do not have enough space here to spell out each and every nonsensical claim about the new laws that govern the details of health care (I have read most of that 1300 page law and understand it as well as any microbiologist would) but I will try to briefly, and likely inadequately, outline them. Allow me to use a personal example.

I have adequate medical insurance. Our national and state legislators have adequate medical insurance. Anyone with enough money and wants to have adequate medical insurance can purchase it. For one, I have what we call Medicare, a federal plan for people more than 65 years old; Medicare pays a large proportion of my medical bills. As a former Federal Government employee I also am a member of a self-insured, not-for-profit association which provides health and dental plans to federal employees and federal retirees and their families; a fringe benefit of the job. Of course, people who have well-paying jobs usually are in better health than those who do not have such a job, so the costs to this association are minimized and the cost to me is reasonable. If Medicare pays a large proportion of my medical bills and the association pays most or all of the remainder, in essence I have no bills to pay for my general medical care, eyeglasses, influenza vaccinations, and other routine preventative and expected costs or even for setting and casting a broken leg or receiving a heart transplant. It is a wonderful system and I can choose my own physician. My guess is that if the age for Medicare eligibility were to be reduced to 55 years of age, unemployment in the US would be negligible because all the people who are more than 55 years of age and who do not enjoy their jobs and who work only to retain them so that they can retain their medical insurance would retire, making all those jobs available to younger people.

We also have Medicaid, which is a program for eligible individuals and families with low incomes and limited resources. It is funded by federal and state governments and administered by the states. It serves as a “safety net” for those who might otherwise not be able to afford medical insurance. In sum, if you are less than 65 years old, you are completely on your own unless (a) you are poor or (b) you are able to purchase insurance on your own or have insurance through your employer. If you are an elected official with insurance coverage through your employer (a government entity) and vote against such insurance for everyone else, you are both anti-social and a remarkable hypocrite.

Insurance companies here can charge anything they want to charge and not cover (pay for) illnesses they do not want to cover, the latter including “pre-existing conditions.” What is a pre-existing condition? Type 2 diabetes, heart disease, cancer, high blood pressure, and other chronic health problems are among the possible exclusions, so that the insurance company may not be willing and liable to provide insurance, opting instead to insure healthy people only. The result is that the people who need insurance might not obtain it and those who do not need insurance pay the insurance company to be protected from the lack of risk. Nice business. There are laws that might allow a person to carry insurance coverage from one job to another (“portability”) but those laws do not cover everyone. If, by now, you have the impression that we Americans are just plain crazy, you likely are correct and that, too, is a pre-existing condition. Think all this is anti-social? In order to receive Medicare dollars, hospitals are required by law to be racially integrated, that is to accept patients no matter their race. In years past, many hospitals, particularly those in the South, refused to meet this qualification. That does not occur any more, of course (well, perhaps not “of course,” but it doesn’t happen any more). This all becomes even more complicated but my own lack of enthusiasm for providing such grisly details keeps me from enumerating them, some of which seem to me to be unbelievable.

Cost is, of course, a key issue in any national health plan. No one ever wants to spend more money than they have to and very few people, anywhere, trust their government to be a benign entity, one with better judgment than it has shown in the past. This is not to speak of the feelings of lack of freedom generated by a government that demands one pay a fee for a “service” and to private companies at that! It may even be unconstitutional, which we might find out soon enough. Healthy, albeit short-sighted people may feel they do not need health insurance because they are not sick (i-n-s-u-r-a-n-c-e). Wealthy people may not want government insurance because they already have adequate insurance. Racists may not want to participate in such a program because people they are biased against may benefit. Seemingly, it does not occur to half our population that the healthier the general population, the lower the risk of acquiring an infectious disease and of having to pay for hospitalizations for the needy, and the greater the manufacturing productivity. I compare this sort of thinking to the motorcyclist who does not wear a helmet because he does not want to wear a helmet but who is taken to a hospital emergency department on a Saturday night because he has had an accident and his head is in 3-4 pieces. Who pays? In 1965 health care costs consumed 6% of US economic output, but by 2009 it rose to 18%. Continuing this trend would lead to unsustainability of our economy and prosperity. At the time of this writing our national debt is nearly US $13 000 000,000 000 (2), according to the World Bank this is 188 times the gross annual domestic product of Croatia (3).

Christianity, Judaism, and Islam all support taking care of one’s own fellow human, at least in theory. That does not always translate to reality, however. Standing armies and navies, palaces, roads to nowhere, bribes, and schools that teach nothing useful are expensive. In many countries there is no money left over to fund useful social programs, such as adequate vaccination programs, for example.

The larger question is “Why not?” Why not take care of our citizens? If they were healthier and more secure, they would be happier and not throwing bombs at others and at each other, and they would be more productive and more able to purchase items from the market place: better food, clothes, education, cell phones, automobiles, rapid transit systems, and other items they need, or think they need, or want. Increasing the wealth of poor people can only be good for an economy and it all begins with good health. Imagine what scientists might do if grant money were more readily available.

If the current US health care system argument is baffling to you, join the crowd. The argument is a mélange of governmental takeover anxiety, tax-scare hysteria, racism, and politics. It is, however, just another revolution here; we’ll get over it.

In conclusion (4), it must be remembered that in the US we cherish freedom above all. But we need to decide “Freedom from what?”

References

1. The Declaration of Independence. Available from: http://www.ushistory.org/declaration/document/index.htm Accessed: April 30, 2010.
2. US debt clock. Available from: http://www.usdebtclock.org/ Accessed: April 30, 2010.
4. In the event that it is not obvious that most of the above are my own personal views, let me state here that all of the above are my own personal views, and not those of this journal, the Editor of this journal, or a very, very few of my friends.

Articles from Croatian Medical Journal are provided here courtesy of Medicinska Naklada