From the effective date of the American Federal Union in 1789 until 1965, Americans--as individuals or families--were responsible for obtaining their own medical services; just as they were responsible for obtaining their own food, drink and shelter. Six generations of Americans were born and another six died, with no need or expectation for Government to feed, clothe or medicate them. It was inherent to the concept of a free society--the same concept that brings out the best in the economic potential of any people--that families and individuals provide for their own wants and needs. It was repugnant to a free people to have the fruits of their individual labor taxed to provide for others who were less successful, or who chose to be less provident.
This did not mean that Americans were blind to the misfortune of others. For the truly needy--those unable to help themselves--there was always Charity. But that was a matter of reaching into your own pocket, not your neighbors. And in the field of medical services, such a reaching into anyone's pocket was usually unnecessary because of the over two thousand year tradition of the profession of physicians, who had taken a sacred oath never to refuse treatment to anyone in need. The idea of throwing an expensive bureaucracy into the picture made no sense whatever.
But as Twentieth Century trends continued to inflate the costs of contemporary human services in relation to savings, and expensive new medical devices and techniques proliferated, the burden on middle class families for medical services to their sick or stricken elderly, reached destructive proportions. In this situation, the consummate power seeking demagogue Lyndon Baines Johnson saw, and seized, opportunity. And in 1965, he manipulated a compliant Congress into establishing a new entitlement, replacing reliance both on the American tradition, and on that far older tradition of the Hippocratic Oath, with Medicare and Medicaid. Henceforth, those over 65 could look to the Federal Government to subsidize their medical expenses. It was all part of "The Great Society"; a program that was going to abolish human need throughout America.
On a legal basis, the student may search the Constitution from top to bottom, and line by line, and not find one phrase which could suggest a Federal role in civilian health. One can scan the writings of the Founding Fathers, and not find one sentence that proposes such a role. None was ever imagined.
On a cost basis, the result has been a staggering geometric progression. During an inflationary epoch (1960-1980), when the GNP went up by an average of 8.7%, per year; the expenditures on health went up by an average of 11.7% annually. The Federal expenditures on health care rose by a staggering average of 17.5% per annum. The pattern has persisted ever since, although there may have been a slight slowing of the geometric explosion, with the modest Welfare Reform, during the brief period when Congress attempted to fulfill a Contract With America in the mid '90s. National health expenditures, which had soared from six percent of the Gross National Product in 1965 to 8.8% by 1980, roared on to 13.2% in 2000 (a figure actually slightly lower than that reached in the mid-90s). While the Federal percentage of the total only rose from 29% to 31.7% (after hitting a high of 33.1%, before "Welfare Reform" and the patient herding techniques of managed care kicked in), there can be little doubt whence came the overall inflationary pressure.
Nor is it likely that the Welfare Reforms, on which Washington is already waffling, or the other cost containment methods adopted in the 1990s, have really put a cap on the geometric cost escalation--even if we do not consider the inevitable consequences of some of the research being conducted to develop expensive new technology. With every "reform," more paperwork seems to be generated, more ancillary costs that really have nothing to do with patient care, but a great deal to do with providing work for auditors, accountants and statisticians. And what can one possibly conclude from the present fact that well over one eighth of everything being produced in America, today, is being eaten up in supposedly treating our illnesses? Are we the sickest generation in human history, or is something seriously out of balance? By contrast, the generation that fought World War II grew up in an America where only 4% of GNP went for health care. And in those days Doctors--especially Pediatricians--made house calls.
[While some of these vast sums would officially be labeled as preventive, that does not really change the picture. What they do not include is good diet, or dietary supplements that people take on their own initiative to prevent having to incur medical problems (or expenses), in the first place. Periodic check-ups to head off medical problems, on the other hand, clearly reflect a sense of urgency about those medical problems. If the premise, that they will either head-off or lessen the problems that would otherwise arise is valid, they actually tend to decrease the sums spent on health care. Anyway you look at it--and the most obvious approach would be the historic--America's health care bill, since the advent of Medicare, has reached terrifying proportions.]
There is no point to even consider the possibility of putting Medicare on a sound actuarial basis. The Medicare program has never paid for itself. Throw in the Medicaid program, which is basically a matter of robbing Peter to pay Paul to treat Phil, and you would have a disaster, even without an aging population. Throw in the aging population, and you must realize that we have not yet seen the worst of this.
We would certainly not make a blanket suggestion that all physicians, hospitals and medical supply houses, have been corrupted by the enormous influx of Federal money into their field since 1965. But the advent of Medicare has, nevertheless, proven something of a cultural watershed for those most involved in the healing arts. We have already alluded to the explosion in paperwork and clerical detail, connected with the provision of medical services, and the mechanisms for payment. But it is the vast shift in the attitudes of many practitioners and their staffs that is still more alarming.
Before the Medicare/Medicaid revolution, the staff in a typical physician's office were primarily involved with functions directly connected with administering medical care; assisting the physician in his immediate diagnostic and therapeutic services, and preparing reports for other physicians concerned with the same patient. Duties involving billing patients and processing insurance forms were comparatively minor aspects in the beehive of activity in the office of the typical practitioner. But the greatest change came in an evolving mood. While Medicare was directed at those over 65, by securing a source for payment for services often provided previously without a firm expectation that the recipient would ever be able to pay for them; it suddenly became vastly more profitable to treat the elderly. This comparative windfall tended to shift the general focus, by degrees, from the healing to the business side of medicine.
Before 1965, a patient visiting a physician's office would be questioned primarily about symptoms; the medical purpose for his or her visit. Today, such queries usually have to wait until all questions of how the visit will be paid for have been resolved. And the person with neither Medicare or Medicaid, or private insurance coverage, may be asked to pay on the spot. As for the charges for specific services? Those, even as the costs of the Federal programs, have soared far beyond any inflation rate; while the actual level of service has definitely tended to decline. (An excellent example, would be in the number of days allowed for recovery from ordinary hospital procedures. Thus in the Welfare State utopia, the typical hospital stay for a young mother, delivering a baby, has been reduced from five days to one.)
To be fair, a decline in the more personal touches in medicine was already underway before 1965. The once common "house call," had already become a great rarity. One has to be fairly advanced in age to even remember when a Pediatrician came to the home of an ailing child, rather than expect parents to bundle up one already sick, and take him to a place where he would very likely be exposed to additional forms of infection. But, certainly, the greater focus on the business side of medicine, as the greater need for paper-work, which followed increasing Federal involvement--as well as the subsidized emphasis on the needs of the elderly--further accelerated an already very unfortunate trend.
It might be suggested that there are different individual physicians, who would be treating the children, from those attending the Medicare and Medicaid recipients. But a changing economic focus--fueled by an annual injection of now over $400,000,000,000 of Federal money--must certainly be expected to influence the chosen fields of practice among medical students as an aggregate.
One of the other most obvious effects of this marshaling of enormous funds to underwrite the medical needs of the elderly, is that it provides an economic incentive for businesses that offer medicines or medical equipment, to develop exotic new products. At first blush, this will appear to be a major benefit. But in an era, when the Government has created a common expectation, among many aging Americans, of an entitlement to all the best that modern science can provide in the health field; is it more a problem solver or a problem maker? Are the bureaucrats formulating Federal Health Care policy even addressing the most important issues?
One may question, what is basically anecdotal evidence of a shift in medical attitudes with Federal involvement. But what cannot be questioned is that the population is growing older, or that there are vast sums being spent to develop more and more advanced medicines and mechanical devices to counter both specific diseases and the normal aging processes, as well as to extend life and offset the various disabilities of the aged. While a sharp fall in the birth rate, to abnormally low levels, has greatly aggravated the aging tendency of the population on average; the effect of this life extending research is such that a continued aging tendency may be expected, on average, even after the birth rate returns to more normal levels.
Thus an increasing percentage of the electorate can be expected to be those who most rely on the Government to subsidize their medical care, stirred with a growing expectation that new research will both lengthen and enhance the quality of their lives; while a huge industry has every incentive to continuously increase both the supply and exotic character of its products. There is no definable limit on the potential upward cost spiral; nor any on the deteriorating ratio between those who will reap benefits and those who must pay for those benefits. Before the medical supply industry advances its technology to the level of an old horror film, where heads without bodies are kept alive, plugged into exotic equipment, there are very serious moral questions--as well as obvious economic problems--which must be addressed. Yet virtually no one in Washington wants to be bothered; they are too busy "saving" Medicare.
In this bizarre picture, there are many possibilities for the abuse of trust and misapplication of funds; ways to profit that violate all standards of decency and compassion. Just consider all the opportunities for keeping people technically "alive," who have lost the mental capacity to refuse treatment, but have utterly ceased to function as sentient beings; who no longer have any capacity to enjoy life or to contribute to the well being of their loved ones. The involvement of the Federal Bureaucracy, in funding medical services with hundreds of billions of dollars, has created an enormous incentive, not only for the legitimate providers of services that focus on elderly Americans, but for the vultures who are always looking for potential new windfalls to exploit. In twisting the focus in health care from the healing to the economic, it is not just in office practices or fields of study, where one must expect to discover the greatest likelihood for adverse effects.
Perspectives on the underlying moral questions may depend upon the cultural heritage of the viewer. Admittedly, there are societies where parents consciously breed children to provide for their own old age. Yet this is surely not a traditional Western view. For many generations, the ideal has been to leave a better, more prosperous situation, than the one which each generation inherited, to the next. If there were sacrifices to be made, it was the older generation, generally, that made them; giving up considerable current enjoyment in the interests of the generations to follow. The confluence of technology, Medicare and an aging population, without some currently not present intervening factor, promises to reverse these priorities.
It is also clear that if the relative age of the population continues to increase, while more and more expensive technology becomes available to a defined clientele demanding the full benefit thereof, we will be on a path that at some point must challenge the natural balances that control all excess. We will be on a collision course with a more general but ultimate reality. Yet few Americans have personally focused on the inevitable dilemma. Medicare was never envisioned in the Constitution. Coupled, as it has been with Medicaid, it will never be truly on a pay as you go basis. But as serious as are these drawbacks, they do not fully address the most crucial philosophical issues.
Medicare represents the very worst aspect of the psychology of entitlement: The idea that one's problems, of whatever nature, should be solved by some always available central provider. Because of the critical nature of some health and aging problems, once the philosophy of an entitlement to health services takes hold, it will be defended with a fanaticism not seen in the defense of other forms of public expenditure. Yet from what moral basis can such an entitlement spring?
It is true that Medicare has been linked to the Social Security system, which although of questionable Constitutional roots, has obtained a certain justification--from the standpoint of the rights of those who have paid into the system during their working lives--which would establish a species of what we lawyers call an Estoppel--a preclusion from denying a benefit that one has been induced, at some expense, to expect and to rely upon--as against its abrupt termination. Indeed, the Social Security program was upheld by the Supreme Court of the United States, not as a benefit but as a tax. There is Constitutional authority to tax. There is none to run an old age pension system. There is the fiction of a Social Security Trust Fund; but in reality, the funds paid in may be used for the general purposes of the Government. Still, the fact that it has been self-sustaining for most of its history, puts it in a very different category from Medicare. Again, there is no way that Medicare, especially when coupled with its Welfare State brother, Medicaid, can ever be self-sustaining.
If it is proper that a Central Authority guarantee health care, why not the more immediate essentials for life, food and shelter; why not clothing? The underlying premise is a form of Communism, where the Collective (Government) assumes the ultimate role for taking care of everyone. This is the absolute antithesis of the concept of the American Free Society. It is part and parcel of a utilitarian life view that underpinned the great Socialized Societies, which we defeated in World War II and in the Cold War.
The other moral issue is the more complex. Indeed, we may bring down upon our heads a storm of calumny for even addressing it. But it is not a self-evident given that we even have a collective interest in the provision of life extending technology to the entire population. Certainly, there can be no moral basis to deny the right of any individual to seek life extending and life enhancing mechanisms, whether of the nutritional, pharmaceutical or engineering variety, by his own effort or at his own expense. But it is conceptually quite different to suggest that Society, as an entity, should seek to provide artificial means to extend life and the quality of life for all its members, with no other qualification.
In launching so extensive a program, no one ever really sought to define a ceiling on the resulting entitlements. Yet is it acceptable that this program drift along until a time--perhaps no more than a few years off--when the science fiction horror film images become not just possible, but practical every day events? If artificial "life support" systems advance to the extent where we can keep one's brain or body functioning, even when virtually all normal biological systems have shut down, is there to be a right to demand public funding for such support? Is it possible that we may slouch towards a time, when instead of burial, families may simply elect to keep the brains of their elderly operating by a system of tubes, pumps, electrodes and wires--whether in or outside of their bodies--at the expense of their fellow citizens?
In a land with limited space--and however bountiful our past, limited resources--is there not also a moral question as to interfering with the normal progression of the generations. It is not heartless to point out that death is part of Nature's balance. Is there a point, where medical advances can alter Nature's balance to a potentially disastrous extent? Will such finally be addressed by an eventual meltdown, where those with less resistance to new pathogens, become so numerous, and all of us so crowded, that a new contagion, bred within the bedridden elderly, carries off much of the population, young and old alike?
The point is not to alarm. It is to suggest that we really do need to debate subsidized "health care" issues from many perspectives. Certainly, there has to be a weighing of interests, if you are going to tax the productive citizen to fund any program. That has never taken place--rather the assumption has been that if one generation is taxed today, they will be paid back when it is their turn to reap the benefits. But even such an assumption implies a time to move on. Just how is that time to be determined in the face of new research, and vast special interests with an enormous incentive to prevent such discussion (or at least to so demagogue it, as to render it virtually meaningless)? Just who is to have the task of unplugging those on the Federal dole?
And what about those poor souls who have been medicated (for their "anxieties" or whatever) to a point where they no longer have the capacity to ask to be unplugged? Some of these have already been exploited by the small, but still present minority of ethical scoundrels, which sees health care only from the "bottom line." But are those few cases, where the malefactors have stumbled into public attention, more than the tip of an iceberg? Are there not still others, who unlike Norman Bates' unburied Mother, have already become the "living" victims of families in denial? Can anyone argue that the Federal Bureaucracy is equipped to sort this all out; or that Washington politicians are really willing or able to tackle such questions?
1. Federal involvement with civilian health care was never envisioned in our Constitutional system; and none of the vast array of safeguards in that system was functionally designed to deal with such involvement. No one is even addressing this fundamental deviation from the symmetry of the American socio-political infrastructure.
2. The creation of a vast funding stream, with a huge impersonal bureaucracy to administer it, has fundamentally changed the way both physicians and patients, as well as hospitals and medical supply houses, view the healing arts. This pouring of money into the health field, with an emphasis on the aged, has shifted medical resources from the care of younger to older patients, altered the laws of supply and demand to bid up and grossly inflate medical costs at every level, and introduced a degree of crass materialism, never previously seen in the medical field.
3. The confluence of this funding with an already aging pattern in the American population, poses a threat to the natural balances that control the progression of generations, as well as life in general. It fuels political demagoguery, seeking to exploit a sense of "entitlement," which in the long run is not financially sustainable; and creates the possibility for the cruelest possible misuse of those people, who are the least able to protect themselves, in potentially subtle ways, almost impossible to fully guard against.
4. While there are those who have tried to face the economic questions, almost no one is willing to discuss, much less debate, the underlying moral dilemmas.