The US health care debate has been impoverished by the assumption that the current medical system works well, and that a bit of tinkering around the edges will solve any problems that may exist. The ailments of our medical system are much more serious, however. And the opportunities for improving health are far more varied than would be thought from the state of the health care debate.
In the US, we pay more for our medical system per capita, and more as a percent of the overall economy, than any other developed country. The health care industry is among the largest industries in the US, and growing much faster than the overall economy. Health expenditures, which totalled $900 billion or 14.4 percent of GNP in 1993, are projected to reach as high as $1.7 trillion, or 18 percent of GNP, by 2000. In comparison, Canada, Germany, and Japan all spend less than 9 percent of GNP on health care.
The growing price we pay for health care has become a tremendous drain on the American economy. In 1965, health care cost US corporations 14 percent as much as they retained in profits; by 1990, corporations were spending more for health benefits than they retained as profits. The US is virtually the only developed nation that has suffered a decline in real wages during the 1980s in part because workers’ earnings were siphoned off to pay larger health insurance premiums.
Policy analysts sometimes blame consumers for over-using the health care system and driving up costs, but Americans stayed fewer days in the hospital on average than did Canadians, French, British, or German patients. Americans see the doctor on average only half as often as do Italians, Germans, or Japanese.
Despite spending more for the medical system as a nation, we’re getting less. Infant mortality and life-expectancy statistics show that we are significantly less healthy on average in the US than are the people of many other developed countries. Thirty-seven million people are uninsured, and millions more have difficulty getting the medical attention they need. One of the leading causes of bankruptcies in the US today is expensive illness or injuries.
These huge public and private expenditures deplete resources that could be used for strengthening communities and families, and thus may actually be depleting real health. (See Cooper & Taylor for more on the strengths and weaknesses of the current US health care system, and an analysis of "managed care.")
What can be done to develop systems in the US that really do promote health? Adding public subsidies to an already wasteful system, and requiring that individuals and employers participate in that system, will not solve the problem, despite the claims of some participants in the political debate. As public moneys get scarce, first the poor are denied care – then the lower middle class. As employers rebel at higher and higher premiums, the remainder of the middle class may find its choices limited and coverage growing thin. Finally, the real potential of the system will be available only to a shrinking pool of wealthy people.
There are a variety of models from other countries that have been very effective at providing high-quality universal care through relatively simple-to-use systems that keeps overhead costs down. Canada, Germany, and Japan are among the countries that have done so (see Cooper & Taylor for a thumbnail sketch of these and other systems).
These countries all have some variation on a single-payer system in which health care is funded through taxes rather than through insurance premiums. The government has a significant role in setting coverage guidelines and fees.
Costs are kept down by negotiating with health providers to determine how best to spend health care funds and by keeping to a minimum the paperwork shuffling. The US spends three times more than Canada on health care administration; unlike US insurance companies, these other countries have no need to spend millions determining who to exclude from coverage.
This single-payer approach has enormous potential for providing cost-effective, universal medical care, (seeUniversal Care in the issue for an interview with Representative Jim McDermott, chief House sponsor of single-payer legislation) but there is more that needs to be done to bring about real health.
HEALTH FOR THE WHOLE PERSON
Even if the waste and access issues were solved, there is still the question of how effective our medical care system is at actually improving health. The medical approach, which treats people as the sum of a series of body parts, often fails to incorporate the many inter-related facets of illness – emotional, spiritual, existential, and interpersonal. As a result, modern medicine has shown only limited capacity to reduce some of the most common diseases of the developed world, many of which are caused by unhealthy life-styles – smoking, drinking, over-eating, etc. – and unhealthy social and natural environments – exposure to toxins, excessive stress, violence.
We need to revive the historic mission of health care – the healing of the whole self. The world "heal" comes from the Anglo-Saxon word hal, meaning "whole." Healing that treats people as a sum of body parts, isn’t.
Real holistic healing doesn’t mean rejecting the sophistication of modern western medicine, which has shown itself to be enormously effective at treating many illnesses and injuries, particularly those that are acute and immediately life-threatening.
But if health care providers want to be effective in treating some of the ailments that have thus far eluded them, they will need to have the time, insights, and training to help evoke a patient’s capacity to be well.
This includes helping people make the changes that will allow them to live more healthy lives – to stop smoking, to eat appropriately and get adequate exercise and so on. It also may mean helping patients find ways to come to terms with and perhaps change unhealthy circumstances of their lives. For example, while not all stress is unhealthy, the stress that comes from inequality and disempowerment has been correlated with reduced life expectancy (see Empowering Health in this issue).
For providers to work within this broad human territory – from the spiritual crisis to the ear infection – requires that they be more fully present as whole human beings in the healing relationship and that they become comfortable with the subjective, emotional, and spiritual side of illness and health (see The Recovery of the Sacred in this issue).
The healing relationship that emerges when a health provider is able to do this can empower both patient and provider by building on the expertise of the doctor and the self-knowledge and will of the patient. It can facilitate a joint exploration of how a patient can become more well, how he or she wants to live near the end of life, and how he or she wants to die.
Making these choices as a partnership of patient and provider means learning to take responsibility, and this greater responsibility would lead to a more appropriate use of the tools the medical system has to offer. It would also lead to an acknowledgement of the limitations of the medical system, and to a greater capacity to tap healing resources from within and from the community at large.
As important as an accessible and healing medical system is, environmental and socio-economic factors, like the health of the community may be more important in determining health (see Healthy Communities, Healthy People in this issue).
A prerequisite for health may be having access to land for growing food – as the community health workers of the Sierra Madre region of Mexico discovered (see The Politics of Health in this issue) – or getting training for a new line of work. It can also mean reviving cultural or family traditions like the health workers of Hawaii’s Na Pu’uwai (see Reclaiming Tradition in this issue).
Members of a community are often best able to discern the source of their ills and best able to make the choices that will promote health. Ruth Caplan and Len Rodberg suggest that communities be empowered to integrate health care dollars with other forms of economic development and social service dollars, in order to develop the best mix of medical services, prevention programs, and social service projects that enhance the well-being of the community as a whole (seeRx: Federal Support for Community Health in this issue).
Empowering communities to do this requires – and can help to create the conditions for – an in-depth discussion of real values and solutions. An array of different approaches would come into being, some of which would thrive while others would do poorly. But given the human capacity to learn and experiment, this may be the best approach to finding out how we can create real health. Moreover, the empowerment that goes along with increasing a community’s capacity to solve its own problems can itself enhance health (see Empowering Health in this issue).
Because the medical care system in the US is in such crisis and because the political process is geared up to act – nationally and in a number of states – now is a particularly opportune time to develop a medical care system that will provide universal, humane, cost-effective access to the powerful know-how of modern medicine.
But as the contributors to this issue make clear, there are opportunities to enhance health at all system levels, from making the choice as individuals to live in ways that enhance our vitality, to empowering workers to run their own home care service company, to planning the eventual transformation of corporate controlled HMOs (see Consolidated Health Care, Inc. in this issue). There is no lack of opportunities to enhance health, to restore a sense of wholeness to ourselves and our culture.
Himmelstein, David U. and Woolhandler, Steffie, The National Health Program Book, Monroe, Maine: Common Courage Press. 1994.
Lafaille, Robert and Fulder, Stephen (eds) Towards A New Science of Health. London: Routledge, 1993.
Once again we learn order
watching the legs
of the centipede: such
elegance – to make
the precise move,
to know when, and be
convinced your motion is of the
great wave of being.
– Jim Bertolino