Blog March 19 2011 Is there a social contract for our health?

We believe that a government is a social contract between those who are governed and those who govern us with our consent. It is the basis of our own American government which is part democracy and part republic with lots of checks and balances and a Constitution to prevent tyranny. It is an imperfect system but it works reasonably well and we voters have the power to throw out administrations that fail us and we can shift to a new direction. We reject anarchy or extreme libertarianism (a sort of “devil get the hindmost” social Darwinian system) in which the government plays such a minimal role that each person is at the mercy of the good will of the rest of humanity. Herbert Spencer preached that extreme libertarianism some 150 years ago in his book Social Statics and he believed that everything should be privatized, except for the military. We should pay for our police protection, fire protection, health, testing of safety, and education. He opposed public schools because they preached loyalty to the state and he felt the individual should always be an enemy of the state, criticizing it for its encroachments on individual freedom. He also opposed colonialism, the institution of a Royal family, and discrimination against women. He felt all education should be autodidactic with the library (private , of course) as the source of knowledge instead of the classroom.
Unfortunately people are complex and do not work as ideal components of utopian dreams. Those utopian schemes often end up in totalitarian thinking, with conformity rather than cantankerous diversity as the favored state of society. If we are to live in a “real world” we have to recognize the following. Humans are mortal. They are genetically diverse. They are raised in diverse households with diverse idiosyncratic parenting. They are grossly varied in opportunities and the circumstances of their birth. Some will have birth defects (about 3 to 5 percent). Some will have infectious diseases and they vary in their immune systems. Some will have physical impairments of their senses and require eyeglasses or hearing aids. Some will have organ failures. Some will have autoimmune diseases. Some will get cancers. It may not be possible to tell who will be at risk for such disorders. To address our health problems we either have to be lucky and our families have the wealth to pay for needed surgery or medication or we have to have an affordable health insurance that provides most of our basic health needs. If we are born poor then the costs of such health care are beyond what our incomes can provide. If we have a government universal health insurance then the costs are spread across all citizens just as we pay for our military through taxation.
I have yet to hear a proposal from critics of Medicare and Medicaid of a private health insurance program that can exist for the poor. I can only assume that premature death and illness of the less fortunate are tolerable for those who are fortunate enough to buy their own very effective private health insurance plans. That is not just selfish it is morally disturbing. What it tells me is that it all right to ignore the needs of others as long as you yourself are OK. Is this what our religions have taught us? Is this the message of the “good Samaritan?” Is this compatible with the “ Golden rule?”

What surprises me is how we respond with haste to new epidemics but ignore chronic and “familiar” diseases that saturate a good portion of humanity. Here is the reality for the coming decades. We will have more old people who will have lots of chronic illnesses. We have shifted away from employer provided health insurance to individual provided health insurance but for most Americans they cannot afford the costs of private insurance. Private insurance, like fee for service medicine, is wildly expensive and has far outpaced inflation. Most individuals have no factual basis for making informed decisions on what type of health care to buy or what to do if they are not covered. We need to rethink how to provide care with numerous “triage type” health centers instead of hospital emergency rooms so less expensive physician assistants and RNs can assess minor health emergencies (e.g., colds, upset stomachs, sprains, minor cuts) and distinguish those from patients with profound or more complex medical needs. We also have to think about what type of health care should be available to the very old, especially those requiring assisted living. For those who can trade in the equity of their homes for such care this is usually not a problem. For the working class who live in apartments or homes which have more modest equity, this is a very serious problem. For legislators I have a prediction for them to consider. In a few years the very old will be such a significant portion of the population that they will have the votes to favor their own interests.