Recently I have been wondering how we have arrived at the point where our desire for unfettered, and unlimited access to health care is rapidly outstripping our ability to pay for the care we desire. Our understanding of our supposed healthcare system is so specious that the myths of our expectations far outweigh the reality of the system we think we have to deliver it. In fact, we have built an entire culture of props and supports around patently false beliefs that underscore everything we expect and require from healthcare. To a great extent we are obsessed in ever increasing ways with youth, good health, quality of life, and other personal life experience based desires. In addition to healthcare, we have huge consumer industries, neutraceuticals, vitamins, fitness and nutrition, focused on the promise of fulfilling unrealistic expectations of what we think we can expect if we just spend more. And despite all of our own personal experience we continue to believe some miracle cure is out there if we just spend enough.
Less than a century ago this was not the case. People did not have such expectations from healthcare. Today we believe with proper care we can live long lives. In fact, if asked many believe that technically they should “soon” be able to live almost forever. I mean why not? After all everyone deserves to live as long as they want don’t they? Our grandparents and great grandparents didn’t think so it turns out. As you move back in time, people expected to live shorter and shorter periods—mostly because they died much earlier. In the early 1790s the average life span was late 20s to early 30s. By the 1820s, the average life span had increased to about 48 years old. But by the 1850s again the average life span had once again declined to 29 years old—due in large part to the industrial revolution. By the 1970s we were at about 73 years old average life span, and today we are at about 83 years old. And as we have added these years to our collective lives, so too we have added costs. Not just the cost of food, housing and survival, but the cost of the things we need to continue to not get killed by our own life experience adds up as well. Today 85% of what we can expect to spend in our entire life on healthcare will be spent in the last five years of our lives. Some estimates suggest that 50% will be spent in the last five days alone.
Just a half century ago few people did not expect to live that long. They worked, they saved for a day when something bad would happen to them in order to protect their family. They expected to die. Their best hope was that it would not be a violent death or long lingering death. In those days, long lingering deaths were not as common place, as many people died from diseases more rapidly and often earlier in their lives. If they had not died by their mid-20s they likely were going to die suddenly from accident, fire or catastrophic illness. For those that did end up with a debilitating disease, often the cure was what killed them long before the disease had much of a chance to.
People, were intimately familiar with death. People saw death on a regular basis, often up close and personal. It was as much a part of life to them as birth. Birth and death were the bookends of a life well lived. When people died they were missed. Death was mythical, and life was reality. To better understand the context of death, people were closer to their god(s). Religions tend to be a key nexus for the ritualization of death to bring closure, rationalization and explanation. Unexplained or not, death then was more easily accepted. It was part of the perceived natural order. Mourning was more about the person than the event of death. Death was feared, but so too were many other things regularly seen in day to day existence. Things we take for granted today, caused significant fear. Fire, storms, lunar and solar eclipses, birth defects, diseases, and strange events like static electricity, instilled fear. The fear of death was in good company. Life itself was a string of unexplainable, irrational, fearful events.
That brings me to today? I see a much different picture of death. In fact, I think for many it is a much more horrifying concept—one that is almost irreconcilable for many people. We no longer actually see much death and we long to explain and understand it. Many of my friends have never seen a dead body. And the few that have, have seen them in the most defined and ritualized form in funeral homes, in repose in caskets posed as if in perpetual sleep. For those with religious affiliations they deal with death in context of their own religious rituals. Some religions find death as a celebration; others as a time of sorrow and mourning. For those with no belief in a higher order, death is either a big unknown unable to be reconciled or nothing more than a biological process leading to some assimilation of the body’s energies and life forces back to nature. Most people today that I know are significantly afraid of death.
I do not know if it is fortunate or not, but I have seen death a number of times. I have been there when some have died and I have also worked in the funeral business, dealing with the un-pleasantries of the process of death in both its peaceful and violent forms. For me, this has brought an understanding of the naturalness of death and dying and a realization that the abstraction of the mode of death, whether violent or peaceful, while significantly coloring how we perceive a specific death is unchained from death itself. I also have developed an appreciation for the role of religion and ritual in helping ease the fear of death and the loss of loved ones. For me I believe this has been a very good thing, as I don’t believe that I fear death. In fact, I would say I am curious as to where death’s path leads, if anywhere. However, I must admit that I do hope that the existentialist, Jean Paul Sartre, is not correct. If he is, I also understand that I will likely never know!
In writing The History and Evolution of Healthcare in America, I spent a lot of time thinking about the myths that we have developed regarding, what medicine can deliver, what technology can deliver and how far we are willing to go to disconnect cost from the equations. We now do this very well, all the while rationalizing why someone deserves some thing when it comes to healthcare. Most of the things we believe about our healthcare system are crap. And, the biggest problem is that the people that tell these things to us, mostly, know they are crap but they have convinced themselves that they are necessary to tell—important for us to believe in order for us to continue to live in blissful ignorance and preserve the status quo. It’s almost as if they believe that if they were tell the truth, then the myths will fall apart and we will all recognize that no matter what we are going to die! Oh my, woe is us, we are all going to die!
I guess, this is the key point. Nothing, not one bloody thing is ever going to stop us from dying! If we get shot, and are transported rapidly to emergency care, and the EMTs and the Surgeons all pull off miracles and we live a bit longer, you know what? We are still going to die. And that, as they say, is that! The best thing we can hope for is to find something that will delay the immediate cause at hand for a bit more time. We have become quite good at this over the past 1oo years or so. We can delay the date of death, over, and over, and over throughout our lives. I likely would have died a half dozen times already not that many years ago if it was not for these advances. Having my neck ripped open by a dog when I was 6, kidney stones, an infection here and there, an allergic reaction to penicillin, and then another to sulfa-mycin. I have been in a bad car accident with a major concussion, had a few bouts of other illnesses and take cholesterol lowering drugs, that I am led to believe without I may have croaked by now. I have had two sons both with major medical issues both of whom are now alive and kicking and effectively can reproduce the species if they are so inclined.
The questions none of us want to ever ask is, at what cost? At every step of the way someone has paid for these things. Early on in my life my father had old fashioned indemnity insurance. Some of the catastrophic stuff, like the dog bite was covered, but much came out of his own pocket, or from whatever savings he had socked away for just that unexpected need. I know that the reaction to both penicillin and sulfa were covered by someone else, but do not know who. Later, these things were covered by either HMO, or PPO based coverage mostly through employer plans. But still they cost a lot of money. My second son was born premature and believe me his care cost a whole lot of money. And while insurance did cover part, it by no means covered all. I was not making great money in those days but I paid as much as I could, and providers worked to forgive quite a bit as well. In the end we survived to life another day and perhaps reproduce the species.
But money is not the only cost. Another uncomfortable question we need to ask is, what cost to the human species? Evidence is now overwhelming that we are getting weaker as a species. People that would have died in their early years from infections, metabolic deficiencies and other problems now easily grow to adulthood and have children. They can then reproduce the species, and these children are now more likely than not to have the same problem and pass that susceptibility on to their offspring, in other words to the human genome. And in the end, it is clear that this is not good for the species. We are becoming more dependent on artificial means to survive and reproduce. There is a rising incidence of infertility, potentially deadly infections, obesity, chronic disease and other problems, yet we are able to continue to delay our date with death, find a mate and have children.
It simply costs us much more to live the longer that we choose to live. And, we have so acclimated ourselves to the belief that we are deserving, or entitled, to whatever care we want for whatever standard of care or quality of life that we want, we do not even acknowledge or notice the cost. But, it is the cost that will kill the current system. There is simply no way we can sustain the path of indeterminate and unattainable expectations regardless of systemic cost to us all. We simply cannot get everything for nothing anymore and expect that somehow our collective economy will support it all.
But what do we do about it? How do we systemically address it? Do we put the onus for survival back on the individual or to we collectivize survival and place the cost on the whole system? Do we continue on the path we are on, knowing that we are building a weaker species, more and more dependent on artificial costly methods to continue to reproduce and survive or do we begin to make decisions that are for the good of the species? Do we continue to make decisions based on our heart, like not allowing genetic based manipulations as a form of treatment that would be inheritable and improve species viability because we are afraid of the development of a master race or some economic inequity that will drive species survival?
Long ago we began the process of removing ourselves from natural selection! I guess in the end, the question is who will win? Us or Mother Nature? Has our prowess over natural selection really been only a temporary stay of execution? Are the rising incidences of deadly diseases only evidence of some interspecies checks and balances? There has been some research over the years that the rise in certain behaviors, like increases in same sex attraction may also be natural forms of population control. In the end, it matters little. Because in the end, we are meant to die! It will be the bookends of life that are immutable. In the end there will be a determination of the appropriate period of time that we get to be counted among the living. Whether it is determined by some natural collection of checks and balances, our own determination or some divine intervention is irrelevant as it will fall where it must.
Steven Wright once observed that, “you can’t have everything, where would you put it?” The same thing can be asked of our perpetual desire for longer life!