This is the third in a series of short pieces that touch on topics I address in my most recent book Perspective and Guidance for a Time of Deep Discord: Why We See Such Extreme Social and Political Polarization and What We Can Do About It. I wrote the book because of deep concern I feel about how, with issues of every sort, people today are dividing almost immediately into polar camps. The Creative Systems Theory concept of Cultural Maturity makes clear that this can’t continue to be the case if we are going to advance in any meaningful way.
After addressing causes, with each chapter in the book I describe how we might bring culturally mature perspective to one issue where divisiveness too often prevails. I chose the concerns I did because each has something particular to teach about addressing issues more systemically. The health care delivery crisis sheds particular light on a key theme that manifests with issues of every sort, the critical importance of a new, more mature relationship to limits.
A basic observation provides the architecture for the book: In times past, when we encountered polarized positions and partisan advocacy, our task was obvious and unquestioned. We assumed that there were only two options and that our job was to figure out which one was right and fight for it. As we look to the future, polarization has very different implications. We recognize that what we are seeing is left and right hands of a larger systemic picture. And the fact of polarization alerts us to the fact that neither side has yet to ask the hard questions that ultimately need to be addressed.
I first wrote about concerns with health care delivery many decades back. But I didn’t expect that they would produce the highly polarized responses that we witness today. Indeed, I assumed that it was a topic that most people would find rather boring. While radical new treatments understandably grab headlines, working out the details of health care delivery would seem more the province of hospital administrators and economic bean counters. That health care reform might become so loaded an issue could seem even more perplexing given where the current version of the debate started. The model for much of the Affordable Care Act (Obamacare) was a Republican plan, the program Mitt Romney instituted in Massachusetts. Yet few topics today more quickly result in advocates retreating to their respective corners.
Asking the Hard Question
Health care delivery makes a particularly good example of just how demanding the important new questions can be. The question that provides the needed starting point for addressing the health care delivery crisis is straightforward, but its implications can stretch us in particularly fundamental ways: How do we make good policy in the face of real economic limits?
The Modern Age narrative was heroic (or more precisely, heroic/romantic). Our task on confronting limits has been to defeat (or transcend) them. The health care delivery debate combines two concerns—access to care and cost containment—that when put together present us with limits that cannot be escaped. Most immediately they confront us with the reality of economic limits. And ultimately, they confront us with an even more fundamental, and easily disturbing, kind of limit.
The need to address economic limits challenges the thinking of both the Right and the Left. As commonly articulated, the health care delivery debate pits free-market approaches against more centralized, government-directed strategies. People assume that choosing one economic approach or the other will provide a solution. In fact, we could make most any kind of approach work. But none of them can work unless we start by first acknowledging the fact of economic limits and their implications.
Health care expenditures today are spiraling uncontrollably—for everyone, whatever kind of system they employ—and there is no natural end in sight. Advocates on each side tend to pin the problem on inefficiencies and excesses. They assume that if we just get the incentives right and set curbs against unreasonable profit-taking, all will be well. But while inefficiencies and excesses play some role in today’s health care crisis, the most important factor is more basic. Spiraling costs are primarily a product of modern medicine’s great success. Early innovations—like sterile technique and penicillin—were relatively cheap. More recent advances—sophisticated diagnostic procedures, exotic new medications, transplant surgeries, and more—are increasingly expensive and promise only to get more so.
Confronting Real Limits
We face a stark reality. Unless we are willing to spend an ever- expanding percentage of national resources on health care, we have no choice but to restrict health care spending. This circumstance puts before us a whole new order of ethical challenge. We need only look to extreme reactions that follow any suggestion that we might have to “ration” care to appreciate the newness of what is being asked of us. We’ve always rationed care, at least in the sense of withholding care from those who were not able to pay for it. And often, effective care has simply not been available. But what is being required today is different. If we are to stop spiraling costs, eventually we must consciously limit health care, and not just care that is of questionable value, but care that is of real benefit.
An exercise I’ve done with groups highlights the unsettling reality of what is being asked of us. I start by handing participants a list of patient profiles—including both information about patient’s lives and information about their illnesses—along with a budget. I then send the group off to a room for two hours with instructions to decide how the money should be spent. The choices that the exercise requires of participants can be so emotionally and morally wrenching that people refuse to make them. But the exercise is not an abstraction. It presents the task we inescapably face if we are to effectively address health care limits.
Few people in the political sphere recognize the full implications of the health care delivery crisis. The Affordable Care Act addresses access to care, but in spite of its name, it does little of substance to confront health care costs. Calls for “Medicare for all” better address access, but in the end almost wholly ignore cost containment (while denying that they are doing so). Republicans want their own plan, but they clearly have little appreciation for the complexities involved, certainly not the economic complexities. Eventually we must confront the fact of real limits.
An Even More Ultimate Limit
We reasonably ask just what makes the task of confronting economic limits so much more demanding than people tend to assume? The need to make agonizing choices could be enough of an explanation. And the fact that choices require this much of us certainly adds to the challenge. But there is more, and more of major consequence. In the end, effectively confronting health care limits demands a new relationship to the most taboo of limits-related topics: our human mortality.
Medicine has always been about life-and-death decisions. But limiting care in the sense I’m suggesting involves consciously withholding care that might at least delay death’s arrival. Add this recognition, and we get the needed even larger question: “What would it mean to approach health care in a way that acknowledges the importance of a new maturity in our relationship with death?”
It is important to appreciate how fundamentally this further question is new—and significant. Death represents life’s ultimate limit to what we can know and control. Always before in our history, cultural belief has served to keep death’s full significance at arm’s length. Increasingly we are having to confront that this kind of distancing has stopped being an option. Effectively confronting health care limits could make addressing other death-related issues such as abortion, assisted suicide, or capital punishment seem like child’s play.
Culturally Mature Leadership and Health Care
What exactly would good political leadership with regard to the health care delivery challenge look like? Certainly it would include some of what we find with the best of current efforts at health care reform. It would emphasize better covering the uninsured, giving greater attention to preventive care, addressing drug costs, and more extensive application of evidence-based medicine. But politicians who want to provide real leadership would also reopen the conversation in a way that better acknowledges the fact of real economic limits. And over time, leadership must go further. It must help people in coming to better appreciate the importance of a greater maturity in our relationship to death.
Needed leadership must ultimately come from all of us. People today tend to celebrate every new, more expensive medical advance at the same time that care becomes increasingly unaffordable, both for individuals and for society. As citizens, we must be clear that this is not sustainable—and ultimately really not sane. And, like it or not, political leadership is one of the last places where we are likely to find an appreciation for a greater maturity in our relationship to death. That can happen best through our everyday conversations.
In fact, we are already seeing changes when it comes to this more ultimate challenge—only first steps, but ones that are significant. For example, we witness growing recognition of the importance of end-of-life conversations between patients and doctors. The role of quality hospice care is increasingly appreciated. And states are beginning to pass legislation that supports doctor assisted suicide. None of this would happen without broader societal changes in how we view death and its implications.
The questions presented by the health care delivery crisis are not just harder than we tend to recognize, arguably they are harder than we have been capable of recognizing up to this point in our development as a species. But they are also the questions that we have to ask. It is important to appreciate how more directly confronting health care limits, even just economic limits, could have effects well beyond the obvious. It could contribute not just to rethinking access to care, but also to increasingly mature and empowered insights about what it takes to be healthy, what it means to heal, and more broadly, about the requirements of a healthy society. For today, isn’t that just what the doctor ordered—a fresh, really big picture look at the whole health care endeavor?
In the end, confronting health care limits should result not just in care that we can afford, but also in care that is more complete, that better addresses the whole of who we are as individuals and as societies. And while getting there will ask a lot of us, we can also think of it simply as bringing the needed “new common sense” to the health care sphere.