Edward Kennedy and Health Care

by Siegfried Othmer | September 1st, 2009

The death of Senator Edward Kennedy prompts a return to the theme of health care, which was his principal cause over his nearly fifty-year public career.The death of Senator Edward Kennedy prompts a return to the theme of health care, which was his principal cause over his nearly fifty-year public career. The facts regarding health care don’t appear to be of decisive relevance at this crucial moment in the drama of health care legislation. Those facts not in hand are simply manufactured as needed. The dominant issue is rather one of values. And of course it was Kennedy’s own values that drove him as well. Kennedy was a faithfully devout Catholic throughout his life, even if the practice in his personal life at times fell short of the ideal. Taking time out on a political trip for mass during the middle of the week, a staff person asked him what drove him to be so passionate on the matter of health care. His curt response: “Have you ever actually read the New Testament?”

So the core belief that inspired Kennedy’s liberalism was rooted in the New Testament generally, and in Catholic social teaching specifically. We have obligations toward our fellow man, and the more we are given in life, the higher those obligations are. Largely on the other side of the divide we have the evangelicals who grew up in the tradition of the Protestant Ethic, grounded as it is in individual initiative and a burden of individual responsibility. Both sides fervently believe in the power of prayer. But on the Protestant side emerged the conviction that if one did well in life, then that was a sign of God’s blessing being bestowed upon one’s enterprise. The individualistic and moralistic bias in evangelical Protestantism ultimately led to a strange alliance of convenience between evangelicals and an amoral and even predatory capitalism. Both nobly wished to be free of the yoke of government, despite the fact that both were effectively in charge of it. We finally have the lamb lying down with the lion, although that’s not quite what the New Testament writer had in mind. It was the lion that was supposed to lie down with the lamb.

Edward Kennedy on Health Care: This is the cause of my life. It is a key reason that I defied my illness last summer to speak at the Democratic convention in Denver.

In the view of the new political evangelicals, what is charity and caring at the level of the individual or the church or the small community becomes quite something else when it is dished out by the national government. But it is also something else when the socialization of health risk is managed by mega-corporations, which is what we have now. The insurance companies will move to cut their losses just when the need for health care is greatest, and they have not declared themselves willing to end the practice of policy rescission under such circumstances. Just how does that square with the exhortation to care for the least among us? Strange bedfellows indeed.

Our ethical mandate, religiously grounded or otherwise, is clearly to bring the uninsured and the uninsurable under the umbrella of care. This is the principal issue separating us from the civilized countries on the planet. Torture is the other. Government is the natural fall-back position for those whom insurance companies don’t wish to take on. If this costs us only $100B per year for 50M people, then that is getting us a lot for a little. It is not ok to argue that we have an inefficient or otherwise flawed system of health care, so we should not be making it worse by bringing even more people into it. For the folks at issue, health insurance is a life boat that is needed now. The quality of the life boat is a secondary issue. And it is a separate issue, to which we now turn.

Our Deeply Flawed Health Care Delivery and Reimbursement System
It is by now well-known that the United States spends much more than any other country per capita on health care. Comparison data are shown in Figure 1. How these numbers stack up in terms of percentage of GNP is shown in Figure 2. Even more important, however, are the health outcomes that we derive for all this expenditure. Here the news are not good at all.

It is by now well-known that the United States spends much more than any other country per capita on health care. Comparison data are shown in Figure 1.

The United States now ranks 50th among the world’s nations in terms of life expectancy. Even residents of Jordan can look forward to a longer life than US citizens. What’s even worse, we rank last in terms of life expectancy after age sixty among the twenty top industrialized nations. It is in end-of-life care that the skills of the medical system are really put to the test. We rank last in terms of avoidable deaths. France ranks first. We rank 37th in the world in terms of infant mortality, and rank last among the twenty top industrialized nations. Our infant mortality rate is a factor of 2.6 higher than that of the top three countries. This is no small matter.

It is by now well-known that the United States spends much more than any other country per capita on health care. How these numbers stack up in terms of percentage of GNP is shown in Figure 2.

Overall health status is highly correlated with socioeconomic status in the developed nations. If wealth can to a certain extent buy you health, we in the United States should be doing better than we are. We are in fact doing much worse than we should be. The health status of the top quintile in the United States matches up with the lowest quintile in England. And yet British health care costs only amount to some 40% of our own. So much for our mocking of the British National Health Service. It turns out that governmental contributions to the health care of Americans are already greater than British government payments for its citizens, on a per capita basis. But for us that amounts to less than half of all health care expenditures, while for the British it amounts to nearly all.

Matters are even worse than the comparison to England’s health status would indicate. The World Health Organization ranking that placed the US in 37th place overall in terms of health care placed England in only 18th place. Another study looked at death rates just for conditions considered treatable. On this measure, Britain came in 16th out of nineteen advanced countries. The US brought up the rear. France was ranked #1. Our performance with respect to treatable conditions is fully one-third worse than that of France.

The Commonwealth Fund commission on health care evaluated health outcomes and quality of service by some 37 categories and criteria. They found the US position to be at 66 out of a possible 100, where 100 represents the top performance observed among countries in each classification. Scores ranged from 51 to 71 for different subcategories. (See Figure 3.)

The Commonwealth Fund commission on health care evaluated health outcomes and quality of service by some 37 categories and criteria. They found the US position to be at 66 out of a possible 100, where 100 represents the top performance observed among countries in each classification. Scores ranged from 51 to 71 for different subcategories.

Much more could be said, but the reality of our third-world status with respect to health is starkly apparent. Recently the volunteer organization Remote Area Medical sponsored a free medical clinic for the uninsured in the Inglewood Forum over a period of several days. Thousands lined up for health or dental care that they hadn’t been able to afford. The organization was created to serve in impoverished Third World countries, but in recent years has received requests to extend their reach to the US, where our uninsured share the fate of the Third World poor. When it comes to health care, we in the US live in a Panglossian fantasy that ours is the best of all possible worlds. (See photo.)

Implications of Our Poor Health Care Performance
First of all, the question needs to be asked whether our health care system is responsible for our poor rankings in terms of health status. If one counts fatalities attributable to hospital-induced infections and other such causes of preventable deaths, we could in principle improve our national death rate by 150,000 per year, and reduce our medical costs by $100B, in the estimation of the Commonwealth Fund commission on health care. Perhaps as many as 200,000 per year fall victim to blood clots following major surgery, according to the Wall Street Journal. These aren’t counted as preventable deaths, but they must be regarded as a cost of health care itself. Taking full account of such adverse events with respect to medication errors, false diagnosis, deaths due to anesthesia, etc., we find that medical care all by itself constitutes the largest cause of death in the United States, outranking cancer and heart disease. If such deaths were to be taken out of the equation, our life expectancy ranking would move near the top. Of course other countries are not immune to these problems either, but we may indeed have more of an issue in our fragmented, compartmentalized health care delivery system than elsewhere.

The World Health Organization was created to serve in impoverished Third World countries, but in recent years has received requests to extend their reach to the US, where our uninsured share the fate of the Third World poor.

Below the level of overt mortality, there is the bleak reality of progressive morbidity in our aging population. The health care we offer does not make people healthy, in many cases, but rather simply allows them to motor on unsatisfactorily a while longer. This is perhaps the bigger issue overall. The health care we do have preempts what should have been on offer throughout life: preventive measures and occasional screening where that makes sense. Less than half of our citizenry takes advantage of either.

There are places in the world where cardiac death rates are much lower than ours, where cancer incidence is lower, where diabetes, Alzheimer’s, and dementia in general are rarities. We must therefore regard these conditions as largely environmentally mediated. The environment at issue here includes our diet and many other factors, such as those that promote sedentary lifestyles. It encompasses our economic environment, in which individual and family security is increasingly brittle. And it includes the family environment, in which many children grow up imprinted with a history of early childhood neglect or abuse. This environment also promotes the sense that medical care is able to bail us out of our difficulties.

The belief that we have a robust health care system to backstop our misadventures has the perverse effect of causing people to neglect self-care, in the same way that some people were willing to drive more aggressively once they started wearing a seatbelt. At the low end of the socio-economic spectrum we are confronted with ignorance. This is not helped by the fact that the US has the highest illiteracy rate in the civilized world, at around 21%. Less than half of Americans even know where the heart and stomach are located within the body. At the top end of the socioeconomic scale, we are contending with hubris, the certainty that one is tough and invulnerable healthwise just as in other aspects of one’s existence.

This brings us then to the heart of the issue, namely that lifestyle factors remain the dominant issue limiting health status in the US, and the health care system we do have gives us a false sense of confidence. No amount of shaping up of the existing deeply flawed health care delivery system will rescue us from this disagreeable reality. Not even greater attention to medical prevention and screening strategies will be enough to turn us around.

A Proposed Remedy
There needs to be, from the ground up, an orientation to wellness and functionality. But in order to bring this about, the objective cannot simply be framed in terms of prevention of illness and avoidance of disability down the line somewhere, decades from now toward the end of life. There needs to be an immediate payoff. This agenda also cannot rely strongly on the human will. Willpower is clearly over-rated. We have to back up one level to take a look at the brain that organizes our lives and sometimes even frustrates our own will. Training the brain quite naturally strengthens our ability to lead a healthy life, and it also gives us an immediate payoff in terms of functionality. This neatly aligns our near-term interests with our long-term interests. It also aligns us with the way nature actually behaves because the issue of regulation is central to our health concerns.

The historical neglect within medicine to deal with brain function has cost us dearly. The central nervous system plays the key role in our self-maintenance throughout life, and yet that has not to date ever been made the topic of conversation within medicine. At least two psychiatrists have so far told us something to the effect that “It was neurofeedback that first caused me to take a look at the brain.” But even now that we are finally looking at it, the perspective remains one of targeting specific deficits that relate to the traditional concerns of psychiatry. The real breakthrough is yet to come. It lies in the recognition of the centrality of regulatory function in health and functionality. This places optimum function and dysfunction on a continuum that can be embraced under one conceptual model.

We must somehow get beyond the current “reality” in which medicine plays a pre-emptive role with respect to what needs to be done. First of all, standard medicine is taking all the oxygen in the room, and secondly it insists on its own terms of debate. Innovation in neurofeedback has therefore had to be taken entirely out of medicine and psychology. Within those fields neurofeedback research and development were at a standstill for many years.

We are finally at the threshold of recognition that the brain and the CNS are central to health maintenance, and no doubt both medicine and psychology will in time want to reel the neuromodulation technologies back into their embrace. As long as both of those fields are wedded to models grounded in pathology rather than in function, however, that would represent a step backwards. And unfortunately the existing system of health care and of reimbursement are so thoroughly organized around the pathology model that they are incapable of fundamental change. Incipient health problems are ignored until they reach some diagnostic threshold, and then one of the standard medical/psychological remedies is administered. The self-regulation model is antithetical to this enterprise.

Biofeedback in general and neurofeedback in particular can be the heart of a wellness model for health care in the future. But that cannot and will not happen at the hands of the pathologists. Likewise, it cannot happen within the current reimbursement system. It must be sponsored firstly by those who identify themselves principally with the self-regulation technologies, augmented by those professional disciplines that are already oriented toward the maximization of function: these include physical therapy, occupational therapy, social work, life coaching, sports psychology, and education. Neurofeedback will be done by a combination of individual practitioners operating on the basis of private pay, and of institutionally funded professionals. And it will also be adopted by individuals themselves. Of course the medical and psychological professions will come aboard as well, but they will not lead the change that needs to occur in American medicine.

Neurofeedback turned out to be something for which none of the existing rules worked very well. Now that it’s beginning to flourish, it can in turn change the rules that have applied to health care to date. Revolutions, as we know, rarely come from the inside, and are rarely welcomed by the insiders.

Returning to our theme at the start: We are happy to see the uninsured finally being brought under the umbrella of health care, one way or another. This is way overdue. But even as that is being accomplished, we dare not cheer that as an end goal. We know that the system must be fundamentally altered to actually serve our health care needs, and to do so in a manner that our society can afford.

Resources:
The Commonwealth Fund Commission on a High Performance Health System, Why Not the Best? Results from a National Scorecard on U.S. Health System Performance, The Commonwealth Fund, September 2006

Siegfried Othmer, Ph.D.
www.drothmer.com

4 Responses to “Edward Kennedy and Health Care”

  1. captainvideojw says:

    “The individualistic and moralistic bias in evangelical Protestantism ultimately led to a strange alliance of convenience between evangelicals and an amoral and even predatory capitalism.”

    I’ve never heard this so thoughtfully explained.

  2. Thelxie says:

    Thanks for all the information. This is a very good article.

  3. Nicholas Kristof supplies more data points regarding our deficient health care system in an article titled “Unhealthy America” on November 5, 2009 in the New York Times. He takes issue with Senator Richard Shelby’s Panglossian appraisal: “We have the greatest health care system in the world. Sure it has flaws, but it saves lives in ways that other countries can only dream of. Abroad, people sit on waiting lists for months, so why should we squander billions to mess with a system that is the envy of the world?”

    First of all, Senator Shelby, we should change it because the uninsured are not part of it. What justice is there in having the best system for 85% of the people?
    Secondly, this involves no novelty at all. Fifty percent of Americans are already involved in government-funded care through Medicare, Medicaid, S-CHIP, the military, and the prison system. This system is now being extended to those whom the insurance companies don’t wish to insure. What’s the problem with this?

    But as Kristoff points out, it’s not the best system at all. Far from it. In addition to the points already made above, he observes that the US ranks 34th in maternal death rate. This is not a matter of small differences. A woman is 10 times more likely to die in childbirth in America than in Ireland. And even if an American infant survives childbirth, he is 2.5 times more likely to die by age five than in Sweden or Singapore.
    Of course race is a factor also: “An African-American in New Orleans has a shorter life expectancy than the average person in Vietnam or Honduras.”

    So, Senator Shelby is predicating health care policy on what may be “the greatest distortion ever told.”

  4. Not quite. The Congress is trying to solve a problem of the uninsured in this country, and that means applying the insurance principle that everybody buys in to share the burden. This mostly involves payments to insurance companies, and only secondarily more taxes.

    But it is true that the new fees will be seen as a burden by some businesses. This policy dates back to World War II, when companies first started offering health care as a benefit. In our modern globalized age, that is a handicap with respect to businesses elsewhere who don’t have to cover such costs.

    So we should move away from having health care handled through our employers. But Congress cannot mandate that!

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