The First Two Great Commandments of Healthcare

Chuck Summers is the Director of Practice Growth for MCM CPAs & Advisors, one of the midwest's largest business advisory firms, where he lead the charge in developing and implementing best practices in business development, marketing, service development, and community engagement across the firm’s midwestern footprint. He prides himself in being a connector of people, ideas, and resources, and invests a lot of time working with and on community and regional initiatives. 

Among all of the rhetoric of conflicting values and behavioral expectations in our society, many rely on the simplified Biblical direction of the First Two Great Commandments. In an equally complex and juxtaposed reality of healthcare in the US, maybe a similar simplification would be helpful. “Thou shalt prioritize the health and welfare of the greater whole and the second is like unto it, thou shalt prioritize the health and well-being of an individual.” And many will argue that the order should be reversed. Whether contemplating the priority between deity and friend or the health of our country or self, neither are intended to be at odds with each other, but intentionally intertwined, requiring a deliberate balance and consideration for both. 

In our third and final Liberty Fund Foundation led Socratic-style discussion of our MDLF fellowship, our class gathered around the now familiar oval slate to hurl ourselves into a vibrant and thorough discussion of Healthcare, its costs, how the US system compares globally, the intended and unintended role of health insurance, and the ultimate political battle between single payor, socialized healthcare and the free-market alternative. I have come to appreciate and long for these conversations, though the preparatory readings can feel like studying for a masters level political science course and the discussions themselves are nothing shy of cognitively exhausting. But there’s nothing quite as exhilarating as participating in a civilly moderated discussion with intelligent, passionate, and curious pupils about a challenging yet relevant issue. 

There’s no question after reviewing the data that the cost and consumption of healthcare services in the US is astronomically higher than any other developed country in the world. And yet the often recommended solutions of reining in the behemoth that is our healthcare system highlights the relative success of European single payor systems, but seem to neglect addressing the translation error to our very large, our very diverse and our very individualistic economy. But before we cuddle up to the saving graces of the European-credited system, we must remember that a significant percentage of US citizens are already part of one of the largest single-payor healthcare systems in the world comprised of Medicaid, Medicare and the military focused TRICARE. It therefore must not be the debated payor system that indicates success but rather the operational execution of balancing both a public system and a private system that works for the whole. 

Healthcare Insurance, or what most view as the predominant method of paying for Healthcare Services, is unlike almost any other Insurance, which tend to only cover the unpredictable, catastrophic emergency that our hard-earned salaries and savings can’t handle. We’ve now come to expect and demand that our healthcare insurance not only cover the big stuff, but everything that could possibly be considered medically or health related, whether predictable, preventative or an accident. It wasn’t always this case. Before World War II, most Americans paid for their own medical care, either directly to the provider, or through nonprofit health insurance entities that were created to offer guaranteed service for a fixed fee. Back then, health insurance only provided coverage for major items like hospitalizations that people couldn’t afford to pay for themselves. All other expenses were paid out of pocket, directly to the provider. Though, in an effort to control hyperinflation during the war, the US instituted wage and price controls, which didn’t sit well with the then popular labor unions, and resulted in exempting employer-paid health benefits from wage controls and income tax. This historical accident has snow-balled into a tax advantaged demand for employer-provided health insurance plans, remaining one of the primary considerations for evaluating employment opportunities, and unintentionally leaving small-businesses and aspiring entrepreneurs in the disadvantaged dust. While reform from this monopolistic structure has been attempted and threatened, the status-quo is so well entrenched that it seems nearly impossible to dethrone, regardless of a starkly different employer-employee relationship than existed in previous decades. Perhaps this is another pet project that one of our dear billionaire entrepreneurial superheroes can tackle during the next decade. 

The US has benefited from more than a century of relatively constant economic growth, creating an enormously consumptive economy, viewed by many around the world, and even within our own borders, to be either evidence of our envied popularity or a complete egotistical meltdown. Our individualistic “I want what I want and I want it now” mentality is equally present in our expected delivery of health care and also what we expect health insurance to cover…everything. This has led to frivolous consumption of healthcare services and testing, primarily because there is no incentive not to. The inherent goal of any market transaction is to maximize the personal benefit, and if doctors schedule a litany of tests for their patients, which of course benefit their evaluated service and value, so long as we as patients only have to pay our $10 or even $30 co-pay and gives us piece of mind that we aren’t knocking on death’s door, why should really care about the unpragmatic economic value of excessive healthcare? Someone else is paying for it, right? This current behavior would suggest that we either do not care or do not understand how the US healthcare system works. 

However, before we all spiral into a sense of self-deprecating guilt for our individual role in this catastrophe, we must remember that the vast majority of the costs associated with our gargantuan healthcare spending rest with the select few, namely those suffering from and being treated for catastrophic illnesses and those in end-of-life, palliative care. Therefore, the cost reality appears to be more tied to our value of life, the aggressive innovations to prolong it, and the ethical dilemma of whether pulling out all stops to save or prolong the life of an individual is more important than the financial burden shared with the larger group. Theoretical arguments would argue for the First Great Commandment of Healthcare to consider the greater good, but I don’t see a mad rush to be the proverbial line-leader to “pull the plug” on Grandma or tell an ailing colleague that they are not longer able to participate in the group health insurance plan because their driving up the cost for others. 

Furthermore, just as the averages of cost and consumption data that policy makers use to evaluate the system shield the select few from public finger-pointing accountability, so do the averages of access to healthcare services veil the disparaging gap for geographic and marginalized population access to both core and specialized services and providers. And while the efforts of rural and minority groups are present and appreciated, we must recognize the difference between equitable geo-political access and equitable circumstantial usage and adoption. It appears that much of the philanthropic accommodations and equitable conversations relate to geographic accessibility of healthcare services, being that rural or within marginalized urban communities, which is without question important and should remain a priority. But as these conversations occur, we should be cognizant of the need for equitable education and understanding of the services being rendered and the difference in circumstantial accommodations. For example, just because someone has access to a doctor, an urgent care, hospital and/or pharmacy, does that person understand their insurance plan, what it covers and does not cover, or is their a communal understanding of the potential life impact for a recommended treatment that will impact the person’s employment or ability to work for a time, their mobility and ability to provide and care of loved ones, etc. For some these circumstances can be an inconvenience, but for others it can be debilitating. 

My MDLF fellows and I recognized the privilege we had at being sufficiently comfortable in life to sit around the table in a beautiful facility to pontificate on these issues and theorize how the politically-suicidal changes could actual find their way into reality. Yet it did not pass us by that many of those most negatively impacted by our antiquated healthcare system are doing their very best to simply survive, provide for their families, and navigate the system that is before them. It is therefore the job of those who do have the luxury of debating and strategizing to represent the voice of those who cannot and I would argue for the need of prioritizing the prompt implementation of “good” healthcare reform when “perfect” reform seems eternally unachievable. 

For those still reading, let me suggest that instead of arguing whether we should keep up with the European Healthcare Kardashians or prioritize the group over the individual, let us recognize and appreciate the unique advantages and challenges of our great nation and focus on developing an equitable healthcare system that is relevant and appropriate for the US. We’re big, we’re diverse, we’re the most individualistic country in the world, and we are the land of liberty and opportunity.

MDLF Fellowship Class V | Liberty Fund | February 24, 2023