The Continental Divide:Why the healthcare system will always be divided

The Continental Divide: Why The US Healthcare System Will Always Be Divided

Maury Osbourne

In 1944 American Folk singer Woody Guthrie penned the song “This land is your land”.  The song interweaves the story of a traveler who moves around the country and describes all the different sights that he saw as a tourist.  Over time, there have been many different versions and variations of this song and one of the variations includes the following stanzas:

When the sun came shining, and I was strolling,
And the wheat fields waving and the dust clouds rolling,
As the fog was lifting a voice was chanting:
This land was made for you and me.

As I went walking I saw a sign there,
And on the sign it said "No Trespassing."
But on the other side it didn't say nothing.
That side was made for you and me.

In the shadow of the steeple I saw my people,
By the relief office I seen my people;
As they stood there hungry, I stood there asking
Is this land made for you and me?
(Woodie Guthrie, 1944, stanzas 4-7)

On the surface, it would appear that this song has nothing to do with health care; however, with this paper I am going to define how our health care system is divided, which side of the no trespassing sign the majority of Americans are standing on, and who has access to the health care system.

The Heath Care System
What is the system?

To examine the health care system we must first define it.  Health care can be summed up as the description of how an individual takes care of their health issues in order to maintain a state of optimal functioning and or a healthy well-being.   This pseudo definition takes on many different meanings depending on which phase of life or health status an individual is in.  For instance, a healthy newborn baby has a different set of requirements for its healthcare than a teenager and so forth.  Financially, “The distribution of health care costs is strongly age dependent, a phenomenon that takes on increasing relevance as the baby boom generation ages. After the first year of life, health care costs are lowest for children, rise slowly throughout adult life, and increase exponentially after age 50 (Meerding et al. 1998). Bradford and Max (1996) determined that annual costs for the elderly are approximately four to five times those of people in their early teens. Personal health expenditure also rises sharply with age within the Medicare population. The oldest group (85+) consumes three times as much health care per person as those 65–74, and twice as much as those 75–84 (Fuchs 1998). Nursing home and short-stay hospital use also increases with age, especially for older adults (Liang et al. 1996)” (Alemayehu & Warner 2004).  As you can see, the more one returns to the system, the more expensive the bills become.

For a majority of individuals born around the world, they are born as healthy babies with presumed APGAR scores ranging between 7 and 10.  These children and mothers briefly entered the healthcare system as a result of their birth and quickly exited the system due to their birth going off without a hitch.  But there is a small percent of women and children who experience a healthcare crisis en utero and they will pay a dear price financially for this unfortunate life issue.

The ones who require critical care during their prenatal development and also individuals who require medical attention during their life span will need the education and assistance from people who have advanced knowledge of their health issue as well as the ability to solve or mitigate the problem.  These additional individuals can either have informal education such as what can be passed down from an elder or they can have advanced degrees or certifications such as ones that can be obtained from schools, community colleges, or universities.  No matter how those individuals obtained their education they acquired information about a certain discipline that they spent time educating themselves on and that accumulation of information is a valuable resource.  In any community, it is impossible for any individual to know and do everything and thus loose coalitions are formed and healthcare networks are established.  In a capitalistic community where someone has spent time learning a subject there is an expectation of payment beyond that of a layperson.  Those individuals can determine how much they want to charge, what premium they want to set for access to their knowledge, and can also determine who they want to work with in their network of services.  This relationship amongst these health care providers is called “the system”.

The healthcare system in the United States is extremely complex and intricate.  This is on purpose and designed to keep certain people out while allowing certain people in.  The people who are on the outside, the vast majority, the ones who can read the “no trespassing” sign, are left out there intentionally.  In order for someone to post a no trespassing sign, there must first be a legal establishment about the boundaries of certain borders and who comes and goes between the borders.  Once citizenship within the border (“the village”) is established, the individuals inside the village will designate someone to establish policies about who can live within the community and take advantage of those resources and what security forces will be employed to protect them.  These villagers will make up convoluted rules and regulations that only their attorneys can understand and then place all the details within fine print so small and voluminous that it takes a college level education to understand them.  By the time someone outside the village figures out the code, the villagers will change the rules again to make it more difficult for someone to gain access.

If you are standing outside the village and observe the majority population of Caucasians as you look in, it would be easy to throw the race card on the table and call foul because historically, the United States has not had a very good relationship between its majority and people of color.  According to the US Government, there are roughly 330 million Americans with Caucasians comprising a majority percentage of roughly 77% (CENSUS.GOV) but race issues alone are too easy of a scapegoat.  We have to dig deeper and avoid the knee-jerk reaction that is easily summoned with a well-written newspaper headline.

When Woody peered towards the steeple he recognized “his people.”  The reference to his people could be a vernacular for his friends but in this context of the stanza and considering the timeframe that the song was composed, it is believed that he is referencing Caucasians and common everyday people who look like him financially.  Therefore, Caucasians are also outside the village and denied access.  So if it is not skin color alone that allows someone into the village and Woody isn’t the only person on the outside, then who gains access?

Insurance

Now that we have defined the system we have to answer the question of who has access to the system.  We have to get to the heart of the matter.  At the dead center of the problem is the culture clash between the haves (the villagers) and the have–not’s (the Woody Guthries’ of the world).  The 100-foot titanium health care access barrier between the haves and the have-nots is the insurance industry.

Insurance has been hawked as a benefit to employees but it is not designed to give people access to healthcare.  It is designed as a protection against financial collapse due to illness or injury and as a capital gain opportunity for the wealthy.  The people who need the greatest protection against financial collapse are not the poor and middle class, rather, it is the wealthy members of the village who vow to never return or enter a financially distressed status in life.  “In Europe and the United States, modern insurance for medical care expenses has its origins in diverse actions undertaken by unions, fraternal organizations, employee associations, employers, commercial insurers, governments, and other less easily categorized entities. The primary objective of most of these initiatives was not reimbursement for medical expenses but protection against the loss of income due to illness or injury (Institute of Medicine, 1993).“ In spite of the collaborations and intense negotiations to make health care more affordable for Americans, insurance has helped create a tremendous policy failure for a vast majority of those who pay for it and financial devastation for those who cannot afford to pay the health insurance premiums.  The table below illustrates the national healthcare expenditures per capita for the United States and highlights the per capita increase from $353 in 1970 to $14,570 in 2023.

There are many factors that one could argue about why the cost has increased.  But no matter what the argument, if you cannot afford healthcare, the argument for why it is so costly does not matter.  We have been taught that having insurance is what creates access to health care; however, that is not true.  Having financial means it what ushers you to the top of the line with health care as evidenced by insurance premiums.  If you cannot afford to pay the premium, you are pushed outside the village into the shadow of the steeple and have to learn how to read the signs.   The answer to how the US can have an affordable health care system lies within the construct of the military.

TRICARE

Members of the US armed forces fare the burden of managing the security of our great nation and with such a heavy responsibility comes certain privileges.  One of the less spoken about privileges of being a member of the armed services is their health care system.  Military bases are small sub-communities within the greater community that they serve.  A military service member, depending on where they live, does not have to leave a military base at all if they do not want to.  They have access to grocery stores, recreation, entertainment, family and friends, schools, and most importantly access to healthcare that they do not have to pay for.

“The Department of Defense (DOD) provides health care for 9.5 million military service members, retirees, and family members through military treatment facilities (MTFs) and a self-funded, self-administered insurance program called TRICARE.^[1] The mission of the military health care system is to maintain the health of military personnel, and their families, so that they are capable of carrying out their missions, and to ensure that military medical personnel are prepared to deliver all necessary health care services to any service member injured in battle.

Health care is provided to active duty service members at no cost to the individual. Family members of active duty service members pay almost none of their health care costs and receive second priority (ahead of reservists, retirees, and retirees’ family members) in military health facilities; the purpose of providing such priority and keeping the cost-share to families so low is to help ensure service members are not distracted from their mission with worries over the health of a loved one or their family’s financial situation. Retirees and their family members are also eligible for care as a lifetime benefit for serving in the military for 20-plus years. Veterans who served less than 20 years, and thus do not officially qualify as a “retiree”, may receive health care through the Veterans Health Administration.[2]” (Hayes, 2015).

The members of the military service and their immediate family do not have to pay for their medical care and a vast majority of them do not have to pay for their housing.  Those two expenses alone can take up a large portion of a person’s income. Imagine a world where everyday citizens could live their lives and focus on their daily mission knowing that if they were to fall ill, they would be cared for and not buried underneath a mountain of artificially inflated medical bills thus ruining them and adding additional financial and social burdens to society.  Tricare proves that it is a financial possibility, and it can be done, but people with money will not let it happen.  They will continue to encourage participation in convoluted insurance programs and painting “socialism” in a negative light all the while paying cash for their care.  They will frequently use “insurance” as a means to use other peoples money for their health care and not their own.  It is a ponzi scheme that eventually contributes capital to the insurance company float and will continue to inflate until it burst or until it runs out of waves of people willing to participate in a plan that they believe grants them access.  As described by Warren Buffett, the villagers have built a molt around their community and utilized money from the trespassers to grow their estates.  "Our float has grown from $16 million in 1967, when we entered the business, to $62 billion at the end of 2009. Moreover, we have now operated at an underwriting profit for seven consecutive years. I believe it likely that we will continue to underwrite profitably in most -- though certainly not all -- future years. If we do so, our float will be cost-free, much as if someone deposited $62 billion with us that we could invest for our own benefit without the payment of interest." (Goldstein, 2010).  Buffetts mega conglomerate Berkshire Hathaway owns the following insurance companies that they have made publicly known; Geico, National Indemnity Company,  General Re, Alleghany Corporation, MedPro Group.  The also have stakes in Chubb Limited and UnitedHealth Group.

Although large corporations and high income earning individuals create opportunities for people they tend to store their earnings in offshore accounts, rental properties, and tax shelters outside of the reach of the IRS and government officials.  When those financial vehicles fail, they expect the taxpayers to bail them out (Kiel, P., & Nguyen, D., April 2020) and those are the very same people for whom they created barriers to healthcare in the first place.  Members of our community would be more prosperous and better educated if they were able to direct health care premiums towards their education and pump money into their communities rather than paying for bad business deals, hyper-inflated rent, and spiraling out of control health care costs.

CONCLUSION

Like Mr. Guthrie, I too have walked the land and been on the inside as well as outside the village.  I’ve participated in Tricare and now I am participating in whatever plans get thrown my way as a “benefit” of my employment.  Tricare is the greatest working example of how a health care system can encompass the majority of US citizens and deliver excellent win-win health care.  Access to health care should be affordable to every citizen and not only partitioned to the villagers.  We must advocate for optimal health for everyone and not use the statement “do you have insurance?” as a way to shame the trespassers away from appropriate healthcare.  When we advance the health of every American citizen this country will be great again; for everyone.