The U.S. Population and Health Care Challenge

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W.J. Van Ry - January 2004

As a retired health care executive, people often ask why I am involved in national population issues, when the local hospital might want the benefit of my experience. The answer that follows may seem somewhat obtuse at first but as you read on, hopefully, it becomes clearer.

After a thirty-year career in health care, there is no question in my mind that every citizen of this great nation wants and expects high quality, affordable health care, whether employed or not. Unfortunately this need for health security will remain illusionary unless two things happen: the population is stabilized and the environment begins to recover. How so, you might ask? What possible tie is there between these seemingly remote concerns and the more immediate issue of health care for all? Please stay with me as we examine the underpinnings of this complex, yet real connection.

There are four elements critical to the success of any national health care delivery system: (1) political will, (2) predictability, (3) manageable scale, and (4) a healthy environment. While sounding like administrative jargon, these terms do translate into everyday language.

Political will, as we know all too well, can be short term or enduring, depending upon ever-changing public opinion and economic forces. While the rhetoric has existed for years about the right to health care, the will to implement such a system quickly disappears when Congress sees the huge expenditures involved. But cost is not the only limitation....there are other factors as well.

One of them is predictability. Our current population of over 292 million (and headed for nearly half-a-billion by mid-century) continues to explode exponentially with the highest birth rate in three decades and a yearly infusion of 1.4 million immigrants flowing across our porous borders and into our welcoming ports. As with any group, many arrive needing maternity, medical and dental services, many with little or no means of paying the bills. Further, as many newcomers take low-end employment, the probability of their finding a job with health benefits is quite low.

Another concern is the necessity to create an estimated 2.2 million new jobs each year just to keep pace with population growth and working-age job entrants. One can readily appreciate that any down turn in the business cycle, as recently experienced, can have devastating socio-economic consequences. As a result of both high immigration and new jobs that fail to materialize, thousands are added yearly to the ranks of the uninsured, currently reported by the U.S. Census Bureau to be 43.6 million. In addition billions of dollars in unpaid medical bills get translated into ever-escalating health insurance premiums to employers and individuals across the nation.

This extremely fluid and open-ended situation frightens insurance actuaries and government budgeters alike, for there is no way to assure payors that costs will not run amuck. In other words, without controllable costs and a steady revenue stream, private insurance companies are averse to assuming the risk of a legally defined and uniform package of health benefits for all residents unless financially backstopped by Congress. In turn many Congressional representatives oppose being the guarantor, fearing that runaway expenses might unnecessarily deplete our federal coffers, thereby jeopardizing other national priorities such as national security and defense.

Whether we agree with the wars in Afghanistan and Iraq, they and any future pre-emptive wars with subsequent nation building will sadly consume a sizeable portion of the treasury. Contrary to the promises by electoral candidates, it is unlikely that a much desired universal health plan can be funded in the near future in view of mounting federal deficits and an uncertain war on terrorism that could last for decades.

As for manageable scale there is no precedent for creating a nationalized system that matches the scale suggested for the U.S....not in Australia, Canada, Germany, Japan, the United Kingdom or elsewhere. Most of these developed nations are less than one-third the population size of the U.S. and may not have the same penchant that Americans do for the best available high-tech services. While China and India have larger government systems, neither country provides a base of health services anywhere approaching our elevated standards.

A nationalized system would be a huge organizational undertaking with problems not readily apparent to some of the proponents. Certainly it is possible, but look what happened to the Clinton administration when it tried. There was no end to the criticism that the proposed top-heavy bureaucracy would be overly complex and riddled with cost uncertainty. For this type of undertaking to be politically acceptable there would have to be an integration of a myriad of private and governmental plans into some kind of mammoth centralized or several decentralized regional systems, any of which would make the Medicare enrollment program of 40 million seem picayune. Scale of this magnitude becomes an unparalleled management challenge for the nation and should not be underestimated by either the electorate or the politicians.

It is clear that each year our population grows, the bigger the obstacles become in launching the start up of a radically new health care system for all Americans. This is just another example of what John D. Rockefeller III (Chairman of the Commission On Population Growth and the American Future) warned about in 1972. In paraphrasing a letter to President Nixon he wrote, "Our problems would be easier to solve if we stopped growing." (That was almost 83 million people ago.)

Finally, let us turn to the concern about a healthy environment. With each passing year surrounding toxicity rises and water becomes a scarcer commodity for a swelling country. There may be glimmers of hope as air and water quality improve on a spot basis, but additional growth coupled with more business and industry, simply blunt these gains in time. As the population grows the environment is further wasted in spite of our faith that science and technology can somehow mitigate the damages. A sick environment eventually leads to a sick people. No health care delivery system, no matter how comprehensive and well funded, will be able to totally cope with the human misery that ensues.

If America wants a workable delivery system that meets expectations, we must get on with the business of stabilizing our numbers as other developed nations have done and then strive for a more optimum size. Not only will smaller numbers better enable us to provide better health care, but restoration of the environment will be enhanced as well. Until then, the health care system we so desperately want and believe to be our right will remain an elusive dream. That's why I'm so committed to helping solve the U.S. population crisis, and hopefully in the process, protect God's generous gift of nature that sustains us all.

First published in Pop!ulation Press, Spring 2004, Vol. 10, No. 2