I’m somewhat taken aback by the elephant in the room in America’s healthcare debate. On one hand we hear from the libertarian position that healthcare choices are purely a personal responsibility and there’s no place for the government interference. Some of the more shrill voices equate universal healthcare to slavery. On the other hand we have the descendants of the moral majority taking the high ground in protecting the unborn from death by abortion, and demanding a strong government role in the pro-life cause.

Ironically, both causes are often championed by the same people. The Evangelical community rails against abortion, yet at the same time promotes the gross inequities of American healthcare. Go figure?

This bizarre juxtaposition begins to hint at the shape of our invisible elephant. On the surface of things, American morality assigns each life an infinite value, whether it’s the life of a fetus, the life of a loved one, or perhaps even one’s own life. No price is too much to pay to preserve human life (red blooded American life, that is.) When your child or parent is dying, no stone must remain unturned, no cost is too much for your insurance company to pay, no cost is too much for the government to pay, and ultimately no cost is too much for a moral American to pay. Life is precious, and this is a good thing.

American libertarianism, an evolution of the frontier ethic of self reliance, is one of the core values in our society, and has enabled us to conquer a vast and wild continent. But there’s also a sinister side to libertarianism, the materialistic side which obsesses on what’s “mine.” It posits that people with material wealth possess it because of their own hard work and efforts, and that those who do not labor successfully are, by definition, slackers. Any attempt to “redistribute” accumulated wealth to the slackers is inherently un-American (aka Socialism, Marxism, etc…) In short, supporting the common good is a personal choice, not something that flows from the elected government.

So we have a faction that vehemently insists on the supreme value of human life and we have another faction that prefers to hold fast to 100% of their material possessions, and specifically that the value of their lives as a group is demonstrably (in terms of health outcomes) greater than the value of the tens of millions of lives who lack the financial means to access healthcare, be they slackers or just plain unlucky. Were these two factions not one in the same, the elephant in the room might actually be visible.

But I’m not here to simply mock the irony of this situation. The relentless march of medical knowledge and technology means that we will have increasing numbers of methods to preserve life. In a market where there’s some defined balance between supply and demand, this often results in greater efficiencies on the supply side. However, when demand is infinite, as it clearly is amongst the “buyers” of life preservation, supply simply ramps up to absorb the (infinite) demand. Efficiencies or not, in a free market with infinite demand for a good whose supply can be limitlessly expanded, purchasing power for all demand limited goods is crowded out by the good with infinite demand.

Otherwise stated: we’re on a trajectory where healthcare crowds out all other markets. We will all work (presumably in healthcare) and remit our entire incomes back into the industry of life preservation: healthcare!

How do we prevent this from happening? By using intermediaries, either private or public, who are tasked with taking the heat from consumers who are unable to fulfill their unlimited demand, and from suppliers whose revenues are constrained by the middlemen. In the private sector, these intermediaries are better known as insurance companies, and absent any regulation or moral compass, they cherry pick, connecting those consumers who can pay the most and consume the least with healthcare providers who provide the most for the least compensation (and perhaps with greater efficiency.)

The other intermediary is the government, who takes on all consumers (currently of some select classes: senior citizens, veterans, etc…) regardless of their ability to pay or the the condition of their health. As an intermediary the government is also imperfect, subject to the demands of the electorate, in particular seniors, and influenced by the quid-pro-quo money flowing from big healthcare. These forces, combined with the demographics of an aging baby boom, conspire to render government as an intermediary unsustainable.

Where does that leave us? Ultimately there needs to be more rational thinking about the value of sustaining life in an unrestrained manner. These are thoughts and discussions that do not flow from industry or the government. They flow from moral and philosophical leaders, if there are any truly remaining. Society will slowly need to come to grips with the knowledge that the means to sustain life are infinite, but ability to deliver these means to the population at large is limited. Do we then continue to find rationales which result in higher value for certain people’s lives in exchange for diminishing the value of others? Or do we attempt to level the playing field, a prospect that is hard to currently imagine? Morality prods us to level, while the spirit of individual initiative suggests that while all people are equal, some are more equal than others.

The discussion has already begun, but our moral leadership is AWOL. This leaves the politicians and captains of industry to do the heavy intellectual lifting. Can this end well?

(This is the first in a series of posts on the future of American health care… stay tuned!)