If in New York City education the signposts to the future are easy to see, that is even more the cast in health care, where an institutional collapse is slowly grinding on even as health care spending escalates. For the shrinking number of people with access to benefits paid for by others, ever more services of greater or lesser value continue to be provided at greater and greater cost — to someone else — with no end in sight. Meanwhile, a larger and larger number of people are entitled to less and less. The one thing that could head off a retirement crisis caused by rising lifespans, moreover, is that rising obesity and diabetes could slash the age of death or disability of those without the health insurance benefits to combat it. Average American life expectancy could fall as a result, the way it did in the former Soviet Union after its institutions collapsed, unless the increasingly long lives to those with the good deals are enough to bring up the average compared with the majority. Moreover, those facing pre-mature disability are, by and large, also those without access to retirement benefits other than an oversubscribed Social Security system. So we could have two classes — one that has to go on working though unable, and one that is able to work but doesn’t have to, and gets to live on while not working, and consuming lots of health care, for a very long time.
There is, however, a reason to believe that present trends might not continue. None of the candidates for President saw this situation — all for some, nothing for others who pay for it, and ever more spending — as acceptable. All promised to put a stop to it. And the leading candidate for President, Barak Obama, is not a member of the generations that have set up a very good deal for themselves and passed the check to those coming after, so he might have a different perspective. Health care, moreover, is a federal issue, and in much of the rest of the country the United States remains a democracy, so it is possible that at some point the national policies that work to the disadvantage of a growing majority will reverse. Congress, however, represents those on the winning side of current arrangements, and takes their donations, so institutional collapse for the majority remains the most likely course, as those with good deals hold onto and expand them no matter what. What might be expected is a repeat of the Medicare prescription drug benefit — more funding for more services for those receive a great deal of funding and services already — combined with a concession that the next President’s “hands are tied” by the exploding budget deficit.
Clearly the U.S. health care industry is not going to disappear. What may be expected is that at some point (perhaps already passed) its cost will have become so great that it just cannot absorb additional resources. Perhaps the trigger will be a massive financial crisis, when those who save (generally outside the United States) are not longer willing to lend money to the federal government that Americans cannot afford to pay back. At that point, the only way those currently entitled to whatever additional health care may come along, at whatever cost, can maintain that entitlement is for money to be saved on the less entitled. For some to have all, with someone else footing the bill, more and more have to have less and less. So what can those not in on the deal, other than high taxes to pay for those who are in on the deal, expect to do for health care twenty years from now?
For education, I suggested that in the future the best option remaining available for middle and working class families might be assisted home schooling – pay taxes for luxury class schools for those who matter, and then teach your own kid at home, perhaps in cooperation with other parents, probably with the assistance of a tutor. For health, the likely result is self-health care, supported by the internet.
Most people, in fact, provide health care to themselves and their loved ones, relying on the health care industry to do testing, provide advice and check on progress. When one is injured or ill, the health care industry diagnoses the problem and recommends a treatment. Subsequent visits check the results and recommend modifications. Today’s young people, lacking access to health insurance and if unable to afford physicians on their own, are likely to rely on the internet and home testing kits – or perhaps tests administered for a more modest fee in pharmacies – to figure out what is wrong with them. Physicians currently retain a monopoly on the availability of restricted drugs, but as both health care and drugs become more expensive many Americans, like those in poor countries, are likely to rely on bootleg and black market pharmaceuticals. Self care chemotherapy for cancer based on a web-assisted self-diagnosis? For many of tomorrow’s Americans, the alternative might be no care at all.
Where the health care industry does provide direct care is surgery. Here the response to decreasing insurance is likely to be an expansion of the already booming medical tourism industry. According to a recent article in The Economist: “over 45m Americans are uninsured, and many millions more are severely underinsured. Such people may find it cheaper to fly abroad and pay for an operation out of their own pockets than to find the money for deductibles or ‘co-payments’ charged for the same procedure at home. Arnold Milstein of Mercer, a consultancy, calls them America’s ‘medical refugees.’” In addition to foreign surgery, we may have home surgery, and home childbirth by assisted practitioners who are paid in cash and do not give their names to avoid getting sued.
So while some Americans receive the finest and most advanced high-tech care at home, health care that the world’s wealthy travel here to receive, other Americans will either have to travel to poor countries or go on an unregulated black market to receive run of the mill health care, paying out of their own pocket. Obviously, I recommend that young people do all they can to remain healthy as long as possible, as they are unlikely to be able to obtain the care older generations take for granted.
And what about the unhealthy, those with serious debilitating or deadly congenital or acquired conditions? Self-help via the internet, home test kits, bootleg drugs, and trips to Thailand for a surgery or two are unlikely to meet even their most basic needs. The life expectancy and quality of life of people with many conditions has improved in recent decades. For non-wealthy people on the outside of the formal government subsidized health care finance system, that trend may reverse.
I do not predict this nightmare will occur because taxes fall and less public money is spent on health care. Indeed, those without any government health insurance or subsidies will probably have to pay increased taxes for past (financed by debt) and future benefits for those with extensive and increasing health insurance or subsidies. This prediction is based on an extrapolation of current trends forward. America’s institutions are being hollowed out from the inside by self-dealing and excess privilege. Health care will be no exception.
For an amusing discussion of a post-collapse environment, read this. The author under-appreciates the flexibility of capitalism, and in particular we are unlikely to have millions of abandoned homes alongside millions of homeless — the homes will be recycled at lower and lower prices until they are filled. Yet some of the insights are worth a look. Particularly in parts of the economy dominated by public policy, such as health care, education, and transportation.