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The other night I awoke from having drowsed off in front of the TV to be confronted by
Stephen Hawking chatting about the genesis and development of the universe. Starting
from the point of being here in this time and place (the anthropic argument), he went
back in time to the Big Bang, stopping at points in cosmological time to point out
imperfections in the universe that caused the peculiarities that allowed matter and
energy to behave in certain ways to make possible human existence. If things had not
occurred as they did, we would not be here. We are here because the innumerable
systems within systems in which we are living interact in certain ways. Since we are,
there could not be any other way. Since I had been thinking about the current American
health-care system earlier in the day, I began to think about the forces and events that
shaped the rules (laws) that govern it today.

Systems defy change. Systems have rules that say how they operate and the role of
each component plays in the operation of the system. In addition, there are rules about
how each component must communicate with any other component specifying which
can and cannot communicate. There are also rules governing the systemʼs and it
subsystemʼs relationships to other systems in which it is imbedded or related to. To
change any rules means changing how the system operates and, effectively, its
purpose. Since human systems are subject to the inconsistencies and unpredictability of
the human component, a regulatory mechanism serves to maintain equilibrium in the
system. This is the purpose of anxiety, the only emotion that appears to be transmitted
from one brain to another and, on occasion, corporately.

Non-substantive changes (first order) do not affect how the several components of the
system relate to one another. The recent Health Care law consisted of first order
changes which did not alter the system. The threat of more substantive changes
resulted in irrational uproars that indicated angst was present. While a government run
option would have altered the system substantially, it was eliminated as an option by the
amount of pressure exerted by vested interests in jacking up a general sense of panic.
The resulting bill left the system unchanged and more deeply entrenched as corporate
interests were served by requiring a larger base of customers. Required acceptance of
pre-existing conditions and the prevention of terminated insurance only balanced what
was gained financially. The system continues as before.

Substantive changes (second order) in a system require altering the relationships

between components of the system and how those components relate to other systems.
These changes require far more effort to accomplish and actually rely on external
events to bring them about. Our health care system arose because of such an event.
Before World War II, individual consumers of medical services interacted with both
physicians and hospitals and paid (or not) their bills directly. Insurance could be bought
by individuals, but the patient remained the consumer. As a result of wage freezes
during the war, employers offered health insurance as an inducement in place of raises.
As employers could buy insurance at rates lower than individuals, they became the
consumer of the product. Over time this led to todayʼs situation in which health-care is a

bargaining chip in labor relations and in hiring. Subject to the vagaries of the economy,
oneʼs and oneʼs familyʼs welfare is contingent on a specific employment. This results in
the determination of benefits between two corporate entities excluding the end user of
the product. The deliverers of health services, through direct reimbursement, no longer
deal directly with the patient financially, but with the insurance company which
determines reimbursement for services. As both the services and the overhead required
increase, the practitioner is forced to economize by increasing patient load and
decreasing time spent per patient. Any change in the system threatens each of the
layers as the system once in motion depends on the acceptance of each individual
component to play its role. Small imperfections can be tolerated, such as non-
conforming physicians and clinics who do not accept third party reimbursement, but
disaffection by a large number of physicians could not. Any serious alteration at any
level would result in serious economic damage resulting in curtailment in the delivery of
healthcare service.

Following World War II, Europe and the United States went in two different directions in
the delivery of health care. Elaborate systems have been developed, one using the
government sector, the other the private sector. Within each there are elements of the
other providing options. Medicare-medicaid in the USA and private medicine in Britain
are examples of this. But these, too, are dependent on the smooth functioning of the
larger system in which they are enmeshed.

Is second order change possible? I do not believe it is possible without some powerful
influence from without such as created the present system. One does not really wish to
contemplate war, economic collapse, the rise of a dictatorship, or alien invasion as such
an intervention. The best we can hope for is slow incremental changes of the first order
type. However, regulating the insurance industry or government mandating coverage
paid for by employers or those persons without resources only places a burden on
government with no source of income specific to the outlay.

However, second order change may be in the offing if the private sector realizes that its
connection to the insurance industry is imposing a drag on its flexibility to change and
adapt to new economic conditions. That relationship is at the heart of the current system
and its beginning is where we must look to see a way out of the problem. It worked both
as a means of maintaining stability in a basic industries manufacturing economy. A
stable, reliable, trained work-force was necessary for the economy. At the same time,
the increasing complexity and cost of medical care demanded a source of
compensation necessary to maintain both growth and demand. Now the growth and
cost of medical services have outstripped the capacity of private industry to pay the bill
of ever-increasing premiums. In addition, the economy is radically changing from the
stable basic industry model to a more fluid one in which technology, robotics, and multi-
national corporations operate with constantly changing employment needs. The
individual can no longer choose and train for a vocation and expect it to last a life time.
Changing jobs and professions occur at increasingly rapid rates. Health care based on
steady employment is at risk. Periods of unemployment and time off for re-training leave
individuals at risk for catastrophic financial drain. In addition, the private sector is finding

ways to use temporary, part-time, or foreign help in place of a permanent work-force.
These trends will not abate as the economy improves as they are intrinsic to the basic
changes taking place within the core economy. What the catalyst will be that triggers the
dissolution of the bond between employers and the insurance industry remains to be
seen. I believe it will happen. When it does, both employers and the work-force will
attain a new freedom to adapt to change and will welcome the increased flexibility.

What will take the place of the current system? If all persons are to be assured
healthcare, then they must assume the responsibility through their government. For all
the opposition to recent health-care reform, it was “hands off my medicare”. It works.
Medicare is a model that can work for an entire population. Eliminate medicaid which
creates a separate class of patients “on welfare”. Rather, guarantee 80% payment of
established medical expenses with reasonable deductibles and co-pays. Let insurance
companies fill the gap with voluntary policies reflecting individual preferences and risk
factors. Pay for it like social security with a pay-roll tax contributed by both employer
and the employed. The more earned the more paid in. If one chooses, as in the UK, one
can purchase health care insurance to cover private care and providers can opt to work
in this milieu without restriction to fees. It would involve for more than this brief outline,
but the basic framework is already it place. Would the country buy it? If the economy
continues on its economic course of change, it will have to. While we struggle to reform
the health care system, forces from outside the system are already intervening. We
need only 3atient waiting and watching for the moment of our intervention.

Ron Cebik
Wednesday, May 5, 2010