The Greatest Injustice - Mike Grady, M.D.

“Of all the forms of inequality, injustice in health care is the most shocking and inhumane”……………..Martin Luther King, Jr.

A thirty year old man, fearing he has pneumonia but more afraid of an emergency visit he can not pay for, visits a feed store seeking veterinary grade antibiotics. A 45 year old man, dropped from Medicaid and eating one meal a day to be able to afford his medications, tearfully rejects a suggestion that he go to the food bank. Customers at a convenience store drop spare change in a jar to help a child get cancer treatment. Meanwhile, every day across this country, patients at the end of their lives receive millions of dollars of publicly funded intensive care and other “rescue medicine” in futile attempts to extend those lives.

Our health care system is a disgrace. The U.S. ranks 37th among nations in health systems comparison. Our rank in life expectancy is 29th and falling. The Commonwealth Fund survey now suggests that the number of uninsured in the U.S. has risen to 48 million, continuing a 20 year upward trend. Lack of insurance causes 18,000 deaths annually with immeasurable suffering and loss of productivity. Medical illness and debt account for 50% of personal bankruptcies. Among 11 developed countries the U.S ranks last in outcomes related to 14 health indicators and in patient satisfaction, but first in expenditure and prescriptions per person. We spend 50% more than any other country to achieve poorer health outcomes while denying even basic health care to one out of six of our fellow citizens. Every hour another Oregonian loses health insurance and every day another dies simply due to the lack of coverage. American medicine is without goals, priorities, accountability, acceptable quality or safety. As the above cases suggest, it fails to recognize basic human dignity and allocates resources in a fundamentally unjust and morally indefensible way.

Two recent attempts to improve coverage point out the absurdity and injustice of continuing to try to change this system in an incremental way. Health Savings Accounts ( HSAs ) allow individuals, most of whom are already insured, to move from conventional health insurance to more heavily tax favored plans. This will financially benefit the wealthy ( those who can afford to actually fund their HSAs) and the healthy ( those who will be able to allow their accounts to grow and rollover each year). The effect will be to remove the healthier and wealthier from conventional insurance, raising the premiums for the sicker and poorer who are forced to remain. Fewer companies and individuals will be able to afford health insurance and the number of uninsured will rise further. One estimate suggests that HSAs will add 600,000 to the ranks of the uninsured. If that were not bad enough, there is evidence that individuals in these “ consumer directed” plans more often forego important acute and preventive care. This is progress?

Medicare Part D is a more blatant travesty. Forgetting for now that it is wildly more expensive and complicated than it had to be, it serves as a prime example of the fundamental injustice that characterizes our health care system. In essence, 43 million citizens already receiving publicly funded healthcare ( Medicare ) and as a group among the wealthiest Americans, were given an additional drug coverage benefit ( at a $800 billion cost over the next ten years, to be paid mostly by future generations ) while 48 million uninsured and poorer citizens, most of whom live in working families and pay taxes that pay for health care for others, received nothing. This is fair?

How did we get such a broken and unjust system? The United States, alone among developed countries, fails to extend a right to health care to all its citizens. Alone among those nations, it fails to understand that basic health care is as fundamental to the infrastructure of society as an education system. We cling to 40-60 year old insurance mechanisms ( Medicaid, Medicare and employer based plans) that do not make sense in today’s world. Our idolatry of market systems has caused us to abandon traditional American pragmatism and notions of community. Despite ample evidence, we refuse to see that buying an appendectomy will never be like buying a hammer and there is no “market” for health insurance for poor people. We decry “rationing” of health care but our system rations by income and chronic disease ( Medicaid), age and disability ( Medicare), race ( Indian Health), military service (VA), employment status, etc. We are fearful of “socialized medicine”, forgetting that education, defense, police and fire protection are “socialized” because, like basic health care, they are essential to the foundation of any society and serve the population most efficiently when paid for by and delivered to all citizens. Confusing health care with health, we continue an illness care model and technological emphasis while systematically undermining support for primary care, public health and prevention where the greatest improvements in the health of societies occur.

Why are we incapable of change? Certainly, trying to fit the square peg of health care into the round hole of a market economy is part of the problem. In addition, our politicians continue the assault on publicly funded health care for the poor even though it does not save money and perpetuates the cycle of rising costs and more uninsured. Well entrenched and profitable pharmaceutical and health insurance industries scoop up premium dollars and buy more lobbyists and another cycle continues, resulting in fiascos such as the Medicare drug benefit. Medical professional organizations and large health care delivery systems have also failed us. Late to even acknowledge the failings of our system, they remain largely self- interested, scrambling for their share of a $1.9 trillion industry. Organized medicine, it seems, is not organized around justice.

Sadly, our churches have failed us as well. They remain locked largely in a charity model of addressing the injustices of society, willing to engage the political process on issues of personal morality, but largely silent when it comes to the staggering and shameful degrees of hunger, homelessness and medical indigence in our society. These problems will not be solved by another food bank, shelter or free clinic but by changes in the priorities of the whole society expressed as public policy. The kind of moral force and public witness of Dr. King and the black churches, so crucial to the success of the civil rights movement of the 1960’s, is seldom in evidence today. As Jim Wallis author of God’s Politics has pointed out, budgets and bills are moral documents and our religious communities could do more to bring moral values to the discussion of public policy.

Ultimately the moral failing belongs to us as individuals. Whether or not we belong to a particular religious tradition, we must see as shameful a system that forces individuals to seek health care from a feed store; that makes patients choose between food and medicine; that has no resources for a child’s cancer treatment, but unlimited resources to spend in an apparent belief that death is a preventable disease.

The United States is a long way from a just, sustainable and morally defensible health care system but the process may have begun. Learn more about the Archimedes Movement and how you can be part of this grass roots effort at http://www.joinam.org/. For those interested in pursuing the topic of health care reform as a justice issue, join the discussion at

Michael Grady, M.D.
Silverton