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The Pronouncement: The Healthcare Debate In Nutshell

The year is 1989.  I drive cautiously along the rutted, pot-holed, brush-overgrown trail in my four drive “Suzy Trooper,’ threading through Tsavo, Kenya’s largest National Park, to one of its most remote and premier rock climbing areas, Kitcwha Tembo. Next to me sits my friend and climbing partner Iain Allan, a crusty and adventurous Kenyan who prefers the bush to civilization.

To this day, I remember exactly the moment he makes his pronouncement. Maybe it’s the lighting, or the elephant that has just blocked our road passage moments ago, or the fact that vigilance is critical to not being left stranded and risk becoming part of the food chain. On the other hand, Iain is always colorful.  “ Alan,“ he said, reminiscing about his more than twenty years of guiding foreigners on adventure safaris through Kenya. “Don’t get me wrong. Americans are great people. They are friendly, generous, and love to laugh.  But in a nutshell there’s one thing that sets Americans apart from other nationalities. Americans don’t like surprises. If just one thing happens, even a flat tire while on safari that wasn’t predicted, it ruins the rest of their day. They can’t take a surprise. If you can predict every flat tire, they might be able to adjust with a few hours warning.”

The “pronouncement” has clung to me ever since: Americans don’t like surprises. Since then I am reminded of the pronouncement frequently. Traveling in an airport offers some of the best examples. Cancelled flights are met with enraged customers screaming and accusing ticket agents as if they hold the power of “no surprises.”    I’ve seen plenty of patients leave a trail of brow-beaten staff but smile warmly once the doctor walks in the room. Most days I can feel the truth of the pronouncement as our national debate takes on tones of “Please don’t let anything bad happen to us. Please protect me, take care of me, feed me, keep me comfortable, reduce my stress, and no matter what: please no more surprises … ever!”

The no surprises stereotype might sum up the way the rest of the world sees us, but we’re blind to this. I cannot stop thinking about “the pronouncement” as it applies to health care reform. To expect fixing health care without accidents and surprises is unrealistic.  Americans might be able to adjust to all the upcoming flat tires if they are given adequate warning and have an understanding of what’s really at stake.

Here are three economic conundrums to the health care debate, and whose solutions will be rife with surprises:

  1. The U.S. spends 17% of our GDP on health care. No where else in the world even comes close to this, with 90% of other nations spending less than 10% of their GDP on healthcare. How much money is enough? How much of the economy can be allocated to healthcare and still have a functioning economy that covers housing, food, vacation, education, energy, retirement, and the security of basic needs.
  2. The amount of money spent in the U.S. on healthcare doubles every ten years and has been doing so for six consecutive decades.  If we don’t understand what drives these inflators, how are we to address solutions that curb the staggering unaffordable care heading our way?
  3. Whatever the amount of money is decided upon for healthcare in a year (and for arguments sake, let’s just say we’ll keep it at our current $2.4 trillion level for a year or two) what’s the best way to distribute this money, giving people the most options and coverage and personal choice?

I can see my friend Iain mulling these economic problems over, his face reflected by a campfire’s glow after a difficult but thrilling 5.10 climb and an unarmed descent through dense brush filled with creatures that only haunt most people’s dreams. Here sat a man who embraces danger knowing that life is nothing without surprises.  How would he handle these kinds of conundrums with Americans?

“Well,” he’d say in his Scottish-Kenyan accent, “If you can predict every flat tire, they might be able to adjust within a short while. Americans are a great people… they only need to better prepare for the surprises in life.”

“That’s too bad,” I would reflect. “It feels like Americans aren’t even close to understanding the surprises that await them in the healthcare bush.”

The terrain ahead is dangerous and riddled with surprises in all directions. There are the insurance lions, lawyers ready to strike with any misstep. Let’s not forget the elephant politicians who can stomp you to death no matter the objection. Of course there are the innocent wallowing, but vicious hippos, the cape buffalo, the hyenas, the vultures… to all the animals there is a purpose and a reason, each feeding and jealously protecting their part of the $2.2 trillion per year corpulent health care body. Lastly there are all of us patients who must journey the bush, hoping that the guide we bring might be as competent as Iain.

“Iain,” I say, “What climb should we try tomorrow? Maybe we shouldn’t make it a surprise.”

Until next week, I remain yours in primary care,

Alan Dappen, MD


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