I rolled over the pass between Perry Peak and Shaker Mountain and headed home into Massachusetts.  Not far beyond the Pittsfield sign I saw the familiar blue square with the white H directing me to a hospital nearby.  Welcome back to Massachusetts, where healthcare is never far away.

Massachusetts spends $6,682 per capita annually on healthcare, more than any other state according to the Kaiser Family Foundation State Health Facts. Like all issues in healthcare, whether you think this is money well spent depends on which side of the fence you place yourself.  So what does Massachusetts get for paying highest in the nation for healthcare?  More than ninety-five percent of Massachusetts residents are covered by healthcare insurance, as opposed to 83% nationwide. 82% visit the dentist (71% nationally), proportionately more Massachusetts citizens are on Medicare and Medicaid, and the state is below average in terms of infant mortality, childhood obesity, teen suicide, AIDS diagnoses, and adults with disabilities. At first glance it appears there is value in so much healthcare spending. Massachusetts is a relatively wealthy state that ranks in the top ten in most measures of personal wealth.  The median household income is just over $64,000.  It has a highly educated populace with more college degree holders (age 25-34) than any other state, and only fifteen percent of people inMassachusetts live below the poverty line (versus 20% nationally).  By most measures Massachusetts is thinner and fitter than other states but it would be misleading to celebrate that, as Massachusetts residents are still more obese than any state’s citizens were twenty years ago. We may be doing better than our peers, but we are still too fat.

How to interpret these statistics is yet another chicken and egg question.  Is our relatively good health because we spend so much on healthcare, or consequently, if we are so healthy, why do we need to spend so much on healthcare?

Since 2006 all Massachusetts residents have been required to have health insurance.  The law includes a range of incentives for employers and individuals, including penalties for non-compliance, and has enabled a boost in the number of people insured.  But medical costs continue to rise more or less in sync with increases in other states and medical bankruptcies continue on par with the rest of the country.  Since Massachusetts already had a fairly high rate of insured citizens, high healthcare costs, and good health outcomes before mandated insurance, the results of healthcare reform are difficult to gauge, though most studies indicate net positive outcomes.

Massachusetts healthcare is deeply vested in what I refer as the healthcare industrial complex – high technology, high acuity medicine focused on people who have already developed serious diseases. Massachusetts claims more doctors per capita than any other state, and with four major academic medical centers (Harvard, Tufts, UMass and BostonUniversity) and twenty academic teaching hospitals, Massachusettsis an important center of medical research and leading edge technology.

Since Massachusetts healthcare reform was the blueprint for the national healthcare legislation referred to as Obamacare, and is a leading player in research and treatment, it is a good guide to where our healthcare system is headed, a system that relies on insurers as intermediaries to people seeking access to healthcare and focuses on treating disease with technology rather than preventing disease through early intervention.  This is consistent with the American character, since we hate to have people tell us what to do and we love innovative solutions.  Our healthcare system doesn’t offer any comprehensive strategy for us to stay thin or be fit, but when we get so fat that we need our stomach stapled, the system will foot the bill.

The failings of our healthcare system are well documented. It is the most expensive in the world by a wide margin (16% GDP vs 6-9% in most other developed countries), and does not provide commensurate outcomes (ranked anywhere from fifth to thirtieth in various studies).  We are the only industrialized nation that does not provide healthcare as a right to all citizens, which again is consistent with our character, since we prefer to stress individual freedoms over collective rights.

From a guiding principles perspective we have to determine how healthcare fits in our quest to form a more perfect union.   There is really only one question that should drive the healthcare debate – are Americans entitled to receive healthcare as a right?  If we determine the answer to that question is yes, then we can establish the parameters around healthcare (what services should be provided) and create critical success targets to measure how well we achieve our goal.  If the answer is no, then the government should get out of the healthcare business and let people buy it themselves, either by paying outright or buying private insurance.  Instead we are enmeshed in a typically American, piecemeal approach to the problem.  Our individualistic streak is not comfortable declaring that everyone is entitled to healthcare; that is socialism; while our compassionate side is unwilling to let people die for lack of care.  So we cobble together a system where certain segments of our population, the elderly, children, the very poor, have near universal access while the rest of us have to pay if we can and have emergent access even if we can’t. The result is this expensive system of extreme care with little focus on well-being or prevention.  Similar to how we discuss education, when we debate the issue of healthcare, we focus on the mechanics of the system rather than the root cause.  If we could make the decision that everyone is entitled to healthcare, the mechanisms of the system could evolve in a logical way from that decision. Without addressing the big question, we are bogged down in logistics that will never produce adequate results because we have not articulated the problem we seek to solve.

T. R. Reid’s thoughtful book, The Healing of Ameirca; A Global Quest for Better, Cheaper, and Fairer Healthcare is a cogent analysis of the shortcomings of our system and an insightful outline of healthcare in both developed and developing societies.  He synthesizes all major healthcare systems into four types; the private insurance model (Germany), the socialist model (Great Britain), the single payer model (Canada) and the cash model (India).  He posits that the biggest challenge with our system is that all four of these models coexist.  We have socialist style medicine for Veterans, single payer for Medicare recipients, private insurance for those who buy it, and the cash model for people who don’t fall into any of the other three categories.  He provides convincing arguments that a primary driver of our sky high costs result from our multiple models as they create incentives for the private components of the system to shuffle their worst cases onto the public realm.  He demonstrates how socialist and single payer models provide the best opportunities to promote wellness and preventive care over acute responsiveness since they are essentially policy arms of government.  He also shows how Germany, a 100% private system with universal coverage, is most like our own insurance system, yet the fact that it is universal actually results in meaningful savings, as the insurers have more transparent ways of bearing the cost of their worst cases than American insurers. While Germany’s system may not be perfect, they provide healthcare to all their citizens for about two-thirds the cost we do and have better outcomes.

Our present multiple healthcare systems tap too many resources for the benefits they provide.  Regardless of providing better, more appropriate care, our systems will have to simplify and become more efficient or they will further drag down our economic competitiveness.  When we spend 16% of our economic output on healthcare (with some estimates projecting 20% by 2015) while our industrialized competitors are spending 1/2 to 2/3 that, and developing nations spend less than a third, we have created a giant hurdle that we must overcome with higher productivity if we hope to maintain an economic edge.

Moving towards simpler, more uniform ways of taking care of sick people is a worthy objective, but it is really just the first order benefit of a longer range goal.  Ultimately we should develop a true heath care system where education, well being, and prevention are the precursors to treatment; a comprehensive model to help people make informed decisions about how they live their lives, with the cost of poor health decisions allocated to the individual in as pure a form as possible.  There is no reason why health insurance premiums cannot be tagged to incentives to reduce weight, increase fitness, stop smoking, have good driving habits, you name it.  Ultimately our healthcare system should incentivize healthy living as much as possible but acknowledge that as human beings we have foibles and as Americans we cherish the right to do as we like, even when it is not in our best interests, such that, after paying a premium for the privilege of unhealthy behaviors, the system will care for all of us, fat or thin, smoker or nonsmoker, drinker or teetotaler.

On the Friday before Labor Day weekend I encountered many cyclists as I pedaled over the Berkshires from Pittsfield to Northampton, whose downtown oozed with pedestrians.  I witnessed dozens of walkers and cyclists along the bike path to Amherst.  As the gorgeous holiday weekend progressed I continued to see people enjoying exercise.  Even so, for every cyclist I saw, I passed at least ten obese people, for every runner I saw, I witnessed dozens of angry headed drivers, for every hiker I saw, I rode by twenty smokers. Massachusetts may be healthier than its sister states, but we still have a long way to go to proclaim ourselves as healthy.