Healthcare as National Security

Building a consensus around US investments in research that leads to defense against bioterrorism as a national security imperative is not challenging. As such and as an extension, the argument for funding specific vaccine research, infectious disease monitoring and surveillance systems along with robust public health response capabilities and capacity comes under the reasoning of national security.  However, despite being vital to enduring national strength, resiliency, productivity, competitiveness and likewise linked to our ability to support our direct national security efforts and investments over the long-term, the idea of universal access to healthcare as a vital national security imperative is an argument less ventured or acknowledge.

Unfortunately, the discussion of America's health care system has, as with most vital issues currently facing America, degenerated into ideological battle lines without informed or objective debate found anywhere within the immense empty gulf between the warring factions. Nowhere is there a megaphone or platform for pragmatic non-ideological voices for universal healthcare centered on national interest in the form of enhanced U.S. competitiveness and sustainable national security objectives. Instead, we are in an endless and fruitless debate over health care as a declared right by one side versus the idea that any discussion of universal access to healthcare represents some slippery slope towards "socialism" on the other side.

Is Healthcare a "Right?” Are we asking the wrong question?

During Kentucky's 2015 Gubernatorial race I had the honor and privilege to be a member of a post-gubernatorial debate question and answer panel at Kentucky State University as a surrogate for the independent candidate.  The panel provided equal representation with two members for each of the three Kentucky Governor candidates -Independent Drew Curtis, Republican Matt Bevin, and Democrat Jack Conway.

Early in the panel discussion, the moderator asked: "Is Healthcare a right?"  The partisan responses were predictable and therefore offered no new insights, but rather rehashed the stock partisan responses that anyone with any political intuition would have known were coming.  The Democratic state senators on the panel instinctively argued yes, and the Republican state senators naturally argued no.

My Answer?  I said that the question fed into the partisanship that divides us and it was the wrong question to be asking.  Rather than ask “is healthcare a right” (Which I believe while morally right, is difficult to argue from a constitutional perspective) the question should be, is providing universal access to healthcare for all the right thing to do from an economic and national self-interest standpoint?  I approached my answer from three angles, all of which go to the core of American strength, competitiveness, and national security in the long-run. One: Support for a healthy ready and more productive workforce; Two: Increase American economic competitiveness/ reduced burden on American businesses; and Three: Our National Security -  not only as tied to the first two points, but related to our ability to provide necessary bodies for our standing military force.

(1) A Healthy Ready Work Force: I am an Occupational Health Physician Assistant.  I regularly see patients for "fit for duty" physical exams.  Too often I see patients with treatable medical issues – hypertension, obesity, diabetes, obesity, obstructive sleep apnea (usually secondary to obesity), old poorly treated injuries (now with chronic functional limitations) or other medical or physical issues that preclude them from passing a fit for duty medical exam or a physical demand screen (simulated work conditions).  For many, the underlying treatable condition has had minimal to no routine medical care and management for years because they either have no insurance, cannot afford the copays and annual deductibles, or cannot find a provider who is willing to provide care through their Medicaid or other base level insurance.  The result is either they are already unfit to work safely and productively without risk to self and others, or will eventually be in such a condition.  The cost to them and our society as a whole is tremendous.  The long-term eventual medical costs compounded with their continued deteriorating health and the comorbid conditions that will develop into costly emergency medical interventions or significantly shortened productive lives.

The United States ranks 26th among OECD nations in life expectancy and had a decline in life expectancy between 2014 and 2015 for the first time in greater than 20 years.

Most importantly for productivity, the decline was primarily secondary to increased mortality among middle-aged Americans, i.e., working aged.  Another way to look at it is in Potential Years Life Lost (PYLL) which measures years of potential life lost from premature deaths in the 0 to 69-year-old population. PYLL, in many ways, is a measure of lost potential productivity in that it measures lost life years primarily before traditional retirement age workforce exit. By this measure, the United States ranks 22nd among OECD nations at 4,611 years life lost per 100,000 population. (2) That figure is over 1000 life years per 100,000 population greater than the Czech Republic, roughly 1700 life years per 100,000 or 60% higher than Germany, and nearly twice the rate for the top five performing nations of the OECD.  Based on 2010 U.S. census numbers, we have approximately 263 million Americans age 0-69 years (309.3 million Americans as of 2010 census, minus around 15% who are 70-year-old and greater).  The total U.S. YPLL is about twelve million Potential Years Lost annually (263 million divided by 100,000 times the U.S. YPLL rate of 4,611 PYLL /100,000)

You want greater U.S. productivity, a faster growing U.S. economy, a higher labor participation rate and fewer folk’s dependent on our state and federal social safety net?  Then invest in a healthier America that will be “fit for duty” and have fuller more productive lives.

 (2) Reduced burden and greater U.S. business competitiveness: Our muddled and convoluted health care system puts U.S. businesses at a comparative disadvantage. This goes hand in hand with argument number one in that a healthier workforce is more reliable, will have fewer sick days or family leave days and be more productive for more years. But let's take this further. Why is our US Health Care system traditionally employer-based?  It is because of the legacy of a World War II loophole in wage and price controls. With most able-bodied men and many women off at war, and our nation's great industrial capacity geared up to supply the ships, aircraft, vehicles, weapons, ammunition and all other needs to support the fight, labor markets were stretched thin.  President Roosevelt implemented wage and price controls to stop the spiraling inflation of labor and production.  One avenue used to recruit and retain workers not constrained by wage and price controls was employer-provided health insurance.  Thus, the employer-based US Health insurance care system was created. (3) Now, rather than a single-payer universal healthcare system as is found in most other 1st world industrial nations, Americans are insured through a convoluted network of insurers and our US businesses are entangled in the endless complications, administrative hurdles, and expense of providing health insurance. Prior to the restructuring of General Motors and Chrysler (and I am sure the same is true for Ford Motor Company), before an ounce of material or a second of time was invested in a vehicle on the assembly line, there already existed a legacy medical cost for retirees of between $2000 and $2500 per car – a cost NOT borne by foreign assembled vehicles from nations with universal healthcare and manufacturers free of these obligations.  

The ACA represents a step forward in broadening access to care for many millions of Americans and offering protections for those with pre-existing conditions and by eliminating lifetime caps for care. Since the implementation of the significant aspects of ACA, 28 million fewer Americans are without some degree of health insurance, (4) secondary to expansion of Medicaid coverage (in states that adopted ACA Medicaid expansion) and by providing prorated subsidies to those in the individual insurance markets up to 400% of the poverty and federal support to these markets. The flip side is that the ACA has also created further burdens of administration and compliance for US employers which erodes our competitiveness, and the ACA is, for political and ideological reasons, under relentless attack and deliberate sabotage that have limited its successes and threaten to reverse the gains. (5) The now constant uncertainty brought about by the hyper-politicization of health care in America comes with a cost in reduced market competition and reduced market stability and rising premiums. (6) Furthermore, the ACA has only perpetuated a system in which individual and family eligibility for varied health insurance assistance and insurance eligibility continually changes as their fortunes, age, or the political whims of their state and federal legislatures change. We would be hard-pressed to produce a more tortuous and inefficient health insurance system.

Universal single payer health care could lessen, though not eliminate, the corporate and business administrative and compliance burden and associated expense of our current U.S. health care system, would allow American companies to focus their energy and time on the products and services they supply, not in meeting health insurance mandates, reporting, and compliance. If the examples of most of our competition are any indication, universal single-payer health care can deliver equal or better healthcare outcomes at a significantly reduced cost. The OECD norm is about 10% of GDP to provide healthcare for all versus the approximately 18% of GDP we currently spend while still leaving tens of million Americans uncovered and tens of millions of other Americans with marginal coverage, along with exorbitant co-pays, and debilitating annual deductible and with very limited access to care depending on their insurance carrier.

A good analysis of the American competitiveness deficit secondary to our current healthcare model is found in the following article from Council on Foreign Relations article - Healthcare Costs and U.S. Competitiveness (7)  The U.S. spends approximately $2 Trillion annually on health care, more than any other industrialized country in absolute dollars or as a percent of GDP, yet the outcomes place the U.S. 26th among OECD nations.

An additional consideration is that universal health care would be a boon to entrepreneurship. More Americans would be likely to take the leap and pursue their creative business dreams if the risk of losing healthcare or the volatile and rising cost of individual market insurance were removed from the calculations when considering striking out on their own. Likewise, small businesses would find it easier to attract and hire employees.  (8)

You want to give America a competitive advantage - or at least level the playing field? Then reduce the burden on US businesses, lessen the risk for an entrepreneurial enterprise, reduce the overall cost of America's health care system, and stop treating our healthcare system as a political piñata for short-term political advantage at the expense of and long-term detriment to our nation's health, competitiveness, and economic stability. Implement universal health care in America.

(2) National Security: What does the current state of the U.S. health care system have to do directly and immediately with our national security?  According to the organization Mission Readiness: Military Leaders for Kids in their report "Ready, Willing, and Unable to Serve," 75% of young adults in America cannot join the U.S. military. A fair percentage are secondary to failure to meet minimum education standards, having dropped out of high school, or having criminal records, but a staggering number are ineligible secondary to health issues. "Twenty-seven percent of young Americans are too overweight to join the military. Nearly a third (32 percent) of all young people have health problems – other than their weight – that will keep them from serving. Many are disqualified from serving for asthma, eyesight or hearing problems, mental health issues, or recent treatment for Attention Deficit Hyperactivity Disorder. When weight problems are added in with the other health problems, over half of young adults cannot join because of health issues." Additional numbers are ineligible because of drug or alcohol problems, which is also a health issue/ illness. "Even when recruits qualify, health problems can cause significant deployment and expense problems later; for example, 20 percent of the Army's reservists arrived at mobilization sites with dental conditions that made them non-deployable." (9)

Lack of routine medical care, poor or sporadic disease and injury management, and a lack of prevention for many of our fellow Americans is a significant contributor to this current dismal state, exacerbated by 32.2 percent of American children living in poverty (the U.S. ranks 36th out of the 41 wealthy countries). (10)  With our current force drawdown (for my thoughts on military strength and the value of national service see (10)), our dwindling number of able-bodied potential recruits may not be an immediate insurmountable obstacle to meeting strength targets. However, the trends indicate we cannot stand up an able-bodied force of significantly greater numbers if and when the need arises.   Many factors contribute to the poor physical and medical conditions of too many of our young Americans.  Lack of consistent quality care, lack of preventive health service, and lack of continuity of care are factors we can address as a nation through universal healthcare.

The strict partisans and ideologues will continue to argue whether or not healthcare in America is a right guaranteed to all, but again, that is not the question we should be asking.  I will continue to argue that universally accessible quality health care is the right thing to do morally, as well as for our economic competitiveness, to maximize workforce participation and productivity, and for the nation's sustained strength and security.  Regardless of where you stand on the healthcare as a right debate, universal healthcare is the pragmatic sensible right thing to do for our nation's best interest and sustained national security.

 “The human and material resources that make a great society are produced at home, not abroad. An ambitious foreign policy built on a deteriorating domestic base is possible only for a limited time; like the light cast by an extinct star, it is predestined to come to an end.”

Senator J William Fulbright, 1966 The Arrogance of Power

Sources :

(1) Lenny Bernstein, U.S. life expectancy declines for first time since 1993, The Washington Post, December 8, 2016 (https://www.washingtonpost.com/national/health-science/us-life-expectancy-declines-for-the-first-time-since-1993/2016/12/07/7dcdc7b4-bc93-11e6-91ee-1adddfe36cbe_story.html?utm_term=.ebfdf34aa630)

(2) OECD (2017), Potential years of life lost (indicator). https://data.oecd.org/healthstat/potential-years-of-life-lost.htm

(3) Stephen Mihm - Bloomberg View, Employer-based health care was a wartime accident, Chicago Tribune, February 24, 2017
http://www.chicagotribune.com/news/opinion/commentary/ct-obamacare-health-care-employers-20170224-story.html

(4) Kaiser Family Found Key facts about uninsured population, September 19, 2017 https://www.kff.org/uninsured/fact-sheet/key-facts-about-the-uninsured-population/

(5) Center for Budgets and Priority: Sabotage Watch https://www.cbpp.org/sabotage-watch-tracking-efforts-to-undermine-the-aca)

(6) Erin Trish, Loren Adler, and Paul B. Ginsburg, To promote stability in health insurance exchanges, end the uncertainty around cost-sharing and other rules, Brookings Institute, April 20, 2017 https://www.brookings.edu/blog/up-front/2017/04/20/to-promote-stability-in-health-insurance-exchanges-end-the-uncertainty-around-cost-sharing-and-other-rules/

(7) Toni Johnson, Healthcare Costs and U.S. Competitiveness, Council on Foreign Relations, March 26, 2012, https://www.cfr.org/backgrounder/healthcare-costs-and-us-competitiveness

(8) Alex Smith, Uncertainty Over Health Care Law's Future Hobbles Entrepreneurs, September 23, 2017, http://www.npr.org/sections/health-shots/2017/09/23/550994054/uncertainty-over-health-care-laws-future-hobbles-entrepreneurs

(9) Mission: Readiness - Military Leaders for Kids, Ready, Willing, and Unable to Serve, www.MissionReadiness.org http://cdn.missionreadiness.org/NATEE1109.pdf

(10) Christopher Ingraham, Child poverty in the U.S. is among the worst in the developed world, The Washington Post, October 29, 2014 https://www.washingtonpost.com/news/wonk/wp/2014/10/29/child-poverty-in-the-u-s-is-among-the-worst-in-the-developed-world/ 

(11) Ronald Leach, Thoughts on National Service, January 21, 2015 https://drive.google.com/file/d/0ByM18Zx3ojQPeHhtckJfZENGUjg/view?usp=sharing) and posted at https://ronleach4ky.com/blog/?viewDetailed=201501212249