A failure of trust

There is good news on the pandemic. The number of new cases is down and declining. There is some evidence that we may have turned a corner. However, it is too early to begin to talk about easing protocols that help to prevent the spread. Like many others, I have been struggling to understand the dynamics of the crisis, in which people continue to choose not to be vaccinated and to engage in behavior that clearly contributes to the spread of the disease. Having received our vaccinations and being in line for our booster shots, we are not feeling personally vulnerable, but we are deeply missing opportunities for our church to gather and struggling with the fear that continues to dominate many conversations in the congregation. Part of the situation is that there are a lot of people in my age group who, like me, are having a hard time understanding the behavior of others.

I grew up trusting doctors and nurses and other medical professionals. My mother was a nurse and our town’s doctor was a close friend and business partner of my father. I can clearly remember being 9 or 10 years old and deciding that I would no longer work on my penmanship. The decision was based on having seen our doctor’s signature on a prescription. He was clearly a brilliant man who was a community leader and yet I couldn’t make out more than a couple of letters of his name in his signature. I knew his full name. His sons were my friends. If he had a sloppy signature, I reasoned, perhaps so should I. i practiced writing my name so that the letters were scribbled together and nearly illegible. I thought that such a signature was the mark of an educated person.

There are a lot of people my age who have lived our entire lives with a deep trust in scientific medicine and the way that health care is pursued in the United States. We tend to think of those who are skeptical as uneducated or misinformed, their behavior the result of being misled and correctable by teaching.

The pandemic, however, has revealed a dark truth about health care in the United States that we had failed to see. Trust in the health care system has eroded to the point where there is a significant portion of the population who no longer put their faith in the system. This erosion of trust has been pretty steady over the course of my adult life. People who are younger than me, including the majority of millennials, are not likely to put their full trust in the medical establishment. There are several factors and some key events in our shared history that have contributed to this loss of trust.

The year that we were married, 1973, was the first year when health insurance companies were allowed to operate on a for profit basis. The Nixon Administration believed that opening up health insurance to profits would increase access and decrease costs due to competition. It didn’t work out that way. Costs soared and insurance rates dropped. The rapidly rising costs resulted in raising the costs of other goods and services due to the cost of providing health coverage for employees. Over the span of my career health care costs made it impossible for many congregations to afford a pastor. At the end of my career, the cost of health care was double the total salary and benefits package with which I began as a minister.

This also opened up an additional revenue stream for many physicians. Because of their concern for health care, many physicians invested in creating health insurance programs. The change in the law meant that they began to earn money from the insurance as well as from the practice of medicine. With that new revenue stream, and a few other sources of income, salaries and lifestyles for doctors began to separate physicians from the community. For profit health care corporations began to grow, often through purchases of other corporations. I have a friend who was a cardiovascular surgeon with a thriving practice. At his retirement he told me that he made more money from the sale of his practice to a large hospital corporation than he had earned through a lifetime of surgical practice. And he was a rich man with three homes, three airplanes and a fleet of automobiles before he realized that profit.

This consolidation of wealth was exaggerated by the tight control of admissions at medical colleges. Well qualified students were turned away simply to keep the competition between doctors low. By keeping the supply of doctors low, the prices continued to rise and physician salaries continued to rise at rates well beyond that of other professions. There is so much excess wealth in the system that non physicians have found ways to profit from managing practices and other means.

People who were born after the rise of for profit health care frequently find themselves in a position where they simply cannot afford it. They have tried to access health care and ended up with costs that bear no relationship to the services provided. No one in the health care industry can explain the costs. While they are simply accepted by many, those who are in their thirties and forties have enjoyed relatively healthy lifestyles with minimum access to health care. They believe that the system and those who work within it are operating an extractive industry, designed to extract maximum profit with little actual care. They have read the statistics on the imperfect application of medicines and know that there are many failures of the system and that medicines are at best imperfect and at times harmful.

This erosion of trust has begun to affect the health care system. Hospital capacities were based not on the need of the community, but on the flow of consumers. Until the pandemic hit there were people who had never consumed hospital care and who had no intention of doing so. As a result hospitals lacked the capacity to deal with the crisis. Despite the shortage, trust in health care continues to be very low.

Trust does not automatically return. It has to be earned. And that takes time. It appears that anything less than a total re-thinking of how health care is delivered in our country will work to restore trust.

While I do not understand those who are intentionally choosing not to be vaccinated, I acknowledge that there is more than politics involved. The broken trust in a broken health care system has to take responsibility for its failure to deliver the promise of the vaccine. Blaming those who are not vaccinated will not work. Earning their trust is a much more difficult task and it won’t be accomplished soon.

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