This article first appeared in the Daily Journal on September 11, 2012.

Spectacular – adj.: of or like a public show; striking, lavish (spek ‘tækjulə(r))[1]

As images of NASA’s 2012 “Curiosity” expedition continue to capture public interest, the word “spectacular” has been getting a lot of play in recent national media. By replacing images of our nation’s beloved hero Neil Armstrong bouncing on the lunar surface[2] with “a one-ton, automobile-size piece of American ingenuity” that is destined to spend the next two years “examining rocks within the 96-mile crater” into which it landed[3], NASA has proven how far we as a unified nation can come in under fifty years with a well-designed, properly funded and tightly executed plan.

Unlike with space travel, gauging the progress of the evolution of a health care system is not nearly so cut and dry. While advances in modern medicine since the introduction of Medicare[4] have in many ways been equally riveting from a technological, political and sociological standpoint, each new period of change has brought with it a divisiveness that has forced individuals to decide whether the system’s latest step is spectacular in its success or failure. When it comes to health care, Americans tend to see things in black and white.

Much of what we now take for granted the field of modern medicine was unthinkable fifty years ago. Technologically, the jumps have been astounding. From its humble origins in the 1970s, X-ray computed tomography has evolved from being able to give a reading that included 160 images, each taking 2.5 hours to process, into today’s 256-slice CT scanner which can in seconds measure subtle changes in blood flow or blockages in blood vessels the width of a toothpick within the heart and brain.[5]

Our understanding of disease has also made great strides, as can be shown by improvements in the treatment of HIV. While still a serious condition, the human immunodeficiency virus has become markedly more manageable, and though it still reduces the overall life expectancy of an individual by 5-10 years, it no longer carries with it the death sentence it held when first discovered.[6]

And yet, even as the provision of medicine continues to improve, the lack of unity among Americans as to how health care should be managed has taken its toll on the industry, bringing with it a host of sociological and ethical issues that often prevent modern breakthroughs from reaching the greatest number of people.  In the first decade of this new millennium, science discovered how to sequence mouse, mosquito, rice, chimpanzee and cow genomes.[7]  Controversy notwithstanding, the nation watched as cloning[8] and stem cell research[9] transitioned from science fiction to reality, as did the equivalent of mind reading with the use of the functional MRI.[10]  When the U.S. Food and Drug Administration first approved oral contraception and made it available in 1965 to all married women in the United States, it was only due to judicial intervention by the United States Supreme Court.[11]  Indeed, it is hard to imagine some 47 years later that female contraception was even an issue in the United States, or that the Supreme Court would involve itself in matters concerning public health.[12] Likewise, though the fields of cardiology and cardiac surgery have advanced in great leaps since the first implanted pacemaker, each year more than one million hospital patients in the United States face high mortality rates due to cardiac events thanks to issues of funding and availability.[13]

While science has in many ways replaced science fiction, the system within which these modern miracles exist now finds itself in uncharted waters. Forty-seven years since President Johnson symbolically handed former President Truman the first Medicare card on July 30, 1965, most would agree that the system designed to provide coverage to all persons 65 years of age or older is undergoing a reorganization designed to reshape the very foundations of what Americans have come to know as health care. Like any business, success or failure is inextricably connected to the market it serves.  As Medicare begins its transition to a performance-based system from its formerly cost-based[14] structure, the business of health care still exists, and so the laws of the marketplace still apply.  If the onset of Medicare’s Value-Based Purchasing program spreads industry-wide, we may soon have a chance to gauge the success of paying for results instead of costs.

A nation’s health care system should define its commitment to domestic sustainability, just as the Hippocratic Oath symbolizes the promise by physicians to practice medicine ethically and honestly.  Though certainly laudable, these basic tenets make the field of health care unique in that it must both provide a high level of care and remain self-sustainable.  While the safety of its patients is of utmost importance, every hospital is a business, and as such must adhere to basic economic concepts such as profit and loss, reasonable compensation for services rendered, and the general understanding that certain skills deserve commiserate compensation, such as saving or extending the duration of human life.

If health care expenses continue to grow at the current trend, the Medicare trust fund will no longer be sustainable, which would in turn cast doubt on the future of our health care system itself. National Health Expenditures have grown from $27.4 billion in 1960 to $2.6 trillion in 2010, while the population expanded from 186 million to 309 million in that same period of time.[15]    What was in 1960 a mere 5.2% of the United States gross domestic product has expanded to 17.9% in 2010[16], and not surprisingly sparked a revolutionary restructuring of our health care system more commonly known as the Affordable Care Act.[17]

But it is not only the fiscal ramifications of a health care system in flux that should be taken into account when judging success or failure. Almost 50 years since the passage of Medicare, modern American health care still lacks any meaningful mechanism to instill a sense of pride in individual health, and furthermore fails to educate the people that they must respect their right to health care.  Though Americans will likely never come to a consensus on such ethical topics as when life begins or when it should come to an end, surely few will disagree that from a practical standpoint the best way to reduce the burden on health care is to collectively live healthier lives requiring less of a demand on the system. For the Affordable Care Act’s trillion-dollar gamble to succeed in its attempt to improve the nation’s health and well being, it is up to the individual citizen to help shoulder the burden. Without respect for the system of health care itself, all the progress science has afforded us may well have been for naught.