Book Review: Comprehensive Healthcare Redesign: 25 Keys to Healthcare Redesign, by Dave Racer, Alethos Press, St. Paul, Minnesota , 97 pages, 2011, $15

If we are to achieve a richer culture, rich in contrasting values, we must recognize the whole gamut of human potentialities, and weave a less arbitrary social fabric, one in which each diverse human gift will find a fitting place.

Margaret Mead, (1901-1978)

October 29, 2011 - In most peoples’ minds, 3 basic ways exist to achieve “ comprehensive redesign” of the U.S. health system:

• One, a single-payer system

• Two, a market-driven system

• Three, a combination of the two with built-in managerial controls and goals, aka, Obamacare

To these three, Dave Racer, author of 28 books, publisher, health care analyst, and veteran health care commentator, proposes a fourth idea - a bottom-up culturally-driven system composed of patients and doctors acting commonsensically with high moral principles.

In this gem of a little book, Racer explains why the first three systems haven’t worked and will not work.

He is basically saying: It’s the culture, stupid! Our health system is a creature of American culture – our 311 million polyglot population, our wealth, our Constitution, our centrist bent, our resistance to authority, our partisan politics, our wants, our needs, our health-harmful behaviors, our unrealistic expectation that someone else will always pay.

In Racer’s words, “ We cannot reform the current system. It needs to be redesigned, but from the bottom-up, not the top down. Ask the people who get their hands dirty everyday while paying for and delivering the world’s best health care.”

He supports his argument with an extensive review of the health care literature and these 25 key features of American culture.

1) The population of the United States – The U.S, he says, with its 311 million people, is the world’s 3rd largest nation – a “nation of nations, “ with wide racial differences, a heterogeneous ethic mix, and a tendency to behave as we please, These characteristics make us different than any other country.

2) We live in the richest nation in the world – We therefore have more disposable income. We spend more on health care because we can.

3) Public health systems result in cost shifting to private health care – Medicare and Medicaid don’t pay what it costs to provide the care. So we shift roughly $90 billion to the private sector.

4) Wasteful health spending - We waste enormous amounts of money in our free-wheeling culture because patients often do not comply with doctors’ orders, behave in manners destructive to their health, and show up at doctors’ offices with incomplete medical records with resulting duplications due to our fragmented system.

5) We are a compassionate people – We have developed government sponsored community health centers and laws that say hospitals must accept all comers, including illegal immigrants. People forego personal responsibility for their health because they know the system will care for them and may well fix behaviorally-induced problems..

6) As a people, we are growing older - 77 million baby boomers will become Medicare-eligible in 2011, those of us over 85 will double by 2020, and 40% of us will be 50 by 2050.

7) We embrace and protect the life of our tiniest infants - The cost of neonatal ICUs is $10,000 a day, the total ICU bill may run $250,000, and costs after the ICU may run $40,000 or more for the first year of life.

8) We spare no expense to extend human life as long as possible - CMS says 28% of their Medicare budget is spent caring for patients in the final year. We spend lavishly on high tech procedures that increase function and relieve pain and keep us feeling young, no matter what the costs. . Racer observes, “It is the nature of the United States’ culture to preserve and extend human life, even when it makes no medical sense to do so.”

9) We provide long term care for aging and infirmed residents - Medicaid is the main payer for elderly long-stay residents , accounting for 68% of the cost of care for those residents in 2007, and likely even greater today.

10) We refuse to say “No” to people who abuse themselves. We pay for the care and treatment of drug addicts, promiscuity, smokers, the morbidly obese, through higher taxes and cost shifting to those who own private insurance.

11) We pay whatever it costs to provide care to those with chronic illness – Paying for those 133 million Americans with chronic disease consumes 75% of medical costs, yet we spend little to prevent these diseases. Many of these conditions can be traced to bad personal habits – lack of exercise, obesity, lack of exercise, alcohol, or drugs.

12) We demand the latest and best services - We follow closely recently announced medical breakthroughs and technological advances, and we bring pressure to bear to make insurers pay for them, whether they are proven to work or not.

13) We want to live pain free, but do not want to pay for it ourselves.


14) We want immediate emergency care.


15) We expect immediate access to doctors.

16) We live risk-filled lives and expect health care to fix it.

17) We are a society of overweight people.

18) We take advantage of health plans.

19) We pay health professionals high incomes.

20) We sue doctors.

21) We expect others to pay our health bills.

22) We have no idea how much health care costs


23) We tolerate a dishonest and misleading health care billing system

24) We abuse high deductible health insurance plans

25) Politicians


Most of these 25 observations are self-evident. Taken together, they explain why are costs are so high.

But observing them is one thing, cursing their dark side is another, correcting or modifying them is quite another.

Racer suggests three strategies for redesigning the system:

1) encouraging people to minimize costs by taking better care of themselves;

2) moving to a system, such as health savings accounts with high deductibles to encourage financial discipline by having patients spend more of their own dollars up front, thereby having a higher personal stake in health care;

3) having “Christian individuals, in particular, practice what the Scriptures teach about personal health and finances and Christian compassion for others.”

These are laudable strategies. Some are gaining traction. Wellness is much in vogue. People are more health conscious. Fitness centers are springing up everywhere. Employers are setting up and rewarding measurable good health. About 12 million Americans now have health savings accounts; 30% of employers are offering high-deductible plans . The Christian evangelicals are making themselves heard through the Tea Party and other forums.

But let’s face it. We live in a secular society in which anything goes. It promises freedom to behave as one pleases, with no penalties for misbehavior, and expectations that someone else will pay.

Cultural changes come slowly and from within. Our permissive society does not lend itself to top-down legislative actions. One cannot legislate behavior or morality.

I recommend Racer’s book. It tells us why we have the health system we have and why our culture makes it difficult to change.