I suspect we all have our rogues’ gallery of vexing social issues, those that get under our skin and, like splinters not easily removed, hurt. Here is my gallery: credit cards, medical technology, global warming, and the automobile. That may seem a disparate, unconnected list. But the four have in common one disturbing feature: each is giving us considerable trouble and each admits of no solution short of a cultural revolution.
This leaves me with a troubling question. How do we go about changing embedded ways of American life, upending patterns of desire and behavior that are at once very popular, praised for their numerous benefits, commercially profitable, and so widespread that it is almost unthinkable to do without them? I have no clear answer to the question, or even a muddy one, but the question is urgent.
Consider the subprime mortgage crisis. It appears to be the fault of an irresponsible industry that made bad loans to millions of people, and that is surely true. But it could not have happened so easily had Americans not become captured by a way of life that made it easy for them to take out foolish loans so that they could own their own homes. We had already been preconditioned by credit cards, the beginning of the slippery slope.
Initially those cards were thought of as nothing more than a convenient way to avoid carrying cash to pay small bills. When it gradually became clear that they were also a fine way to run up large bills and to pay only a small monthly credit charge, a great jump in lifestyle became possible. Credit debts running to the tens of thousands of dollars are now possible for low- and middle-income people, even when there is little possibility that they will ever pay them off. And when borrowers reach the credit limit on one card, they can get another one, and then another.
All this can easily be blamed on the irresponsibility and cupidity of the credit-card industry, but it would hardly have been so destructive had millions of ordinary Americans not been eager to live a high life with little thought of the future. Now it may well be that the growing and immediate pain to many people living this way will force a correction, much as the Depression of the 1930s forced those raised in the affluent ’20s to change their profligate ways. Those of us raised in the ’30s and ’40s imbibed a fear of debt at our mother’s breast. For many not similarly nurtured, the change will be hard, and no less hard for those industries-and the thousands of people they employ-that have feasted off the poisonous extravagances. It is just possible, however, that the children of debt-ridden families will respond the way the children of the 1930s did.
The credit-debt problem may be easier to manage than the three other examples I want to look at: our addiction to new medical technologies, our insatiable growth-oriented industrial practices, and our unsustainable reliance on automobiles. There is considerable overlap in these examples, but the thread that runs through them is the triumph of “the American way of life.” To complicate matters, many people willing to make sacrifices to combat global warming may not be inclined to give up a few months of expensive cancer treatment to help lower national health-care costs. Nor do those who see the growing number of vehicles as a menace usually have in mind ambulances, school buses, produce trucks, transportation for the frail elderly, driving children to soccer or art classes, or getting around in rural areas where no public transportation exists.
My own work in recent years has focused on health-care reform, and particularly on the role of technology in raising health-care costs, so I will begin there. Those costs are rising at an annual rate of 7 percent a year, and that growth rate is projected to continue for the foreseeable future. If that happens, the present cost of $2.2 trillion a year will rise to $4.3 trillion in ten years. In that same period of time, the cost of the Medicare program for the elderly, now at $400 billion a year, is projected to rise to $800 billion-at which point the program will go bankrupt. The ideal annual rate of cost increase should be 2 to 3 percent, consistent with the annual cost-of-living increase. Only that option would make long-term sustainability possible.
For years, health-care economists and, most recently, the Congressional Budget Office have determined that 50 percent of the annual increase can be traced to new medical technologies and to the increased use of older ones. There are many ideas about how to deal with this cost problem: enhanced information technology, reduction of waste and inefficiency, research to determine the efficacy and cost-worthiness of medical technologies, and (from the conservative side) consumer-directed health care, increased patient choice and responsibility, and better competition among health-care providers. The Right and the Left both have their own nostrums, most of them based on hope, speculation, and dubious data.
One obstacle to putting better ideas to work is cost. It costs money to save money (it would cost $120 billion to put information technology in place for patient records). But there is also powerful resistance to doing anything that would reduce access to technologies. The public loves them (they work, save lives, and reduce suffering), doctors are trained to use them and are paid better for doing so rather than for talking with patients, and there is a huge pharmaceutical and medical-device industry that makes billions of dollars selling them. And since 1965, influenced by industry and physician opposition, Congress has refused to take cost into account in determining which technologies and other treatments Medicare will pay for.
The cuts that would be necessary in health spending to reach a sustainable point are enormous, and they would hurt all but the most affluent. No doubt for just that reason contrarians have emerged, not many but influential. There are those, like the Harvard health economist David Cutler, who contend that the high costs are “worth it” in longer, economically more productive lives. Then there are those who say it doesn’t matter how much we spend. Improved health is as good a national expenditure as any other. There are also the hope-mongers who believe more and better medical research will find cures to expensive diseases, that cheaper technologies can be developed, or that disease prevention can save the day, though prevention does not cure death but only delays it. Finally, some argue that health services are a reliable area of employment and economic growth.
If Americans are enamored of endless medical progress and technological innovation, they are no less hooked on the kind of industrial progress that has been the source of our enormous wealth and high per-capita income. But it is also the source of global warming, which is a long-term threat to our prosperity. Constant economic progress turns out to require enormous amounts of energy and relies on fossil fuels to provide it. The Intergovernmental Panel on Climate Change estimates that close to 60 percent of CO2 in the atmosphere is generated by fossil fuel, and that it grew by 80 percent between 1970 and 2004.
The United States is the leading source of global emissions, though the Chinese are likely to overtake us soon. As with medical technology, it is easy to see the economic and social benefits created by industrial growth. Americans live fine lives on the whole. We enjoy widespread prosperity and have amenities that earlier generations could hardly have imagined. We show no sign of wanting to live any other way. China and the other developing countries aspire to the same kind of lifestyle, and they are doing so by polluting the atmosphere just as we are doing. While the Chinese recognize that atmospheric pollution is a serious problem, they don’t think it’s as bad as being short-changed on the prosperity and consumer goods enjoyed by developed countries.
There are many proposals available to cut CO2 emissions: reduction in the use of coal (perhaps the most important), developing alternative sources of energy (wind and water power, nuclear energy), and promoting change in lifestyles (the greening movement). Yet it is hard to believe these efforts will be enough to radically reduce emissions, and not just slow the rate of their growth (which is about all the Bush administration has been willing to consider). The push for individual prosperity and for constant economic growth remains unabated. That drive is precisely what will have to give way.
Just as the medical-technology problem has its deniers, so does global warming: it is not all that bad, some say, dire projections are often false, and better technologies can save us. Again and again in the medical-technology literature there appears a profound ambivalence: technology costs are a problem, but nothing should be done to “stifle technological innovation,” which will save lives in the future just as it has in the past. How can we give that up? Similarly, when it comes to global warming, there may be a problem, but upsetting the economic engine that provides growth and prosperity is too great a risk to take now.
So the environmental follies continue apace. The average gas mileage for automobiles is no better now than it was twenty years ago: engine improvements have been more than offset by the added weight of safety features. Hybrid cars are, for some, a third family car. They are even driven more than other cars precisely because of their fuel savings. The diversion of crops to ethanol production is hurting the provision of food in poor countries and adding to the world’s smog. The affluent summer residents of Nantucket Island object to offshore wind turbines as an eyesore. When an environmentally conscious citizen in my area erected a wind turbine in his yard neighbors took him to court for the same reason.
We have known for a long time that automobiles and trucks pollute the environment, but there is another problem that is almost as important: their effect on our work and family life. As of 2006, there were 244 million vehicles in the United States, and that number increases at an average annual rate of 2 percent. Stories about the problems of commuters have become a staple of news broadcasts, and every major radio station provides regular reports on road and traffic conditions.
The effect on family life is no less evident: we leave for work earlier to cope with the traffic and arrive home much later because of the length or slowness of the commute. Family dinners are just about impossible when parents arrive home late; children can’t wait to eat. But it was the automobile that made suburban living possible, and it was hard to discern even a couple of decades ago that the cars that liberated people from cities would soon prove a trap, a trick played on us by the promise of greater mobility.
As with medical technology and global warming, there are many proposed solutions, few of which have made a great difference. Improved public transportation seems an obvious direction in which to go, but apart from the high costs of putting a good system in place, mass transit doesn’t appear to have much effect on automobile use. Some of the worst traffic jams and commuting times are in cities with good systems of commuter trains, subways, and buses. Washington, D.C., Chicago, and New York City all come to mind. Probably half the residents of my small town north of Manhattan commute to work, some going south to the city by train, others driving north to businesses that moved out of the city for less expensive facilities and the putative ease of suburban commuting. It is noticeable at our train station, and in just about every town on the train line, that parking space is increasingly at a premium. Each year, more and more people commute by train, but most of them are from two-car families (and half their cars seem to be SUVs). They drive to the station in order to commute by train to the city, but once they get there, traffic is so dense they find it is faster to cross midtown Manhattan on foot than to take a bus.
President Bush recently proposed that average vehicle gas mileage should be raised from the present 25 mpg to 35 mpg by 2021. I did a little math on that goal. If there are now 244 million vehicles, at a 2 percent yearly increase there would be 328 million by 2023. If each of these vehicles averaged 35 mpg, that would still translate into only a 4 percent reduction in emissions, a trivial gain. Meanwhile, we would have added 30 percent more vehicles to the road, thus lengthening the pleasure of our already-long commutes.
The American love of the automobile no doubt accounts for much of our travail, and it hasn’t helped that the U.S. auto industry early on resisted public transportation initiatives. But a trip to any European city shows that people there are in a similar fix. Just about everyone everywhere is infatuated with the automobile (here come China and India) and even good public transportation systems don’t stem the tide.
I began by saying that I have no solutions to the problems I raise, not even fuzzy ones. But perhaps we could start by recognizing that at bottom all of these problems are cultural in nature, based on common ideas of what makes for a good life: prosperity, good health, and physical mobility. They cannot be fixed by more and better technology or smarter ways of organizing health care, traffic patterns, and emission controls. All of that will be needed, but it is not sufficient. To address the problem we also will have to be prepared to put up with worse health (or at least without ever-improving health), less prosperity, and less mobility. Few people will be ready to make such sacrifices, which are far harder than foregoing an optional CAT scan, setting our thermometers lower in the winter, or buying a hybrid vehicle.
It may well be that nothing less than disasters of one kind or another will bring about basic changes in our way of life. Nothing is harder than getting human beings to alter the way they live when the worst scenarios are still in the future, the present is still tolerable, and the costs of change seem exceedingly high. But the fact is that, just in my lifetime there has been a major civil-rights movement, changing the way we look at minorities; feminism, doing the same for women; and the environmental movement itself. Each still has a long way to go, but together they have achieved serious momentum. We think differently, often act differently. It remains to be seen whether the four problems I have explored can force the momentum necessary to save us from a bleak future.
If they did, we could have a better country. Our lives have not improved much over the past few decades; in most ways they are worse, and moving in the wrong direction. It has forever been said that clocks cannot be turned back. Wrong. We could still live good lives with less medical technology, more saving, less debt, less industrial growth, and fewer automobiles. We are now being hit over the head with our failure to see that. Maybe when the headaches get bad enough we will change. Less is more seems true to me. But it is a hard truth, one slow to sink in.