At one reception during the meeting a man overheard me say that I was glad that the reform legislation passed, despite that it left so much unaddressed and so much work still needs to be done. This comment, apparently, sealed my character in his mind and probably led to this subsequent exchange several minutes later...
Him: "Obama thinks doctors would rather charge thousands of dollars for a tonsillectomy than prescribe antibiotics. Senator Schumer thinks that doctors charge $4000 to a patient after they wave at them in the hall. Obama says we'd rather amputate a diabetic patient's foot than keep their sugars controlled..."
Me: "Well, there is a grain of truth behind the hyperbole because..."
Him: "WHAT DID YOU SAY?!? DID YOU JUST SAY... ARE YOU INSANE?!? [etc]"
Me: [trying to clarify, but unable to get a word in edge-wise] "No, none of those things are real, it was hyperbole... I only meant that there is truly an incentive for overtreatment in our system..." [etc]
I genuinely thought for a moment this man might go ballistic and start throwing punches. His wife, also a physician, looked at me as if I were slimy. It was not a pleasant conversation. Nor was it really... you know, a conversation.
Misunderstandings are unavoidable, I think, in a conversation about something as complicated as our healthcare system. However, ironing out misunderstandings requires more conversation, and the types of misunderstandings I've seen have been based on dogma and ill-will often enough that more conversation is extremely unlikely. People retreat to their respective tents to reinforce their existing biases and dialog goes nowhere.
Luckily for me, people who read this blog are generally my friends/family and are willing to give the benefit of the doubt. Conversations are possible here, if limited by the medium.
So, here are a few follow up thoughts from my last post.
The overarching goals of healthcare reform are (in my mind... and evolving all the time!):
- Making care of the highest quality
- Facilitating the economics of care
- Promoting freedom and associated responsibility
In order to make care of the highest quality, we need comparative effectiveness research in the best sense: information about the best ways of delivering care that is not solely dependent on industry funded research, and that does not interfere with the autonomy of physicians and patients.
Case in point from MSSNY: one of the resolutions asked for policy that supports mammography guidelines from the 2002 USPSTF rather than the more recent guidelines. Some believe that the government has removed the rights of physicians and patients to screen from ages 40-50, and that this decision was a kind of rationing of healthcare resources. In fact, I read the new USPSTF recommendations after the meeting and they emphatically stated that they were only recommending against "routine" screening in this age group and that access or payment should not be denied based on their recommendations. Essentially, they just wanted to the doctor and patient to actually talk about the risks and benefits before enacting a rote screening algorithm.
The new healthcare reform law includes provisions for publicly funded comparative effectiveness research. Opponents cite the inability of the government to administrate anything effectively ever, which is a bit lacking in nuance. I'm glad CER is included. I think it will prove to be money well spent, and public money is the only money that will fund some of the most necessary data as there is a financial dis-incentive for decreasing certain costs.
ECONOMICS OF CARE
I mentioned in my last post that transparency of cost is something crucial for reform that is largely ignored in most conversations. Proponents of a public option (or, more inciting, a dreaded single-payer system!), point to the ineffectiveness and broken nature of our current "free market" system. We've tried it and it's not working, they suggest. I've never had an economics class in my life (lamentably), but if nobody knows what anything costs or makes any actual supply/demand decisions about consumption, I don't see how our current system is much of a free market. Regardless of the left or right leaning direction of proposed reforms, I see cost transparency as a necessary starting place for any real accountability by anyone.
There are incentives to over-treat. It's a fact. However, vilifying physicians as parasitic and unconscionable predators is not only politically stupid, it's unfair and contributes to the polarized unfriendly nature of the conversation.
Philosophically, freedom is a mixed bag. Grown-ups understand (hopefully) that obligations are attached to certain decisions and so freedom is never fully free. I bring this up because it's the principle that seems so often disguised and/or misunderstood whenever we consider healthcare reform.
People need to actually pay in some manner or another for what they receive.
It's the economics of the universe that entropy isn't going to carry you comfortably through retirement. Someone's gonna have to pay, and that someone is likely you earlier in life. Now, the manner in which this is arranged is a great debate. Should it be through health savings accounts or public programs? I have friends/family on both sides of that issue and I'm aware of merits and drawbacks either way. I've personally decided I favor an insurance mandate, and I'll explain why.
Requiring people to purchase health insurance is distasteful because it removes an individual's options of how they want to pay for their healthcare. It takes away freedom in the literal sense. It imposes an approach that means profits for insurance companies at the compulsory expense of working individuals and families. I appreciate this problem. However, I think this is mainly an academic issue as very few people are wealthy enough to self-insure. Extremely few. And those people who are wealthy enough typically buy insurance anyway. We're talking about a legitimate loss of freedom by a very very small group of people.
That's the harm of mandating insurance, so what's the benefit? In our society we don't just let people suffer. We care for them. And that care costs money. Frequently the people who need the most care are the people least able to pay. In our immediate past we have tolerated tens of millions of people disconnecting choice and responsibility through not having health insurance. Many good people believe they don't need insurance because they are healthy enough or wealthy enough that not having insurance is the better economic option. In the pools of shared risk, most of them are right, but there will statistically always be high costs for everyone to cover those who end up wrong. The inevitability of that displaced cost means the everyone's freedoms are limited by the choice to not carry insurance by this pool of people who seem arguably justified in doing so.
Take for example, this article.
Karen: "No one in my family has has ever had to go the emergency room. Our belief system is that if you know who you are, you won't even need ER visits."
Your belief system seems to ignore that bad things happen to good people. Would you shoo away the ambulance after a car accident and just hold pressure until you get in to see your FP?
Joan: "I just have strong opinions about taking care of yourself, and I'm willing to pay the consequences for that point of view. If I get sick, well, I guess they can just scrape me up off the street and put me in with the landfill!"
Lovely sentiment, but our society doesn't work that way. You can't have the economic benefits of American society if you want the social responsibility of Afghanistan. You get a matched pair.
I could write a response to each of the folks highlighted in the article, but you get the idea. Mandated insurance isn't a perfect solution to the problem of freeloaders, but it certainly brings the costs of healthcare risk to a larger portion of the healthcare risk consuming pool. In this way, it actually increases the freedom of the majority not to subsidize the care of others. People can be delusional about the way they are subject to healthcare risks (statistics make it very easy to fool yourself... just like smoking is overall unlikely to kill you and yet simultaneously is the leading cause of preventable death our country faces.) and consequently displace responsibility for their own poor decisions on society. Mandating otherwise is, unfortunately, both effective and necessary. On balance, the freedoms gained outweigh the freedoms lost.
Without going into the relative merits of a democracy versus a republic, I will just acknowledge that our leaders did act against public sentiment by passing the law they did. And, although violating the will of the people seems reprehensible, one may argue that on occasion leaders of a republic act in the best interests despite the will of the people. Because one's own understanding of the issues determines whether you see it as reprehensible or politically courageous to violate the will of the people, I don't really factor any of that in my views of the central issues of healthcare reform.
Sorry for the long post. I still didn't manage to say as much as I intended! But... well, there's that much.