Thursday, April 22, 2010

Organized insanity

Got back from the Medical Society of the State of New York meeting over last weekend where many health system reform issues came into focus for me. I'd say the crux of the problem with the reform process is the closed-minded approach that many people have committed themselves to at this point. It's McCarthyism and hyperbole, all the way.

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..."


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!):
  1. Making care of the highest quality
  2. Facilitating the economics of care
  3. 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.

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.


Anonymous said...

Coach, I'd like to say that supply and demand decisions were constantly being made on the costs of health-care, and though few individuals self-insured, Insurance policy is part of what makes a person choose one job offer over another, so a universal health-care policy doesn't help at all there.
Second, This health care bill instigates health care run by the government. The government is very very good at what it does (spend money, waste money, initiate taxes)and therefore is not a good handler of personal money.
Third, it is spiritually better for someone if in a time of economic trial as a result of health care, they get help from other people. Not help from a disinterested bureaucracy, if only because the spirit will bless the giver as well as the recipient.
Fourth, The Health Care Law is a 1700 page long monstrosity with so many pages of pork and baggage, that much of the 900 billion dollars we're spending doesn't even go toward health care.
Fifth, (this is my personal pet peeve) they instigated several new hidden taxes and regulations in this law, including: a tax on planting trees, a regulation that allows the government to require home sellers to pay to replace every single appliance and light bulb in their home, if it's not "green enough," and there is a ban on using wood stoves or wood to heat anything. Now, maybe city dwellers don't know about it but what else are you supposed to do if you have to take out a tree that's threatening power lines. Now, this is just my opinion, but I believe that there is going to be a negative impact from the health care bill
-Laundry Man-

Coach said...

Hey, Laundry Man, nice to have you comment. Can you elaborate on some of your comments? What are "supply and demand decisions" and how are they constantly being made? I'm not clear on how employment insurance benefits impact the value of mandated insurance (assuming you mean mandated insurance when you say universal health-care policy). How does this bill instigate health care run by the government? The public option for insurance is not part of the bill. Do you think the government is inefficient in its handling of money in every case, or do you feel there may be examples of effective government?

I agree with your assertion that individuals helping individuals is a spiritual issue that is very important. This new law doesn't replace our individual responsibility to care for each other, that's for sure. However, do you feel that there is no value in addressing social problems on an institutional level because of this? I disagree, if that's the case.

The law that was passed fits on about 500 pages when you use standard margins and font size (as opposed to congressional document formatting) according to my friend who read the bill in about 6 hours one day. Pork in the bill was decreased substantially during reconciliation, thankfully, and I ascribe the problems of pork to the political system, not this individual bill.

As for the tax on planting trees, home sellers meeting green standards, etc., I haven't heard much about those issues. Can you provide a reference for me to read up?

Thanks again for jumping in to discuss. It's always a fun topic. At least for me. ;-)

Belle said...

My sister had medical problems and lives in Nevada. She needed tests to see if it was cancer, but because she had no insurance she was turned away. Luckily, she is a dual citizen of Canada. She came up here, had the tests and then the treatment and was cured. I guess she would have died if she just stayed in the States.

Our medical insurance is very inexpensive, around $110 a month for my husband and myself. We never pay to see a doctor, go to emergency or have an operation or treatment of any kind. I thank God the Canadian Government passed the government medical progran.

Having a baby is completely free and a nurse comes to see the baby in your home for the first two months. Our country has this care and yet we are a prosperous nation with a high standard of living. If we can do, it you can too.

curtstest said...


Curt Bentley here. Don't know if you remember me or not, but my wife and I were in your ward for a couple years out in Iowa City. I came upon your blog this morning and got engrossed in your thoughtful post about an issue that has become only *somewhat* less hot-button in the months since you posted :)

Like you, my own views on the issue are constantly evolving. And I'm not sure where I fit politically right now. Out here in Utah we have such a hard time getting past the ideological issues regarding health care reform that we generally never get to a discussion of the merits of specific proposals. On one side you have the "freedom" types (exemplified by the woman referenced in your post who argues that the risk of premature death is a cost of liberty). On the other side, you have the "compassion" types, who just can't believe that people are OK with a system that leaves so many to face the extraordinarily difficult and painful decisions that result from being uninsured. For these individuals, the *only* concern is whether every person can obtain health care for their family . . . the practicalities fade into the background. This group is, most ironically, exemplified, or at least championed, by Ted Kennedy.

Maybe outside of Utah people are actually getting past all this into the merits of health care reform, but I fear what we really have with this healthcare bill is a referendum on the moral issue of universal coverage, without real scrutiny of the practicalities of proposals.

(continued below...)

curtstest said...

(continued from above...)

On a personal level, I have no ideological objection to universal health care--not even to a single payer system. If the government can "run" healthcare, and provide it to all, even somewhat efficiently and fairly without any significant negative impact on the quality of care available, I'm all for it. But I do worry that we haven't had a real discussion about whether that's possible. And when you strip all the ideological arguments away, this is the real strong argument that the anti-health care reform group has (pardon some more hyperbole here): Do you really want your doctor's office and hospitals to become like the DMV?

Lurking in the asymmetry of that somewhat laughable question is a significant and legitimate concern. Can government do this better? Because we can definitely make things worse . . . . Of course, the primary response of the reformers to the "DMV" argument has to be: Look at the other countries that have gone down this route. They got a decently good system, one that's actually quite popular, and by building on their experience, we can make ours even better.

I hope this statement is correct, but worry about whether what we have begun to create is really sustainable given changing demographics and individual expectations. I sometimes fear that the result of all our ideological combat over health care has been to set us irrevocably onto a one way road that will prove unsustainable and problematic at its end. But, I guess we'll see.

Regardless, I guess, the times they are a changin' :)