Justice and Fairness in Health Care #2: A Follow-Up

In the comments to my post yesterday, a bit of an argument with an anonymous commenter emerged. My latest response was getting too long for just a comment, plus I thought our argument might be worth sharing with the Teeming Masses of the Internet in general, some I'm putting it up here:

Anonymous #1,

A friend of mine, James Meloche, who for the past decade has helped run a Local Health Integration Network in Ontario, CA, tried to reply to your comments; here's what he has to say:

"Hey Anonymous,

None of your scare tactics are based in fact or reality. Reactionary fiction is your spin. Try doing some research and you will find that Americans pay many times the amount on health care premiums than ANY part of the G20. Further, you make a very INCORRECT assumption that MORE CARE is BETTER CARE--in fact, the converse has shown to be true. Dartmouth Institute compared low vs. high spending Medicare/Medicaid states and showed that higher spending regions had both lower performance and perceived scarcity by health professionals than those lower spending regions. My knowledge is built on 10 years of senior management of the Canadian healthcare system and multitude of connection in US and Europe. And, by the way, our docs in Canada order the tests and drugs for the patients they want--not what we tell them."

Let me also chime in in regards to some possible problems with the claims you made in response to my last reply:

You said: "Obamacare doesn't impact medical costs that are reflected in insurance premiums. It just changes how the costs are distributed."

For one thing, there is no such thing, as yet, as "Obamacare"; Obama has, wisely or not, trusted to the Democrats in Congress to hammer out a bill, and to date hasn't officially endorsed any particular plan. For another thing, this strikes me as rather ignorant argument. Redistributing costs won't have any affect whatsoever on the total amounts spent, you say? But that's not how it works when we're thinking about where to build highways or railroads (the same people may always need to travel the same distances, but a wise distribution of access points and delivery systems will mean less backtracking, less wasted time, the ability to chose between more or less economic forms of transportation, more rapid use by greater concentration of persons, etc.), or any number of other collective concerns. Premiums, like all sorts of other incidental costs always associated with any kind of large scale endeavor, very clearly are driven up (perhaps not wholly, but quite significantly) by the enormous expenses generated by unwise, too-late, repetitive treatments delivered in ad hoc ways to uninsured patients in hospital emergency rooms. "Redistributing" the costs of caring for those uninsured very likely (at least if the economists I'm reading have any credibility) will reduce premiums, and thus up-front costs, all around.

You said: "Giving people free health care will not pay for itself."

I'm not saying those up-front savings will entirely pay for the whole thing. No, it won't; that's why the current plan being debated in the House may include a surtax on the wealthiest of Americans built into it. This is where we have to leave economic, utilitarian justifications (as important as they are), and attempt theoretical/moral ones. I don't think delivering equal medical care to all is as essential a human right as some others, but I do think it's an egalitarian aspiration which ought to guide our policy decisions. What do you think?

You said: "Silence about 'defensive medicine.' Tort reform can never be part of the solution, right?"

Did I ever say that? I recognize, as I think any rational person (like Tom Daschle) would, that our paranoid, overprotective, vindictive lawsuit culture is a contributing culprit here. (Though just how much of a culprit is a seriously disputed question.) Overall, it seems reasonable to conclude that the extension of some sort of minimal coverage to everyone, provided in a more accessible and regular way, will undercut a great deal of the need for that defensiveness, because doctors will be dealing much more regularly with patients that they have a history with and records of treatment for, and that's leaving aside the many costly, risky, and lawsuit-attracting situations which will be eliminated, or at least be made much less likely, by making certain that people can get the medicine or treatments they need when symptoms very first appear, rather than waiting until the have to throw some desperate situation into their doctors' laps. But no, beyond all that, some sort of tort reform will likely need to come along eventually. I admit that I'm reluctant to take that position, since in a society with great economic divisions, lawsuits against the corporate powers-that-be are often the only recourse the poor have to achieve some justice. But if we could achieve a slightly more sensible, slightly less arbitrary and unfair health care system, then providing more protections to medical professionals from the irresponsible lawsuit-hunters out there would probably make some sense.

You said: "You think eating french fries is a ridiculous and destructive personal habit that the government should be able to ban or stiffly tax?"

Where do you get this? I've heard of some people that have run calculations about how much revenue this kind of "sin tax" might generate, but I've never heard it suggested that the health care debate was going to fund itself, or that the federal government in general was looking to restructure its budget needs, around taxing french fry consumption? All that being said though, what's the big freaking deal? We use taxes and regulations and laws to shape, encourage, discourage, or limit human behavior all the time, from speeding tickets to underage drinking. Sometimes these efforts are misguided and offensive, and sometimes they work. Are you making a particular argument (in which case, in reference to what proposed legislation, exactly?), or are you just opposed to any kind of moral or social or collective government action whatsoever? In which case, I'll look for you at the next Decriminalize Dope booth I pass at the state fair.

You said: "Obama and the Democratic congressional leadership have overreached in a dangerous way....He should have stuck the camel's nose in the tent, rather than trying to cram the whole dromedary inside in one fell swoop."

Dude, if you think the current plan in the House is the "whole dromedary," I can't imagine what tiny reforms you believe would have constituted a "camel's nose." Good grief, single-payer is completely off the table, and the public option (central to the idea of health insurance exchanges) is barely hanging on as it is!

Just last night, in association with National Health Care Call-In Day, I attended a meeting sponsored by Health Care for America Now. Given the fact that our two Kansas senators, Brownback and Roberts, are both going to oppose anything the Senate Democrats come up with, and given that our local federal representative, Todd Tiahrt, is actively working against House Resolution 3200 as I write this, there really wasn't much we could do productively to generate positive votes. To my mind, that gave us a certain amount of freedom: since we knew the best we could do was to generate as much popular awareness and support as we could, to perhaps make their votes at least little uncomfortable for them, that meant that we could avoid many of the above-mentioned technical debates, and concentrate on the fundamental, theoretical issues: that it is simply unjust (and unChristian) that some--mostly the poor, old, and sick--are denied, generally through no fault of their own, access to something which most every other citizen can enjoy. In other words, we can make it about fairness and decency, making our congressional delegation own up to the ridiculousness of the current system. And yet most of an hour was taken up by folks arguing in favor of this aspect of reform or that one, almost always taking the position that the plan which Obama is gently, from a distance, nursing along is a compromised, half-baked solution.

Whether or not you would have agreed with any of the decent, devoted, determined people at that meeting, what we're looking at right now clearly isn't the whole dromedary. What it is, on the contrary, is a once-in-20-years chance to do something sensible with a health care system which, whether we like it or not, is almost certainly going to have to be national, and most definitely going to feel obliged to do something about those who crowd our nation's emergency rooms and can't pay for it. I call that justice and fairness, every little bit of which ought to count.