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Wednesday, July 29, 2009

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.


sister blah said...

Regarding defensive medicine and lawsuits. One of the reasons that individuals feel compelled to sue a doctor if they have a bad outcome (regardless of whether they think the doctor really did something "wrong") is precisely because of our horrible health insurance system. People know that as soon as they have an expensive condition, their insurance company will find a way to drop them, or if they ever change jobs or lose their insurance, they'll be uninsurable forevermore after that. This means that if they anticipate considerable cost going forward as a result of their bad outcome, they need to have a huge trust fund set up to take care of it, and the only way to do that is to sue and hope for a really big payout. I think most people "get it" that sometimes, despite everyone more or less doing their job, bad things do happen. But our society has turned litigious because of the GOP "every man for himself" mentality. If people had confidence that their medical bills and basic safety net will reasonably take care of them in the case of a major misfortune, they wouldn't need to sue. On the other hand, if you are parent whose child is born with some problem, and the government won't pay that child's medical bills, won't support you to stay home indefinitely to care for the child, etc, and your whole family will go into bankruptcy and be homeless trying to do this yourself. Well, yes, you're going to sue the OB.

Anonymous said...

So a Canadian health care bureaucrat doesn't deny that we'll see rationing. He thinks that rationing will make us healthier. Less care is better care, he says. (If so, the uninsured would be better off than anyone else, but why let logic stand in the way of a good social program?)

I talked about "medical costs that are reflected in insurance premiums." I didn't talk about "insurance premiums." Apart from a minor reduction in costs by substituting preventative care with emergent care, how will medical costs be driven down? (Do you think Paul Krugman represents most economists?)

Egalitarian aspirations are fine. But if you ask the 9.5% of the population (and counting) who are out of work whether they would rather have free well baby screenings or a job, most of them would rather have the job. This isn't the time for sweeping, costly reform.

You were silent on tort reform. Even now, you think that it's something that might be looked at down the road, but not worth demanding immediately as part of an overall solution. Why not try tort reform first? Unlike the Democrats' plan, it wouldn't cost anything to implement. Democrats line their pockets with trial lawyer cash, so they won't do that. But what loyalty do you owe to ambulance chasers?

No, you didn't mention french fries specifically. You said, "heaven forbid that the law ought to take into account our inalienable individual right to engage in ridiculous and destructive personal habits when they start tallying up costs." And you said it on a day when Democrats and left-leaning blogs and columnists were talking about taxing fatty and sugary foods as a way to help pay for this program. I threw out French fries as shorthand for that kind of sin tax. Sorry if that wasn't clear enough for you. But since you say that you're fine with that, then there's not much more to discuss. I don't think most Americans want Uncle Sam taxing them into eating asparagus. (The only "Decriminalize Dope" voices I'm hearing are from California Democrats who want to legalize and tax marijuana, so they can get high and pay for social programs they can no longer afford. What principles!)

You're a hoot, if you think the Democrats are proposing a watered down half measure. You want an example of what you call "tiny reforms" that would have stood a better chance of passage? How about expanding Medicaid and SCHIP to cover over 8 million uninsured children in America?

Would helping 8 million kids be too "tiny" a move towards "justice and fairness" to get the attention of someone like you? Do you think it's better to go for a long shot to insure maybe 27 million (out of 47 million) and end up with nothing?

Robert Patterson said...


You have stuck to the high road. I admire your forbearance in dealing with "anonymous," or as I have come to think of him/her, Coulreillybaugh.

I can't think of many sites where an anonymous poster such as he/she would receive such cordial and accommodating attention.

Christopher said...

Thanks for these two thoughtful posts, Russell. They have each resonated with me in analyzing what is a very complex and difficult issue. I think what I appreciate most is that you address both the economic/utilitarian aspects of the debate and also the theoretical/moral aspects. Too much discussion on this topic addresses only one or the other, but you've managed to articulate a reasonable point of view on both that makes sense to me.

sister blah said...

Anonymous, you talk a lot about rationing. Can you explain what your definition of rationing is?

A lot of people aren't able to get care because their insurance won't cover it and insurance co's very frequently have limits on various things (ex: "no more than x times a year").

Is that the kind of thing you mean by "rationing"? If not, what do you mean by rationing?

Paul said...

It appears you are leaning to your populist and socialist views. Could I suggest that you follow more your communitarian and localist beliefs? Wouldn’t they support their local hospitals by their own means? In other words, being you have joined your local socialist organization, why doesn’t your local group reach deep into their pockets and subsidizes these hospital E.R.s.—show the nation how it can work. OK, OK, this probably sounds silly to you, so let me put it another way. When these social programs are created, folks tend to opt out of their existing plans. A case in point, my employer offers Healthcare partner’s HMO plan for families at a premium of $1054 per month. Healthy Families of CA offers a better plan of healthcare through the same Healthcare Partner HMO, but they also get dental and vision and pay I believe only about $20 per child per month—some less. I have values, so I pay the $1054 per month out of my pocket and live below my means and pay rent. Where I work of 500 employees, I am the only person with family insurance. Nearly everyone else is on Healthy Families and drives $30,000 to $40,000 cars and are trying to pay for homes they cannot afford. This is the bigger reason why premiums are so high, not the E.R.s. Healthy Families enrollment has now switched to a waiting list; we are waiting for the rest of the nation to bail us out--forcing the program to work. Why don’t socialist put their money where their values are? No one is stopping them.

Russell Arben Fox said...

Thanks to everyone for being part of the argument--even if I disagree with you, I appreciate being forced to think more about things.

Sister Blah--excellent comments and questions about "defensive medicine" and rationing. I think it's unfair to label the "every man for himself" mentality a GOP creation; it's roots are much larger than that, tracking back, in my mind, mostly to the generally defensive and therapeutic individualism which is a hallmark of modern America. But I think your reasoning about how the insecurity of our insurance system generates lawsuits is dead-on.

Anonymous--Paul Krugman may not be to your liking, but you can't deny that a pretty significant chunk of profession economists agree with him. As for some of your other points, you don't seem to want to make the obvious connection between controlling "real costs" and setting up disincentives to certain individual behaviors. Doing tort reform first of course could have been an option, and maybe you're right that the Democratic party's choice of what to pursue first was driven by politics...but that's neither here nor there at the present time, which is all about the politics of the possible. Which goes to your final comments: are you genuinely of the mind that health care reform will collapse, and suck down any possibility of making improvements to Medicaid and SCHIP (two federal policies that will be easier to make more progressive once/if general healthc care reform happens!) along with it? If so, then what we have here is a disagreement over the president's pragmatic political calculations, not his principles, right?

Bob and Christopher--thanks for your kind words.

Paul--your comment poses both a strategic question (what's the most direct way for a socialist organization to help the local community it is most centrally a part of?) and a moral/theoretical one (to what degree can the vision of a just and fair health care system--which will invariably involve some redistribution, subsidies, and rationing--be reconciled with the local provision of such, where people are given free choice to follow their principles and do what's best for their families?). Simple answer to the first question is that my local organization doesn't has anything nearly like a sufficient budget, even if all of us acted collectively to a seriously deprivationary degree, to support genuine local alternatives. As to the second question--which is a very good one--I don't have an answer. I'm still thinking about it. Perhaps in a later post.

Baden said...

I disagree with the federal government getting involved in healthcare. Two points from the discussion that I can understand are: the idea that we are already paying for those without health insurance through emergency rooms so why not give them proper health care and the other being the need for tort reform. In my view, a strong public option for the poor -and only for the poor- and tort reform would be good things. My question is this: why haven’t the states done this? According to my understanding all states have varying degrees of public health programs, some more than others such as I believe Massachusetts and California. I have to assume it is because it is such a difficult and expensive thing to accomplish. This is what I don’t get, if the states haven’t done it because of one reason or another, why should the federal government being do it? Is the federal government financially in a better position? No. Is the federal government going to run a more efficient program than a state government? No. Therefore, I believe it is on the state level where the reform has to take place.

Russell Arben Fox said...


Thanks very much for commenting. Your comment helped inspire my most recent post on this topic, if you're interested in checking it out.

In my view, a strong public option for the poor--and only for the poor--and tort reform would be good things.

You might run into a little bit of trouble with your "only for the poor" restriction on the public option, because you have to ask yourself: who's poor? and when? and under what circumstances? It's not just the indigent who use emergency rooms, it's people between jobs, whose insurance isn't portable, or use COBRA has run out, etc. Still, overall, I agree with you--universal coverage (aimed primarily for the poor, made possible by a public option insurance plan) joined with tort reform would make an excellent health care reform package--not my ideal, but much better than what we have now. (Tom Daschle agrees with us, for whatever that's worth.)

[W]hy haven’t the states done this?...I have to assume it is because it is such a difficult and expensive thing to accomplish. This is what I don’t get, if the states haven’t done it because of one reason or another, why should the federal government being do it? Is the federal government financially in a better position? No. Is the federal government going to run a more efficient program than a state government? No. Therefore, I believe it is on the state level where the reform has to take place.

For one thing, Baden, who might want to take into consideration the lurking problems of justice: some states are much poorer than others, and have differing political cultures, and so will come up with differing regulations. So what happens when families relocate, following jobs from one community to the next, crossing state lines? They may have made plans to address their childrens' health needs that might be thrown into the crapper by a job transfer. Not very fair, that.

More broadly, why do you assume that state governments are always more efficient than the federal government? Surely they are in some ways, but will they be in regards to this issue? (When it comes to dealing with nation-wide crime operations, the advantages of having an FBI as opposed to 50 state police coordinators have been pretty persuasive.) And as for the financial issue, looking around at state budgets these days. Some states are on much more solid ground, in terms of deficits and making their budgets, than the federal government is. But on the whole, the federal government is much richer than all of them, and much more solvent than most.