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Thursday, August 06, 2009

Can Health Care be Local? (Justice and Fairness in Health Care #3)

[Cross-posted to Front Porch Republic]

A couple of smart comments on my recent posts on health care have gotten me thinking--or rather, have helped force to the front of my mind a question I was already thinking about: if, when it comes to public policy, I'm continually balancing between my socialist/egalitarian/establish-a-just-and-equal-context and my localist/populist/empower-communities-in-their-differences sides, on which side do I think that efforts to reform health care should come down on? National coverage, or local control? Baseline justice, or state-level variety? And might there be some ideal way for it to straddle both?

I have, for a long time, basically been of the mind that populism--which I take to mean politically and economically empowering people in the places they live--and egalitarianism--which I take to mean arranging politics and economics so that all people enjoy basically equal recognition and opportunities--while clearly different ideological projects, overlap more than they diverge. What they have been common, as a starting point if not as an ultimate goal, is solidarity and a grounding in "affectivity." As I put it in the above-linked post, nearly five years ago:

It is affection, specifically that which arises from and depends upon a shared life, a defined (and therefore somewhat limited) life, that makes possible real social concern, a concern which is not restricted to a needs-tested distribution of a few select goods (which at best can only result in the just treatment of those who accept the terms of choice which the market--and those who are lucky/hard-working/well-connected enough to dominate it!--imposes), but which actually seeks make the distribution of and decisions about goods a component of one's participation in the community. Not for nothing did late 19th-century populism often merge with socialism, and not for nothing are social democrats today often the most responsive to the diverse demands of distinct communities, whether in neighborhood design, public schooling, welfare provision, or a dozen other areas. To talk about populist justice means to talk about "the people" not in the abstract, whether behind a veil of ignorance (John Rawls) or as individual choosers confident in their holdings (Robert Nozick), but to begin where they live, in their various (culturally or historically or religiously defined) communities. The goal is not some rigorously Marxist collectivizing of the material and economic and social life of all communities in the name of uniting everyone's species-being....[but rather to] limit and constrain the meritocracy in the name of civic equality....by granting recognition and opportunity to communities and people's identities as they are.

I don't want to pretend that I had figured out answers to all the questions I'm taking on today a half-decade ago: I hadn't (and no doubt I will continue to work on these same and new questions far into the future, whatever I might happen to conclude today). But I do feel some confidence in saying that the "conservative" (or maybe better, the "communitarian") essentials of any populist or localist or socialist alternative to modern liberal capitalist/consumerist/individualist lifestyles and destinies can be, by and large, much benefited by certain broad egalitarian actions--by certain progressive compromises, you might say.

What sort of compromises? Some are so obvious to the majority of Americans that their careful balancing act goes unnoticed. The guarantee of universal and basically equal public education, for example, often results in massive bureaucracies and headaches, it's true, but it also serves as a vital way-station between the principled goal of providing all children with an education and a taste of civic life, on the one hand, and the necessity of keeping those children grounded in the communities and families that shape the lives they actually live, on the other. Other compromises, though, for a variety of reasons, have never struck the majority of the American people as particularly crucial: despite all the obvious ways in which an up-front investment in public transportation and bike paths would help local communities to thrive by building pedestrian and rider friendly (read: not overly automobile-dependent) residential and commercial zones, thus avoiding as much as possible the isolating and environmentally unhealthy costs of suburbia, Americans by and large instead seem to figure that only poor people ride the bus, and the rest of us just want to pour on the gas.

That brings us to the current, huge question over another potential compromise--health care. While the majority of Americans (including me) have health insurance and are, despite our regular complaints, generally satisfied with the coverage they receive, almost everyone is aware of the injustices and inefficiencies of our current patchwork of hospitals, emergency rooms, government programs and private insurers. If the moment for reform has truly come--as even many anti-government conservative thinkers have come to acknowledge--how should we understand our options? Is the proposal to create an ostensibly more equitable and coherent system of providing and paying for medical care going to result in an oppressive bureaucratic monstrosity? Or can we see broad, egalitarian reforms as part of an effort to put people on a similar level, discouraging dependence and injustice and enabling more people to feel security and affection for their local places? And would variations in delivery make all the difference?

It's not hard to come up examples of variations that hardly anyone, no matter how convinced a localist they may be, would be willing to endorse: the just look at the many poverty-stricken societies around the world, where basic nutrition, immunizations, and simple emergency medical care are nearly absent, and where as a result infant mortality is high, pregnancies with complications are often a death sentence, diseases like measles or bronchitis routinely kill, and a compound fracture or head trauma will often mean a life of disability or death from resulting infections. I'm not setting up some puerile claim about the "march of progress" here: this was simply the way of the world for nearly everybody, even in some of the wealthiest and most scientifically advanced parts of the globe, as recently as the end of the 19th century, and people accepted and flourished in the midst of and built their lives around such expectations. However, given a chance to escape all that, through the various blessings of specialized and concentrated technological advances (think of penicillin, sterilization, or artificial limbs), only the most determined of Luddites decline the opportunity, and not even all of them. (For what it's worth, there is nothing in the Amish Ordnung that speaks out against modern medicine, and the Amish will patronize neighborhood doctors and hospitals just as anyone else might.) That such resources ought to be reasonably available, without the interference of bankrupting paperwork and arbitrary exclusions, seems to be something that practically anyone who desires that the inhabitants of local communities be able to maintain themselves should hope for.

What about variations on the other end of the scale? A friend of mine, who works at and has health insurance through one of America's top universities, recently shared this story with me:

[W]e had to rush our 3-1/2-year-old daughter to the emergency room last Friday night. She was admitted and spent the next four days being run through a torturous string of tests....The hospital we brought our daughter to was...[one of the] best children's hospitals in the world....It's an extraordinary place....Once admitted, you're assigned to a "team," like on the "House" TV show, led by one star doctor and about a dozen "fellows" i.e., med "students" about 10 years out of school. They hover around the lead doc as they do rounds on the floor, having little ten-minutes lectures, as the doc stands at a rolling computer-cart, about each patient before entering the room....Because my daughter's problems are GI-related, we were on the GI floor--25 rooms, with everyone there having somewhat similar problems; the other floors of the high-rise were also arranged by malady. The hospital also employs special nurses who organize activities for the kids to get their minds off their hospitalizations, and counselors to help them cope with their illnesses....

During our first meeting with the doc, he asked about our insurance. We told him we had...the most expensive of the three options [their university] offers. He was delighted. It meant we could get anything we needed. He scheduled the battery of tests after he heard this good news. He also transferred us to another doctor--his mentor--who's the world's leading expert on precisely the problems our daughter is having. He'll be handling everything from here on out. So, leaving aside the awful bad luck of our daughter's health problems, it seems like we really got lucky....[W]e have basically unlimited access to what is literally the best care in the world for our daughter. If we had inferior insurance, let alone no insurance, we couldn't possibly be enjoying these benefits. We'd be at a lesser hospital in the area and potentially facing catastrophic medical bills. And that's assuming we were [in their home urban area], where most of the hospitals are very good. But what if, say, we were in or near my wife's home town in rural Ohio? The hospital in the town itself is pathetically bad, and the one in the nearest city is merely OK. Why is that? Well, part of it is the simple fact that we are a huge country with a huge number of hospitals and a limited supply of super-smart people: the best medical students, from the best schools, all want residencies and then permanent jobs at [top university hospitals], and if not there, then at the other good hospitals, etc....[M]y wife's hometown hospital way down below that.

This is meritocracy in action, in other words. And it makes we wonder about what health-care reform in the country could ever achieve as far as equality and fairness are concerned. Give every person in America open access to health care--and yet most people will not be living five miles away from [a top university hospital], and they will never be able to see many patients who travel there from rural Ohio, since if everyone did that, they'd be swamped in about half an hour. So the worth of that open access to health care will vary enormously depending on where people live. And there's nothing that can possibly be done to change it--unless we decapitate the top by getting rid of the [top university hospitals]. Then there'd be much more equality and fairness. But not fairness for me and my daughter. And to the extent that the super-docs develop procedures that are then applied elsewhere, everyone would lose as well.

That's a powerful story, one that just about every parent can sympathize with, as I imagine that just about every parent would be willing to do whatever it took to be able to get their desperately sick child to the best medical care available. Faced with that, very, very few of us would qualm at or complain about the expansive, sometimes invasive, structures that concentrate the resources and expertise which produce the occasional medical miracle. I certainly wouldn't.

So there are two almost undeniable observations that can be derived from my friend's story. First, that we will want, in at least extreme and emergency cases, for "big medicine"--with its teams of doctors and expensive tests--to exist. Second, that, absent some sort of Harrison Bergeron-type of wholly centralized and strictly controlled system, there will always be a some randomness and unevenness in the availability of different much-needed goods, because the people who provide them are following paths and setting goals and making decisions that can't necessarily be directly aligned with egalitarian principles. So where does that leave us? The relative injustices and inefficiencies of our current ramshackle system are undeniable, but neither do we want health care to become the property of some inhuman redistributor of resources. There is already plenty of market-forced rationing of the diverse forms of care out there (and by that, I mean everything from insurance companies denying coverage to select segments of the population, to mostly overwhelmed and often underfunded urban or rural medical practices and hospitals being forced to close their doors) and some of that rationing already leaves some families and communities without the ability to care for their own needs. Is there some way in which egalitarian reforms can address this, if not ever resolve it entirely to every person's satisfaction? Forget utopia; can we at least strike a better balance than the one we currently have?

Probably, if you open your mind to all the options. Consider the much maligned single-payer option, which the Democratic party took off the bargaining table right from the beginning. Of course, we already have a single-payer-type system in place in this country where people can choose for themselves the care they best need out of all that which is locally available to them, and don't have to worry about negotiating through various financially-invested and profit-hungry intermediaries, instead trusting their medical providers to tally up the costs straightforwardly: it's called Medicare, it's been around for seven decades, and seniors love it. Moreover, that notorious, Canada-style, single-payer approach is actually more amenable to the American passion for choice than our current system. Opponents of reform often make a big deal about being able to choose your own insurer, which a single-payer system would of course make obsolete...but I suspect that what really matters for the great majority of us is being able to seek out your preferred doctor--and today our HMOs and whatnot give us a specific controlled list (worked out through backroom negotiations between various insurers and doctors' groups) of medical practitioners and force us to choose between them, even sometimes dismissing local options if the market calculations weren't quite right. Case in point: when during her yearly check-up, our oldest daughter was told that she was developing a curve in her spine, which meant possible scoliosis, we were financially obliged to ignore perfectly adequate Wichita back doctors and seek the help of a medical practice in Salina, a morning's drive away (tally up the cost of the gasoline to take us there and back), because no one local was part of our particular plan. So much for empowering medical options close to home!

(Moreover, note that the single-payer option--or other similarly subsidized or state-supported plans, that set basic foundational requirements for health providers (which will, of course, include some rationing and redistribution, but no more than the gatekeeping which private insurers and hospitals already put in place) so as to make certain no one is excluded from the essentials of care--can be administered in a highly localized fashion. An old friend of mine, James Meloche, whose comments I quoted in one of my earlier posts, helps direct a Local Health Integration Network in Ontario, Canada. The LHINs were set up a few years ago to formalize the efforts on the Ministry of Health and Long-Term Care in Ontario to respond to the diverse needs and desires of the different socio-economic and cultural populations that had health needs throughout the province. By all accounts, they take their devotion to interacting with, make decisions in line with, and trying to strike balances in what is available (and where) amongst the local communities within their boundaries pretty seriously.)

Of course, we're not going to get single-payer (though thankfully, the delightfully goofball Congressman from Cleveland, Dennis Kucinich, has managed--thus far successfully--to keep in the proposed bill an amendment which would allow the different states to pursue single-payer plans on their own, which might be an ideal arrangement for our federal system). What we're looking at most likely at the current moment is a proposal that will keep private insurance companies, with their constant negotiations with hospitals and doctors' groups and other providers over what is available and where and at what premiums and under what conditions, very much in the game. However, the federal government will claim some oversight over (and some subsidizing of) those insurers, making the rescinding of coverage and the excluding of people due to preexisting conditions mostly a thing of the past, which will enable millions of more people to keep their insurance, which means fewer people crowding into emergency rooms and defaulting on the costs, which means fewer pressures to increase premiums, all of which will be good for working families and the local communities trying to hold on to them. The bill may also include a public option, namely a fully-funded government-run insurance plan (or, in other words, Medicare available for someone else besides retirees), which Karl Rove tells us will destroy the country, but which others claim, should the provision survive the House and Senate, wouldn't put private insurers out of business so much as open the door to the sort of public-private supplemental insurance arrangements such as exist in France (which has, incontestably, the best overall health care in the world, and delivers it mostly on a region-by-region basis).

It should be noted, if it isn't obvious, that a more egalitarian provision of health insurance doesn't preclude the choices and innovations that really matter (specifically, who your doctor is, and where you have to go--or he has to go--for health care transactions to take place). E.D. Kain, over at The League of Ordinary Gentleman, made a strong argument against government health care monopolies a little while ago, but while much of what he said was true in principle, overall he was arguing against strawmen. The egalitarian frustration with profit-hungry insurers is not about running the market entirely out of health care; it is about making the availability of health care more populist, more just. Single-payer systems like Canada's are not socialized; all those who are actually meeting with patients and providing surgeries are private actors. All the government does is work with different localities to find out where hospitals need to be build and resources need to be invested...which seems to me to be far more potentially respectful of the communities people live in than our present system, in which (assuming we are not enormously wealthy) we're often simply tossed a book and told to look up and go find one of the eight doctors listed on page 238, wherever they may be, assuming they're accepting patients at the moment. The same things could be said for state-supported insurance systems like France's--yes, they are somewhat socialized, yet private transactions still flourish (and, in fact, are able to reach out to distant or poor communities, leaving them more empowered to protect their own members, than was the case before their system emerged). E.D. even praises the Dutch system, which is famously a combined state-private "third way" arrangement--exactly the sort of social democratic policy-making which, as I and others have argued before, is essentially "conservative" in how it views peoples' lives and their families and homes...certainly more conservative than the not-quite-regulated-but-nonetheless-crudely-centralized patchwork we have today.

Can health care be local? Probably never entirely, not unless we happen to put down roots in a locality that is lucky or wealthy or both--or not unless we become even more willing than the Amish to reject the medicines and technologies and therapies that the modern concentrations of resources have made possible. (I'm not defending, by the way, any particular medicine or technology or therapy here; I'm an old fan on Ivan Illich, and I don't particularly trust in the "medicalization" of modern life...but I'm not going to pretend that there aren't times and places--when our children are desperately ill, for example--when we're glad it's there.) So it comes back to delivery--can the provision of health care be local? In the best of cases, it should be: you ought to know your family doctor, and come to trust her as she comes to remember your children as they grow older. But to make that localist ideal more possible--and especially to make it more possible for all people, in all their respecive places--we need a little more fairness in coverage, we need a little more populist justice in distribution. No plan that emerges from the federal government is going to be without bureaucratic annoyances and consequences. But such a broader, more coherent plan would be, I think, an important aid for communities to build themselves upon.


E.D. Kain said...

Excellent post, as usual Russell. This touches on a lot of what I've been thinking about (regarding health care, but also economics in general) lately - and how to balance the community, egalitarianism, and the very real threat of monopolization and capture of well-intentioned programs by big industry players. I like the "third-way" Dutch program for a lot of reasons. It allows for individual choice and competition, but also mandates that everyone receives coverage. No denials of coverage, no free-loaders - a two-way mandate. Universal coverage, but choice, so that communities aren't reliant upon a centralized system. This model, I think, could very well lead to the resurgence of health care cooperatives in America, which would be excellent for local communities and individuals. Co-ops historically have given a great deal more say and more power to communities and health care providers than the monolithic and anti-competitive, impersonal corporations that run health care today (or the socialized systems in other countries like the UK).

Okay, done with the rambling now...

Russell Arben Fox said...

Glad you liked the post, E.D. Even if it seemed that I was critical of your post, I actually learned a lot from it; I only thought that the narrow application of it to the health care reform options on the table in the U.S. at present (which you may or may not have intended) was wrong-headed.

I like the point you make, in connection to the Dutch system, about "two-way mandates." There are so many different ways that the elements of universal coverage (which could be the "egalitarian" part of my equation) and choice (arguably the "populist" part) can be satisfied, sometimes leaning more one way, sometimes more the other...but either way, both elements really need to be there. It's almost hilarious--if it weren't tragic--that so many people in the U.S. are up in arms over the possibility that health care reform may "mandate" individuals get insurance (Obama himself resisted it for a long time)--as if we aren't already "mandated" to have driver's licenses and such! But the larger point is that without such a mandate, and the structure of choice it makes possible, we have free-loaders, we have desperate emergency-room-users crashing the system, we have the same collective-action problem we've always had. I'm not sure the Dutch system is necessary the best possible way of balancing these overlapping elements, but at least they have both in mind. Too many folks in the U.S. reject one or the other entirely out of hand.

Pilgrim's Progress said...

I'm continually balancing between my socialist/egalitarian/establish-a-just-and-equal-context and my localist/populist/empower-communities-in-their-differences sides, on which side do I think that efforts to reform health care should come down on?

As an observer from the UK I would like record my admiration for your efforts to facilitate a mature discussion on this difficult topic. I am not sufficiently knowledgeable on your current system to join in but your recent introduction above mirrored my own experience of late. In that I have been greatly helped by a new voice here in the UK, Phillip Blond who has a thoughtful contribution here:


Russell Arben Fox said...

Thanks for the comment, GGaann. progressive conservative/red tory revival going on right now in Britain is fascinating, and one that bears close watching. If Phillip Blond or David Cameron or someone else writes something specifically on health care issues, I'll be all ears. I wonder if their commitments would lead them to oppose the NHS, or instead to "merely" rethink how it distributes and delivers its services.

Paul said...

“The problem with socialism is that eventually you run out
of other people’s money.”

—Margaret Thatcher


I like Mackey's conscious capitalism. I have been thinking something along this line of thought as being superior to various forms/enactments of socialism. Must read more. You know of anyone?


I'm troubled by your use of justice and fairness.

Paul said...