I am having trouble staying silent on the current loud and rowdy health reform argument (I haven’t really seen much debate), then again, I haven’t been silent. Here is a repost of my position, first published in February 2008, layed out as clearly as I can make it.
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For over 20 years our country and its undying commitment to capitalism have tried desperately to slow mushrooming healthcare costs, and failed miserably. HMOs, Capitation, things that business was confident would succeed where those fiscally incompetent doctors failed, fell flat. Patients, it seems, did not tolerate their health and well-being treated as a business. I suppose business was part of the problem. After during WWII, with wages fixes and worker shortage, jobs starting sweetening benefits with healthcare and insurance to compete. It turns out patients and workers really, really like this system. It removes us from feeling any of the pain in our wallets with doctor visits and poor health.
Speaking in strictly capitalist, business terms customers were going to receive services from physicians, while a third party, insurance companies and businesses footed the bill. This removes some of the natural checks on inflation of cost. The patient and the doctor can now gang up on the third party payer, making control of spending difficult. So as an economist, obviously we just need to restore the marketplace, right?
It really depends on how one envisions healthcare. I can’t see going to the doctor or hospital the same as shopping for a new SUV, or getting cable TV. Our health is a fundamentally different thing, central to our quality of life, our independence, even the pursuit of happiness. Is it something people deserve or something we buy, dependent on our resources and wealth?
Without question it is dependent on our wealth to some extent, because it is creating a very real drag on our economy. Businesses have been weighed down with the cost of healthcare to the point where even the most heartless capitalist is demanding that the government do something to fix this mess. We spend more on healthcare by far than any other nation in the world. In spite of this, we have huge inequities in care with a mushrooming population of “working poor.”
These are people who have jobs and contribute to society, eliminating their eligibility for medicaid, but don’t have access or resources to get health insurance, so they go without. These people do take themselves out of the equation. The price checks work, as they stop seeing the doctor, that is until their uncared for hypertension, diabetes, cancer, lands them straight in the hospital desperately ill, devouring resources. But hey, a recent study actually showed this saves us money. We should just let them shorten their lifespan right?
You could even go so far as to say they deserve it for not taking care of themselves. If they just ate right they wouldn’t get hypertension or diabetes, right? Problem is fat, sugar, processed food are very cheap. Fresh fruit, vegetables, unprocessed grains are not so cheap and take time to prepare, time that could be spent working away at your minimum wage job to make ends meet. No, I am afraid blaming the poor has become an American pastime, one I am deeply ashamed of.
I have witnessed it firsthand. In medical school, our catholic hospital often received “patient dumps” from another large private hospital. These were medicaid patients, the cost of their care being eaten by the hospital. Medicaid pays substantially less than the actual cost of healthcare with the thought being that Hospitals and Doctors can take the hit as doing their share of charity work. This being the real world, the cost is passed on to everyone else through inflated costs to cover losses caring for the poor. These losses would be very manageable if the poor were evenly distributed among us, and everyone took in their share. Alas, the poor are concentrated in the inner cities, the victims of family flight to the suburbs, or in rural areas where the resources are scarce. We now have laws outlawing patient dumping and ERs everywhere are becoming the primary health care clinic for the poor. ER physicians are frustrated, burnt out and cynical. Many of them blog about it. Many of them grow contemptuous of those they care for. It is sad really.
The president recently stated that we actually have universal health care in this country. He was referring to our “safety net”, government and community hospitals. In fact all hospitals are now required by law to take care of everyone who walks through their doors, regardless of ability to pay.
I have spent a good portion of my training in county and inner city hospitals and I have seen our safety net in action. I have watched as a hospital has closed, causing an overflow of the poor to other hospitals. When the poor arrive in too large of numbers, the old patients get spooked. They equate care for the poor with substandard care. They leave and take their insurance with them. The end result is that, indeed, care for the poor becomes substandard. Morale in these hospitals is exceedingly low. They go bankrupt, they cut staff and wages to make ends meet, they outsource, then they die. All the while, patients with money cause the suburban hospitals to thrive, explode, and expand. This is what it means to make healthcare a commodity. This will destroy our “safety net.” This is a crisis.
A main argument I have seen on other blogs against a single payer system is that people will expect more, waste more and everything will cost more. They state that patients won’t tolerate the rationing of healthcare that a single payer system will require. Governments won’t control the spending because it is politically harmful. I agree. I can tell you right now, patients don’t tolerate rationing. We have a tiered system with quality going to the highest bidder. This is capitalism, welcome to America, right?
I just can’t embrace it. My stomach has turned watching the market in action as hospitals are destroyed and the face of the poor ground upon. The resources available to medicine are not unlimited. We do have to face this. Personally I believe a single payer system would at least be a huge improvement over the fractured system we have now. You could tax business what they are paying for healthcare right now, eliminate all the duplication of beauracracy in insurance companies and with the money you save, put it toward real quality that benefits everyone, all without raising costs, which you could fix with inflation adjustments to force economic responsibility. Since we spend twice as much on healthcare as any other nation, we would have the best system in the world instead of the most wasteful.
Realistically you would still have two tiers. The Uber rich, I am sure, would feel they wanted something better and would pay out of pocket to doctors that would only be too happy to oblige. If they pay taxes and foot the entire bill, I suppose it is only fair. They would be a definite minority. The important thing is that healthcare would become a resource that we share.
There is a certain basic concept that we are beginning to forget in our society, the concept of common wealth. Way back in the days of print media, communities would pool their resources to build a collection of books we call a library. This was because information and education was felt to be mutually beneficial if shared. The poor can only benefit from learning. We all can gain more as a group, enriching the whole, than any of us can individually. This is a way the group can protect resources from individuals who would devour or horde them. It turns out that together we have much more than any of us could ever hope to acquire individually. This is the thinking behind public museums, national parks. These are something different than commodities. They are actual sources of well being. This is our true wealth, and it is shared.
The common wealth of America are habitats, ecosystems, languages, cultures, science, technology, schools, social and political systems, democracy. These are things often so basic we sometimes forget how much we have. They are things we all value together and are well worth fighting for. So is medicine a right, or a commodity dependant on resources and wealth? My answer has to be an unqualified yes, it’s both.
I believe, sincerely in the depths of my soul, our commonwealth has to include medicine. We need to protect it, not exploit it. I doubt any of us could calculate what exactly any of these things would cost on the open market. I think it is safe to say that taken together our common wealth’s value exceeds all we could ever own privately.
This is why collectively, we need to move to protect healthcare and medicine and distribute it among ourselves equally. Yes this means placing some trust in the government, which after all represents all of us. I am just enough of a hopeless optimist to suggest this is something we must fight for. In the end, I have to come down believing health care is a right, inextricably tied with life, liberty, and the pursuit of happiness. I leave you with this closing thought about what I believe society should and can be.
“We need to speak up, to say boldly why we fight for good schools, why we build houses for the homeless, why we protect open space, why we look after the ailing and the elderly, why we pay taxes without grumbling, why we honor government as a force for public good. In a society obsessed with competition, we need to say why we practice cooperation. In a culture addicted to instant gratification, we need to champion long-term healing and the welfare of coming generations.”
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August 27, 2009 at 12:13 am
yanub
I am so glad you have come back to weigh in on health care reform. Even in a re-post, your compassion comes through.
It has been a pleasure to me to see more and more doctors explaining why a universal national health care plan is a must, and why single-payer would not be the worst thing possible. The worst thing possible is to remain with what we’ve got, because the current situation is not geared toward the good health of anyone.
August 27, 2009 at 8:09 am
Suzanne Gilly
When you use the phrase “labor shortage” or “skills shortage” you’re speaking in a sentence fragment. What you actually mean to say is: “There is a labor shortage at the salary level I’m willing to pay.” That statement is the correct phrase; the complete sentence and the intellectually honest statement.
Don’t speak about shortages as though they represent some absolute, readily identifiable lack of desirable services. Price is rarely accorded its proper importance in this sort of “worker/skill shortage” rhetoric.
If you start raising your wages and improving working conditions, and continue to do so, you’ll solve your “shortage” and will shortly have people lining up around the block to work for you even if you need to have huge piles of steaming manure hand-scooped on a blazing summer afternoon.
Re: Shortage due to retirees: With the majority of retirement accounts down about 50% or more, people entering retirement age are being forced to work well into their sunset years. So, you won’t be getting a worker shortage anytime soon due to retirees exiting the workforce.
Okay, fine. Some specialized jobs require training and/or certification, again, the solution is to raise your wages and improve benefits. People will self-fund their re-education so that they can enter the industry in a work-ready state. The attractive wages, working conditions and career prospects of technology during the 1980’s and 1990’s was a prime example of people’s willingness to self-fund their own career re-education.
August 27, 2009 at 11:57 am
A Wealth of Information « Apollo, M.D.
[…] August 26, 2009 – Blog “Mind, Soul, and Body” – Repost: Medical Care, right or privilege? […]
August 27, 2009 at 2:44 pm
Doc
Yanub,
Thanks for the kind words. My biggest fear is that the fear induced rhetoric that has been paralyzing reform for decades really will lead to the exact type of cataclysm that people in town halls are screaming about. Call it self fulfilling prophecy. The HMO, insurance liberalizing reform of the 80s was their work, and look where it has gotten us.
Suzanne,
The shortage I referred to was in World War II when a vast amount of the workforce was overseas fighting the war and wages were fixed by the government. It was then that health insurance and benefits became the solution and end around to compete through workers because it was illegal to raise wages.
However, this is all tangential to my post. I’m not seeing how anything I wrote addresses the point you rebut. My only point was that the introduction of insurance removed some checks and balances on controlling the cost of the medical system.
September 17, 2009 at 10:56 pm
LDS Music
At last. Someone is actually talking sensibly in the debate… Some real-world stories instead of name-calling and backbiting.
September 29, 2009 at 12:17 am
Greg
Scott – Health care reform is a very important issue. Although it may not be possible to return the present system back to a free-market system, I thought you might want to read the History of Socialized Medicine in America. Most concerning is the fact that the proposed bill will create 53 additional government agencies under the executive branch of government in addition to removing fundamental individual rights granted by constitutional amendments.
February 23, 2010 at 5:05 am
Mark D.
“I believe, sincerely in the depths of my soul, our commonwealth has to include medicine.”
Yes. However, there are radically different viewpoints about how best to sustain that common wealth. High quality care at an affordable cost, right?
This is a question of economics. A heavily regulated single payer system is one alternative. The question is whether it is superior to a system where the government takes a role in solving the most serious problems (catastrophic coverage, for example) while removing the perverse incentives that cause our present system to be so ridiculously inefficient in the first place.
Would it be rational, for example, for the government to get into the food insurance business, or provide massive advantages to employers who purchased food, tax free, for their employees?
Not simply free of sales tax, but free of income tax, and payroll tax, and every other kind of tax. Suppose a companies employees are in the 25% tax bracket. Add 15% payroll tax, 5% unemployment tax, and 10% state income tax, and it becomes clear that under normal conditions it costs such an employer nearly $2.00 to pay enough for their employees to purchase $1.00 worth of food.
But food is expensive, and getting more so every day, so we pass a law that allows employers to purchase food coverage for their employees tax free. Now the employer can purchase $2.00 worth of food with a $2.00 expense, meaning that their lucky employees can now effectively get food twice as cheap as those poor benighted souls who have to pay for food with after tax income.
Even better, the favored employees are only charged a 10% copayment on all their grocery store purchases. Any kind, as much food as they want no object to them, if a bit pricey for their employer. As long as their employer is footing the bill, why should they care about how much the grocery store charges their employer, or economize on groceries at all? Should they have anything but pity for those who have to pay (in real terms) twice as much for every loaf of bread, box of cereal, and gallon of milk? Should they care that their government encouraged insensitivity to cost makes the problem worse?
The solution is clear. The government should make everyone purchase food insurance – catastrophic famine or unemployment only policies not allowed. Instead everyone must purchase a food insurance policy that covers steak, ice cream, and soda pop. No agonizing decisions about whether to prepare steak or spaghetti, no child left behind.
February 23, 2010 at 4:41 pm
Doc
There are in fact many perverse incentives to healthcare. We encourage some overuse and this will have to be overhauled somehow. I am not holding my breath for employers or insurance companies to do it. Frankly, listening to many voters and protesters living in a fantasy land where everything in healthcare is a-okay and going to stay that way forever leave me questioning if the government can even fix it.
I am not so naive as to not realize that rationing in some form is inevitable. The fantasy land the American Public seems to live in this regard is alarming. What the naysayers and free marketeers always neglect in this debate is the scope of the problem.
When food takes up well over half our income and is sure to double in cost within the next decade, with half of the country starving, your food insurance example will make sense and lose its intended irony completely, until then it is simply denialist political theatre. Whether a pure market would prevent the crisis or not at this point is academic. With insurance in play for decades, the masses aren’t going to go back to cash only service, even in America.
Nor Should they, for piling on the sick and the poor the way the healthcare market demands has gone out of style in most the civilized world. Equitable distrubution of a public good can only be done publicly. The government as bugaboo, market and savior model breaks down here, just as with the police force, the prison system, the military, the freeway system, the national parks, and every other public good.
January 13, 2011 at 9:35 pm
Chaos and Cupcakes » Speaking up
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