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Dr. Tattersall was a fine country doctor lifted from a Norman Rockwell painting, complete with white hair and kind eyes. He worked out of a pine-paneled office attached to his home on the only road in our area busy enough to have a painted yellow line running down the middle. For most of my early years, Dr. Tattersall stitched me, vaccinated me, and kept me in one piece. I suspect many of us have memories of our first doctor. We tend to equate health care with something familiar, like the geeky gecko personifying insurance giant Geico. But the health care business isn’t really Dr. Tattersall or a cute lizard. It’s a $2 trillion dollar industry, one of the largest in the United States. It has the most to lose in the current discussion and a fitting reputation for playing hard and dirty anytime health care reform is proposed. CNN just ran a story on Wendell Potter, the former vice president of corporate communications at insurance giant Cigna. Mr. Potter resigned from his role after Cigna refused to approve a liver transplant for a California teenager (who later died) because it was a “pre-existing condition.” Potter contends that the industry is playing "dirty tricks" in an effort to manipulate public opinion. "Words matter, and the insurance industry is a master at linguistics and using the hot words, buzzwords, buzz expressions that they know will get people upset.” Potter, while testifying before the senate this summer, assured senators that "I know from personal experience that members of Congress and the public have good reason to question the honesty and trustworthiness of the insurance industry." And how big is this industry? According to the US Bureau of Labor Statistics, it was the “largest US industry in 2006, and provided 14 million jobs—13.6 million jobs for wage and salary workers and about 438,000 jobs for self-employed and unpaid family workers.” Think there might be something to protect? No one should be surprised that such a significant industry is facilitating a deeply visceral response to what Congress has proposed. The health care industry does two things very well. First, it protects its efficiency by eliminating people who need expensive health care. “Pre-existing conditions” are liabilities that don’t make money. If you have not yet experienced this personally, check out Kristin Howerton’s (Mamma Manifesto) post, “Assuredly Uninsurable.” Think about it. Does it make sense to refuse to provide coverage for a health issue because it already exists? It does if you are a business that protects the bottom line by creating an efficient customer base. It does not if your primary purpose is to provide people with great health care. The other thing the industry does well is push high profit tests and drugs through doctors to patients. Brett Arends, in a recent Wall Street Journal article, notes that “according to a 2007 Commonwealth Fund study of health costs in the world's nine richest countries, we spend three times as much on doctors' services as the average, twice as much on pharmaceuticals, and three times as much per day of in-patient acute hospital care.” That is because the system does not try to protect care, but promote profits. Most doctors are paid fees for prescribing specific tests. Obviously, if a doctor wants to make money, he will develop a bias toward the tests that are highly rewarded. Arends also cites Jonathan Skinner, an economics professor at Dartmouth College, who contends that “the system suffers from too many bad incentives and waste. Doctors get paid to perform needless MRIs. Hospitals blow a fortune on proton beam accelerators.” According to Skinner, "It's not just technology, it's the way doctors use the technology," he says. "The incentive structure is pushing things."“Reforming health care” does not mean simply expanding provision. The millions without access to health care are a result of a broken system supported by a broken structure. I suspect that the apparent willingness of health care companies to work with the Obama administration in “reform” is centered on controlling costs, while preserving the structure that exists. The industry itself has more power than is warranted for the good of those it should serve. The structure creates a context for abuse, and this might be our last chance to change it for a very long time. |
Comments
Hey Mark,
Once again, good article, and I hope you're not at the point that you cringe or roll your eyes when you see that I'm replying. :-)
It's somewhat odd that we are shocked and dismayed that businesses are behaving as businesses. As you laid out, business control high costs and try to push up the money makers. Voila- health insurance. I do not think we need a complete dismantling of this or most other businesses- they have always been about bottom lines, not people. Rather, since this comes down to a 'life' issue, and Christians should always be choosing life- I think the church needs to step up in a profound and major way and cover these huge gaps that we never expect businesses to cover. Man, I wish every town had a Zarephath Health Clinic. Doctors volunteering. Agreements with hospitals. Donated equipment and medical supplies. This is what Obama is looking for, and it's coming out of the church- go figure.
Your quote on what we spend on healthcare as a nation of course is technically accurate- we spend the most on healthcare. Sounds absolutely daunting, and obvious that we need reform, until you see- huh, we also spend the most on education (http://www.usatoday.com/news/education/2003-09-16-education-comparison_x...). We VASTLY spend more on defense. Nearly 1/2 our national budget goes to Social Security (21%) and Medicare/Medicaid (23%). All to say that, yes, we spend the most on healthcare, but it seems as though all of our numbers are big.
Last, I really liked your close: "the structure creates a context for abuse". You're right on, it does. But like the old, tired, but true adage: absolute power corrupts absolutely. The only thing that would increase abuse and corruption would be to give control to the government, where even the co-ops exist only at the approval of the government. I don't want you to think I exist in an innocent bubble of conservatism. I have been without health insurance this year, and was shocked at what my drugs cost. My inlaws have liens on their house because of a hospital visit this year (they do not have insurance). I've been given tastes, thankfully in small doses, of the pain people go through when denied access or coverage. You said "The industry itself has more power than is warranted for the good of those it should serve." What if, instead of just the insured, we let health insurance companies take care of 47 Million more customers? Would it increase the level of power and abuse? This is what we want to deliver to the government.
I think we can go hard, first after the 9 Million children, next for the poor, next in reducing costs via free open competition in the health care market, and do all of it without imposing a $2 trillion deficit and such a dramatic ramp-up in government intrusion and power.
David, I'm always glad to see your posts! Wish we could just meet at Starbucks to talk sometime. Meet me half-way? : )
I think the church coming to the rescue is a lovely thought, and completely out of the realm of possibility. While ZCC does a great thing, it does it in a very small place and with great limitations. Maybe if all the big churches turned their fitness centers into health care centers, we would see an impact. Some how I doubt that's going to happen. One other thought: shouldn't health care come without a religious context? I don't mean churches should not be involved. Look at what the Catholic church has done. Amazing. But health care without the need to believe something specific or without agreeing to read a brochure on the last days. It seems like a basic human need that the church should respond to freely, without requiring something in return. I doubt many evangelical churches could do that.
And I agree, all of our numbers are big because we have by and far the world's largest economy. But compare our numbers to other developed nations and you see that they are out of wack. And our view of care is lower as well.
I'm all for reform that is practical, realistic, and truly solves the problem without breaking what works well. The tourniquet is not the solution to every medical emergency -- why should the government be either? The government: those same folks that run Amtrak and the post office. Would it run healthcare any better than these? I rather think not.
There is a way to address insuring people with pre-existing conditions is to create high-risk pools. The larger the pool, the lesser the non-systematic risk to the insurer, the lower the premium for the insured. Thirty states have high-risk pools to insure those with pre-existing conditions, and they do so without significant government intervention.
There is a way to address medical cost inflation that results from needless procedures: eliminate the third-payer system. The current system provides little incentive to reign in costs because those paying for it (employers) are not the ones using it (employees). Let consumers choose which procedures they wish to pay for, and they, in turn, will fund the medical research and innovation that is another thing that our healthcare system does well. Ninety percent of all new treatments and therapies are developed here in the U.S.
There is a far better solution to a public option, and that would be to allow the uninsured to opt into the Federal Employees Health Benefits Program. I blog about it here:
http://the-daily-quidditarian.blogspot.com/2009/07/better-option-give-un...
Ron, I guess you are also saying that the structure is the problem? One of the things I'm running into is a focus on "getting more people covered," when that is not the underlying issue. It's the structure.
You get to that with the third party payments. I agree, that is certainly part of the problem. When I had my hip surgery, I was only glad that I did not have to pay the bill. The numbers on the bill meant nothing. But if consumers pay, how will that impact those who can't? Back to the coverage thing.
Hey Mark-
My son was in the hospital for 6 days this past year. Doctor came in 8 times a day to see how we were. $120 every time they crossed the threshold of the door. Insanity. That worked up to a cool $55k.
Yeah, you know, that dream of having churches step up is out there, and I agree it would need to be given without clause, like Zarephath Health Center is doing, like some of our churches' relief projects do, etc. These- the uninsured- are people that need HELP. Who better than Christians to respond? "Brothers, Be compassionate"- I Peter; "clothe yourselves with compassion"- Ephesians; "comfort those in any trouble with the comfort you received from God." MAN, if everyone drove this as a stake into their heart their would be no health care crisis today! Christians should be first responders here, and anything less is a resounding judgment on the church today.
But back to reality. No, back to my reality: this is where this issue drives me CRAZY. I am confounded that we as Americans, as Christians, and as human beings are so NOT compassionate, that we need the Federal Government to step in and launch a program with deeper financial impacts than any in American history. That is absolutely pathetic. That's what makes me crazy about this. Are we really so uncharitable? I remember during the campaign poor Biden was beaten up for a week for how ridiculously low his charitable giving was- half a percent or something. Maybe what Biden does is not so very different from other Americans. But if that were true, then Americans would know full well about an uninsured 47 Million but still opt to spend their money on our "stuff". ARRGH!
All that said, there is just a lot that really makes me question the motives of the government here. In fact, I don't question them. Why would we work on insuring 300+ million when we need to insure 20-35 Million? (aside: my step-sister Diana, age 25, has decided to not by health insurance because she feels like, at this age, she doesn't need it. That already drops it to 46,999,999- haha). I REALLY like Ron's proposal of adding them into an existing, well run government program, whose costs are driven down by competition. If that was really one of our goals, let's do it! But I don't think that's the government's goal. I think the government is getting ready for one of the most massive power grabs in our history, and buying some votes at the same time. That's why I LOVE the church solution, even if that isn't practical. People walk in the doors of our clinic, and we might never see them again. That's fine. They certainly aren't Christian- that's fine. And they don't have to memorize John 3:16 to get an exam. This country, this world, needs a flood of compassion.
I totally agree with this response.
David, you have lived this in ways that I have not. So far, we have navigated the health and insurance thing with no storms and no near misses. So far. But you have seen it up close, so I read your posts with a lot more caution and interest. So thanks.
I don't know what to make of our charity, David. I really don't. American's compared to other western nations, are far more generous. Feel better? : ) But it does not cut it, as you note. I'm glad that it drives you nuts, since I don't really even consider it. Just seems too much to even hope for a private solution. Maybe it's because we spend a lot of time in Harlem now, and the south Bronx. The issues are so beyond a response. Overwhelming.
Also, David, I don't get the power grab thing. I really don't! I don't see it, but I do see a huge power disparity right now. I don't mean the potential of a power grab, I mean one that has already happened and that has created a devastated class of people right here in America. David, 96% of youthful offenders being sent to upstate prisons in New York are Black or Latino. The state pays $200,000 per year for every youth convicted. 80% are convicted again within one year. All that money goes to support a prison industry in New York that employs thousands. What is that?
And health care reflects this power issue. You are one of the few, compared to the many people of color and urban poor who are beyond the system that exists. What about them? This looks like a power issue to me.
Am I going "bleeding heart?" What do you think? Am I worried about the wrong power issue? Are you?
So glad to be working through these issues in community.
Are you insinuating that some bad person or bad community is manipulating the black and latino youths by creating convictions to support a prison industry in New York?
Really?
That sounds like the conspiracy theory that the LAPD planted a bloody glove in OJ Simpson's backyard....
Are you also insinuating that capitalism has created a devastated class of people? Didn't you also just post the following:
What if brokenness were a process of God destroying the façade that was largely self-created? Brokenness is a revealing process, critical in the pursuit of knowing truth and being set free. As our growth in God is a life-long process, so is this tearing down. But it is not an end, only a revealing.
I'm not sure I understand where you're coming from. I'm also surprised that you're having a hard time seeing that creating a welfare state (which is the goal of the Obama administration) isn't a power grab. It sounds nice to think they're helping everyone.
Blue Diamond, maybe we should take this one step at a time. Can you help me understand how the Obama administration is creating a welfare state? Actually, I would also appreciate how you would define that. What is a "welfare state?" Sounds like we are speaking from very different places, so it would be good to get some language clarified.
Thanks for commenting!
http://www.britannica.com/EBchecked/topic/639266/welfare-state
concept of government in which the state plays a key role in the protection and promotion of the economic and social well-being of its citizens. It is based on the principles of equality of opportunity, equitable distribution of wealth, and public responsibility for those unable to avail themselves of the minimal provisions for a good life. The general term may cover a variety of forms of economic and social organization.
Mark,
I think this discussion is healthy because I am honestly trying to understand how such differing opinions can come from people who share the same world view.
I think I'm starting to understand where the disconnect is. I'm pretty sure that all those who profess Christianity would agree that a utilitarianism philosophy is not in line with scripture. I think those who would profess Christianity would also embrace the concept of giving and helping and sharing with those in need. Are we on the same page?
The difference is, do we believe that the current government embraces utilitarianism? Some may think Obama's wishes are innocent and noble and he does not embrace utilitarianism. Others (like me) may not agree with that assessment.
http://www.britannica.com/EBchecked/topic/620682/Utilitarianism
The second key difference is giving to those in need. Yes, we all agree that we should help the hurting, but the difference is that some (like me) feel that is the responsibility of the body of Christ and not the government.
The needs in this world are overwhelming. It feels futile to even try sometimes, but I will do my best to serve one another as a reflection of my love for my creator regardless of my circumstances.
Am I closer to understanding our differences? I do value your feedback.
You are so gracious! Thanks for clarifying. Couple of thoughts:
The definition you use is crystal clear. And I think about all the areas that we like the government intruding upon now. I was watching CNN and they had several shots of older people (60s/70s) lamenting the health care revision proposals because it was not what happened in "their America." But I had to wonder if they enjoyed Medicare. Or farmers who work in an industry that is sustained by government subsidies. Or me, working in higher education, where even private institutions are kept in business by government subsidy (federal and state student aid). So when someone says something about a welfare state, I have to wonder what aspects of a welfare state (federal highways? public water? public schools?) do they use everyday without thinking about it.
So, what then hits me is that we are fine with the government intervening in what we like, but we don't want the government working to help others who really need it. Maybe that's part of it for us also. I am something of a bleeding heart, in that I think the government should play a role in working with people who really need it. Maybe that means I don't trust the church enough. I guess the Catholic church has a good track record of hospitals, but it's really hard for me to imagine something significant happening. What do you think? Maybe I'm not expecting or hoping for enough.
Utilitarianism is something I teach about in my ethics course. It actually is the way American business works. The whole idea of "shareholder wealth" is based on utilitarianism. It's the basis of corporate ethics. And, interestingly, that also applies to American health insurance companies. So, reform actually pushes back utilitarianism less than it promotes it. Does that make sense?
Love the dialogue! You write with clarity and passion, which I really appreciate. Conversant Life at its best. : )
Dr. Meehan,
I would love to take your class! I bet I would be your favorite student:)
I totally get utilitarianism in corporate ethics. In business, if it's useful, use it, if it's not, get rid of it. I totally see how the American insurance business model isn't compatible with healthcare. Healthcare and business are definitely at odds with each other from an ethics standpoint. But utilitarianism can't apply to our citizens.
I like the idea of reform to push back on the health insurance industry. It is a unique niche in our economy and serves a different type of service to our citizens. But that kind of reform isn't what is being proposed by the democrats.
I do have to ask myself, what should I expect from my government? Yes, I like some of the benefits like a free education, national defense, clean water, and highways. But where does it end? Should the government provide food, transportation, housing? If the government is asked to provide for more than it's citizens can produce, then what?
We could probably go on for a long time about this subject. I hope that we both can push back to check our thinking on this. That's why I do like conversantlife.
You have become one of my favorite writers at conversantlife. Thanks for making me think.
Just checked your profile. Yikes! Internal auditing. You know more about utilitarianism than I ever will! I bet you can tell some great stories . . . . I'm also love dogs, especially large dogs. We have a Rhodesian Ridgeback that is one of my best friends.
Anyway, you are right, where do we draw the line? I really don't know. As soon as I find a place to draw it, a new issue emerges. I really struggled last night with what you wrote about the church. I wonder if I'm too automatic about the government role and less than hopeful about what the church can do. I assume the government has to do something and that the church won't. I don't think that's a healthy mindset! Would really appreciate your prayer for in that, as I need God's perspective.
Thanks so much for your writing. I'm learning so much from this process on Conversant Life. It's like fresh air.
WOW! So much great dialog since I last posted. Mark, life has been coming at me so fast that I haven't been able to respond to some key concepts you laid out in your last reply to me- glad to see Diamond picked right up! haha.
Regarding government subsidy, I take a relatively hard line myself on what I believe the government *should* be doing, and my hard line is reflective of a Federalist's perspective. I believe government exists for protection. That's it. So, I am happy with government subsidy in the areas of, for example, national defense, roads and bridges, etc. Our government seems to believe the government exists for *two* reasons: protection and provision. Provision to me is tax dollars paying for pre-school care, medicare, national banks, subsidy of private sector business- to me these are all arenas that are not core to government's role, and as such should step into sparingly (as in Medicare), if at all (as in private sector business). Essentially, what is laid out constitutionally is that any power not specifically assigned the Federal government is given to the state. So, for example, the decision on health care is really a 'states' issue: there is no power given to the Federal Government on this. My state happens to have indigent care and care for children who are not insured; it's called New Jersey Family Care, and it's the state of New Jersey acting within its Constitutionally assigned rights.
Some of the discussion has been on the issue of whether we can trust the church to move in so great a way as to impact social change (Mark), or if we can trust the government to have pure motives and whether it is up to the government to do charitable giving on my behalf (Diamond). If you would allow me a personal anecdote: Mark as you know a couple of years ago my Dad was diagnosed with a terminal cancer; he was dying in New York. I spent, literally, every dollar I had in tolls and bridges to visit him as often as I could, to the point I was broke. It broke my heart to not be able to visit my own father. My 15 yr old niece wanted to give me money to visit him (who knows how she found out), and like a good prideful man I refused. My sister called me back immediately, and said "please do not rob my daughter of the chance to be a blessing." That has stuck with me ever since, and I was able to visit my father. Application? I would so much rather give willingly and cheerfully to those in need, than to have a government take from me to do the same thing. We don't need a massive government structure infusing itself into health care, into the poor, into minorities. We need a complete heart transformation. I hate anecdotal evidence- it's too gray and too easy to use for either side of an argument. However, I will say this: *my* heart was radically changed by generosity, and I have impacted lives similarly because of what my niece did. Would that have occurred if I visited my Dad by government subsidy?
Hi, David!
Great thoughts, David. Always glad when you post. I guess I get stuck at the end of your post. And as I said to Bluediamond, maybe I don't have enough faith in what the church can actually do. I spoke with my pastor yesterday about this, trying to see if I'm selling the church short.
I want to understand better what you mean about the government's role. Does protection mean only defending from a foreign invader? I guess it would include internal and external threats. And what is being protected? A way of life? An ideal? A governmental system that insures the existance of a way of life? I have the federalist papers at home, need to spend some time with them to get a better handle on the approach.
It's hard for me to think in those terms, David, because I'm so far removed. Growing up in a military home, the government was ever present. We shopped at tax free "Post Exchanges" on base. We received our health care on base. We took vacations at campgrounds on Naval bases in Maryland (right on the bay, very nice!). Maybe that's why I see this as something that the government needs to do, that the church could never do.
A $2 trillion industry will always protect itself. I suspect if church's did get moving, having a real impact, the health care lobby would push for legislation to prohibit church based health care because it was religious based, or sectarian, or something. I don't think it's an issue of the constitution. Fire fighters are government, schools, highways, on and on. If we tried to live by a strict standard of the constitution, we would not live the lives we have today. It seems to me that if we can't do health care because of the constitution, we can't do much else, either.
Mark, that's a fascinating reply. It's more than slightly interesting that I am looking to the Church, while you are looking to the Government, considering I am a PK and you are an MK.
Just a couple clarifications: I don't believe we can't do health care because of the Constitution. I believe in States Rights, which gives power to any state to cover these needs, as in the case of Mass. or NJ. If your point is that we are already navigating outside of the confines of the Constitution, then I couldn't agree more. Also, I agree that a $2 trillion industry will protect itself. It is on this basis that I believe the Government has much more at stake here.
David, what do you mean by "the government has much more at stake here?" Not sure how you are connecting that to the government either taking action or not.
Amazing to see this actually coming to a vote soon! Seems like it's been dragging on forever.