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Health Care in the US

Posted: September 20th, 2010 | Author: | Filed under: Celiac, Personal | Tags: , , , , , , , , , , | 10 Comments »

As a rule, I don’t tend to post on political issues, mostly because I don’t tend to write about or otherwise wrestle with such matters at any significant level. I do stay generally informed, and I also find that much of what passes for political discourse in our country is pretty abysmal.

Health care, however, is one issue which does concern me a great deal, especially since at least two of my children have inherited celiac disease from me. Personally, my wife and I are somewhat insulated and secure from the worst of what has happened to health care in the US over the past decades. I’m a federal employee and as such we are covered under the FEHB. Twenty years ago, the FEHB offered pretty average employer insurance plan with low to average benefits and costs. Over the past couple of decades, I have watched our health care coverage become better and less expensive than that of almost everyone else I know.

And my health care plan has not significantly changed.

Let me say that again. Over the past twenty years, I’ve seen my health care plan go from, at best, a middle of the road plan, to one that seems to be better than that of most of the people I know without changing. I have watched the overall level of health care access and coverage dramatically decline for almost everyone else around me.

That’s not to say they aren’t constantly tweaking and adjusting my health care plan each year. Some years we pay a bit more in deductibles and other copayments. Some years we pay a bit less. Premium costs have pretty much risen every year, but at a less dramatic pace than that of many people I know. They did add a PPO network in the nineties, and reduced coverage for care received by non-participating medical practitioners and facilities. But the plan’s PPO network is so large, that’s been a non-issue. I don’t think there’s ever been a doctor or facility we wanted to use that was not a preferred provider on our plan.

As a result, my wife and I have been somewhat insulated from the abuses in health care coverage in this country and it’s less likely to ever be a critical issue for us personally. However, at least two of our children inherited celiac disease from me — that is they’ve been tested and positively diagnosed with active celiac disease. Thus, they already have one strike for a pre-existing condition and it’s a condition which can manifest in a huge variety of ways. They also have a family history for a variety of other conditions they could develop over the course of their lives. So from a personal perspective, the issue of health care does strike close to home.

However, that statement is true for every single one of us. The odds that we or someone we love will face some sort of serious, life-threatening, and individually unaffordable (unless you happen to be a Bill Gates or Warren Buffet) health crisis at some point in our lives approach certainty. And within the context of the privatized, for-profit system we allowed to balloon over the course of the past two decades, the odds were unacceptably high that during that almost inevitable health crisis, we would not have access to the level of care we might expect and our family would be crippled by debt for the care we did manage to receive. This is clearly the sort of problem that can only be mitigated by sharing the risk, responsibility, and cost as a society. It’s for reasons like this that we group together as a society and a country. There are many things we can do together that we simply can’t do alone.

Of course, it’s a scientifically demonstrated fact that the way our minds function leaves us remarkably poor at evaluating and acting on those sorts of risks. Even when we know the odds, we tend to have irrational optimism that we can beat the odds in some situations. (That’s one reason why, in every flood here, there are usually people who get in trouble and even die from driving around barriers and into flooded low water crossings.) Conversely, we tend to inflate threats that seem riskier, but which actually have a comparatively lower and often even minimal chance of impacting us. The biggest risk many of us personally encounter on any given day is the risk of simply driving to work, school, or the grocery store. But if you ask people to list or rank risky activities, that rarely makes the list at all.

In this instance, managing health care at the societal level in some way is the common sense thing to do from a self-oriented, pragmatic perspective. Ironically, it’s also the only thing you can do if you claim to love your neighbor. In this country, we have organized ourselves as a form of representative democracy. One of the things that means is that we all share in the responsibility of ruling our country. As Christians, that has particular implications. It means we face, though perhaps on a more distributed scale, exactly the same sort of dilemmas that Christian emperors and other rulers have faced throughout history. We are the powers and authorities who will be held accountable by Jesus for the way we have exercised that power. We cannot escape that responsibility and we cannot abdicate it. There are no easy answers to the proper use of that power. There never have been.

Unfortunately, there is no easy button.

So what are our options? I’ve studied what other countries do to some extent and it seems to me that most employ variations of one of three different general approaches. (Yes, I know there are a lot of ideas out there, but most countries seem to actually end up doing one of three things.) It also seems to me that part of our problem is that we are trying to use them all in a disorganized and hodge-podge manner rather than selecting one approach for everyone in our country. If we are going to truly share the risk, responsibility, and cost, it doesn’t seem effective to me to take that approach, especially if, as you’ll see, we segregate pools of those with higher risks and costs from those with lower risks and costs.

So what are these options?

  1. Government run health care. In this system, the government owns the hospitals. Most doctors and other health care practitioners work for the government in those institutions. And basically, health care is delivered directly by the government. England is one example of a system like this. There are many variations and permutations.
  2. Single payer health care. In this system, the doctors and other practitioners largely do not work for the government, nor does the government own or directly operate most of the hospitals and other facilities. Instead, the government is the single payer for health care services. They negotiate payments and they usually distribute the costs to some degree across the populations based on your ability to pay. Canada is one example of a system like this. Again, there are a lot of different ways to do it, but they do share the same common characteristics.
  3. Government regulated health care insurance exchange. Here, the government does not directly pay most health care costs. Instead, it establishes and regulates an insurance exchange and mandates the participation of all citizens in order to spread the risk across the population. Such a system typically must include subsidies for groups like the poor. Switzerland’s system is generally the model for a system like this.

Those are the basic, widely used options. And here’s where the arguments of those who seem to oppose almost anything that is proposed turn irrational. Why? Because we employ all of the above approaches in our country and have for a very long time. Yes, I know there has been widespread demagoguery over government taking over health care or socialized medicine, but though it has been noisy, it’s had no basis in reality. I don’t personally have any strong preference for one system over another. But my life has been such that I prefer to maintain some connection to the world as it actually is rather than my fantasy about it.

Let’s start at the top of my list. Because we are so large as a country, we actually have a government run health care system that rivals that of some smaller countries. It’s called the Veteran’s Administration. While the VA operates many programs on behalf of veterans, one of the largest is certainly the network of doctors, hospitals, and clinics it runs. We hear about it in the news when there is a problem with a VA hospital, but they mostly do pretty amazing work — especially when you consider that we usually choose to underfund them. If a government-run health care system is good enough for those who have served us in our military, tell me again why it wouldn’t be good enough for all of us? Be careful how you answer that question. Though I’m not eligible for care through the VA, I am a veteran.

Or let’s move to the next item on my list. Our government-operated single payer system is the largest single health care system in our country and is much larger, I believe, than Canada’s entire health care system. Our single payer system, of course, is called Medicare. In the debates over health care, both Republicans and Democrats publicly defended Medicare. I remember some of my older relatives, especially the ones with serious illnesses and inadequate coverage, anxiously waiting to reach the Medicare enrollment age. It has problems, of course, because of the way we’ve chosen to structure and fund it over the years, but as a system it works well enough that threats to take it away seems to raise the ire of those who have it.

Finally, even before the recent Act, we had government-regulated insurance exchange option available. It’s the one that has covered my family and me for most of my life, the Federal Employee Health Benefit (FEHB) program. OPM has regulated the program pretty well over the years and overall it’s worked pretty effectively.

The recently passed health care reform act requires that similar exchanges be established at the state level (or the state can opt into a national exchange), but the only population of those exchanges will be those who do not have health care coverage through their employer and who do not participate in any of the above health care systems. (And yes, I know I left Medicaid off my list, but it’s similar to Medicare in the way it functions.) That’s certainly an improvement over our current situation, but it means the pool will be a lot smaller which isn’t very good for sharing the cost and risk across the population.

Personally, I believe we need to move toward some single system. As I said, I don’t have any strong feelings about any particular system. Since I’ve participated in the FEHB for twenty-five years, I probably have a slight preference for expanding it to be the single exchange for all United States citizens. That’s not necessarily easy. In order to fund it and make it affordable, we would probably have to mandate that large businesses pay at least the same portion of the premium for their employees that the Federal Government does for its employees. And then we would need to develop appropriate subsidies for individuals and people in various categories such as the poor and the elderly. And it would obviously require a larger regulatory body than OPM currently has in place. But it could work if we had the will to make it work. Switzerland has proven that it’s possible.

In the interim, the health care act has some excellent features. The changes to prohibit denial of coverage of preexisting conditions and the end of the evil practice of rescission alone are very worthwhile. The extension of coverage under parental plans until the age of twenty-six means I will be able to keep my younger two children (both with celiac disease) on my insurance for as long as should be necessary. The insurance reform requiring that a minimum of 85% of premiums be used to cover medical loss is a great first step. I still remember when the typical medical loss by our mostly non-profit insurance companies was 95%, so I’m not impressed by the 85% number. Still, it’s better than the current 70%-80% medical loss. 85% is at least less egregious than the current situation. There are others, but those were the ones that I found particularly relevant.

Nevertheless, it’s a patchwork law that really doesn’t do enough. That doesn’t upset me terribly. That’s how things usually work with us. The health care reform act was a good start. Now we just have to keep making it better while trying not to take any steps backwards.

10 Comments on “Health Care in the US”

  1. 1 Scott Morizot said at 2:28 pm on September 20th, 2010:

    New at Faith and Food: Health Care in the US: http://is.gd/fjykR

  2. 2 Weekend Fisher said at 6:15 pm on September 20th, 2010:

    I appreciate your good intentions, but … I can’t help but wondering if you trust big government a little bit more than I do. You mean to serve Christ; so do I. But I think the question of means will be different.

    My biggest problem with the recent health care plan is this: it fails to set the correct goals. Rather than trying to make health care truly affordable, it tries to shift who pays for it so that it is affordable in a specific context (my next checkup), but without making any real strides towards the quantity / effectiveness side of the equation that would truly lower the costs of health care. In my ideal solution, those would be the first things addressed: making healthcare actually affordable, not just shifting the costs.

    My next problem is government oversight. When you and I spend charity dollars — acting on Jesus’ instructions — I expect you’re like me in targeting the larger part of our donations to the organizations that are most efficient. My favorite charities spend 100% of their donations received directly on the people being helped. Others spend 95+% in that way. The U.S. government is … not as efficient as the better charities. And recent studies have shown that the federal employees generally make more than the people taxed to pay them. I have no problem at all benefitting the poor; but the administrative cost ratio does need addressing.

    Next, there’s the matter of limits. Just to illustrate the point I’ll mention this isn’t an entirely Christian nation. I think the official mandatory charity rate for Muslims under Islamic law is something like 2.5% of income. The official mandatory charity rate for Jews under the Torah was roughly 10% of income (aside from miscellaneous other things that were required on occasion). Christians often use the same 10% as a guideline. And of course all kinds of people can and do far outgive that. But what is the theoretical maximum that can be taken from someone for charity purposes? Is there a theoretical maximum of how much charity can be mandated? Should there be? And is the country obligated to go into debt to fund charity? If yes, then how far? And at what point does it become counter-productive, causing more poverty than it solves?

    Take care & God bless

  3. 3 Scott said at 7:01 pm on September 20th, 2010:

    I can’t help but wondering if you trust big government a little bit more than I do.

    It’s not a matter of trust at all. There are issues that can only be handled at the societal level. Moreover, in this country we are the government. This artificially generated ideology of antipathy between the government and the people is completely ludicrous and lacks any basis in reality.

    I do agree (and said in my post) that the health care bill falls short of what is necessary. But frankly, most of that is our fault as citizens. We are as a whole guilty of magical thinking. We want, but we do not want to pay. And we certainly don’t want to sacrifice — even to fund two wars. However, it’s a start. And if we didn’t at least get started, we would have simply watched health care continue to decline and costs continue to soar — probably for another two decades.

    The U.S. government is … not as efficient as the better charities.

    And that’s simply untrue. I suggest you go check your facts. The VA and SS administration operate with administrative overhead far below anything you will find in either the non-profit or private sector. Our tax system is one of the best administered in the world. People come from countries everywhere to try to figure out how we do what we do. The TSP (401K for government employees) has costs and fees that put private 401Ks to shame.

    Yes, the federal government has problems endemic to any large organization, but they aren’t really any worse — just different. (The private sector, for instance, doesn’t usually have to deal with laws telling them that they have to keep so many jobs in a particular city.) Actually, from talking to my friends who work for the IBMs, Northrup Grummans, and such, most of the problems aren’t even all that different.

    Moreover, private insurance companies (the part of the health care system impacted by the bill) were only spending 70-80% of premiums collected on medical claims. That’s the abuse this law begins to reform. And that’s the basis for comparison, not care for the poor. There really isn’t anything much in the bill about the poor. There are subsidies for those who fall in that gray area where they make too much for Medicaid, but not enough to pay an unsubsidized health insurance premium, but that’s not charity.

    In fact, nothing the federal government does is really comparable to “charity” work. Our government does those things that we as a society believe need to be done collectively. Frankly, even on the social welfare side (WIC, food stamps, school lunch programs, etc.), none of our charities could even come close to filling the gap if the federal government stopped doing what it is doing.

    I think you are making a category mistake with all your talk of charities and almsgiving. Yes, as individuals we must practice the discipline of almsgiving. I’m pretty bad at it, but I absolutely agree. However, as the rulers and authorities of this country (that whole government of the people thing, remember), our Holy Scriptures seem to be pretty clear that we will be held accountable for how we wielded that power. At the time it was written, the more concentrated power of emperors and their governors was probably what people had in mind. But in our country today, we are all to one degree or another part of the powers and authorities. This isn’t about how we practice “charity”. This is about how we rule.

    And recent studies have shown that the federal employees generally make more than the people taxed to pay them.

    As even the authors of that study have said, the way it is being used is an abuse of their work. The reports you cite are comparing apples to oranges. In reality, for the same age, experience, education, and scope of responsibility, federal employees make — on average — twenty some-odd percent less than equivalent private sector workers. Our workforce is heavily weighted toward professional, scientific, technical, and other white collar jobs. Moreover, we have an aging federal workforce — mostly because we have under-hired for the last few decades. The time is fast approaching when that will be a crisis of its own. At any rate, the “news” reports you cite have been thoroughly debunked by people more competent at the task than me if you care to actually research it.

    It really doesn’t matter what the mandatory charity rate in some systems was (although the OT system of mandatory tithes and gifts actually works out to about 26% of income total if you add it all up) because we aren’t talking about charity. We’re talking about taxes and what we should and shouldn’t do as the powers and authorities of our country. Our overall tax burden is among the least of industrialized nations, though we do seem to like to gripe and bellyache a lot more than most. And we might want to abdicate our responsibilities as the powers, but as citizens our form of government doesn’t really give us a way to do that — which means we are accountable to God for what we do and don’t do.

    And the existing health care reform act, certainly, has nothing whatsoever to do with “charity”, which seems to be the primary basis for your argument.

  4. 4 Scott said at 9:12 pm on September 20th, 2010:

    Hmmm. And I’ll add that the 26% (recognizing that specifics varied according to what you did for a living with the bulk of it falling on the majority who raised crops and animals) in mandatory tithes and gifts for OT Jews was in addition to the taxes they paid from the time of Saul on. First to their own kings, then to Babylon, then to Persia, then to Greece, and finally to Rome. And as far as tax burdens go, we have it pretty easy compared to them. When we’re discussing societal level issues like health care, social safety nets (whether for the poor, the elderly, the mentally ill, the disabled, the very young, or anyone else), civil rights, labor laws, insurance, banking, and other industry regulation (food and drugs being a good example) and all the rest, it’s our collection and use of taxes that is under discussion, not our charitable gifts.

  5. 5 Weekend Fisher said at 6:03 pm on September 21st, 2010:

    Wow, touched a hot button, didn’t I? Had no idea.

    Let’s suppose for a moment that the “overpaid government workers” thing is exactly as you say; with you being one of those government workers in question, you’re more likely to have read the follow-up literature than I am. So let me take your word that that’s a mistake; sorry if that was misinformed and caused offense.

    Meantime, that was hardly my main point. I’m far from convinced that the current bill is a good idea; the majority of what I said doesn’t change.

    There are a few things at the root of our disagreement, I think. While you’re firmly convinced that seeing “the government” as a separate entity is a category mistake, I’m firmly convinced that seeing it as an organic part of us is a category mistake, otherwise we would never have had many of the policies we’ve had, and probably would not be involved in a war in Iraq. The government “of the people, by the people, for the people” is often amazingly tone-deaf and resistant to the stated wishes of the people. I realize that you’re a Fed yourself; I don’t mean to paint you personally (or your coworkers) as necessarily any more responsible for any given mess than a private citizen. But there has been for many years in the U.S. a widespread disillusionment with government that it does not necessarily share the same interests as the private citizens; I share that disillusionment. Again, please don’t take this as a comment on yourself; I can gladly assume that all your areas of responsibility are handled impeccably, and *still* be disillusioned with the overall picture of our government.

    Again, the idea that there’s a sharp demarcation between charity/alms and what the government does for the poor does not seem entirely clear to me. Consider that Jesus would have us feed the hungry or support the poor; that’s something we’ve largely given to the government to do, and it cheerfully deducts the price from my paycheck to pass along to the poor. Again, I see taking care of the sick as something Jesus would have us do (and I expect you do too). So there’s not quite a neat and clean distinction between taxation and forced alms. My calling as a Christian is to “go the extra mile” — to give what is taken by fiat without resistance, and even give more to make it plain that it never was the fiat that prompted the donation. But that doesn’t change the very real overlap between what the government does and what Jesus commanded Christians as charity. And therefore the questions still stand: Should there be a theoretical maximum to how much alms can be extracted by fiat? Is society obligated to go into debt for alms? If so, how far? At what point does it become counterproductive? Those are very much live questions as we review our current deficit.

    And, once more, the percentage of my donations reaching the beneficiaries for my favorite charities is in fact a better percentage than that of the federal government; for you to accuse me of falsehood there was out of line. My favorite charities do in fact, as I said before, pass through literally 100% of contributions to those serviced. (As a side benefit, I also get to choose my charities so I can pick where I think the need is greatest, which is more involved in the ‘democratic process’ for my charity dollars than the government would ever imagine.)

    But on to more constructive things. I think the main problem with health care has been this: the person paying the bill and the person receiving the service have been two different people. I get the service; my employer foots most of the bill — and the care is managed and bargained for by a third party still, the insurance company. That removes everyone’s normal incentives for the whole supply-and-demand thing to have any effect at all on innovation, availability, pricing, and the normal market factors that might make things less expensive given the normal course of business. The normal course of business hasn’t applied to the healthcare industry I suspect mainly because of the mismatch between who pays expenses and who receives services and who negotiates rates. To say that the only possible solution is to head towards the single-payer system is interesting but I find it unconvincing … I think there are more options than that. The single-payer system is not any more the “easy” button than anything else.

    Take care & God bless

  6. 6 Scott said at 10:20 pm on September 21st, 2010:

    The administrative overhead of the SSA is less than 1%. There is neither a charity nor a retirement system (though neither are really exact parallels for what the SSA does) that can rival that. Similarly, the fees and administrative costs we federal employees pay for the TSP are a fraction of a percent. No private 401k even comes close. The idea that some seem to have that “government” is inherently inefficient while private organizations are inherently more efficient is simply false. A government agency or program can be inefficient or corrupted for any of a number of reasons. We saw that clearly in the Deep Horizon disaster, where we had tasked the same agency both with the job of marketing and selling oil leases (and rewarded them based primarily on that function) and with regulating those same entities. But it’s hardly a given and private organizations can suffer from the same flaws.

    Charity cannot set societal policy. Charity and almsgiving can alleviate some (but hardly all) of the pain if we decide as a society that it’s acceptable for the poor and elderly to go hungry or die, but that’s really all it can do. It also doesn’t matter if we feel our voice is ignored or if we feel alienated. Our system of government gives us no alternative. We are a part of the powers and authorities whether we like it or not, whether we feel effective or not. Thus all the words in Scripture addressed to the powers and authorities are words by which we will be judged. We may not ultimately be effective, but I don’t see where we can do anything but try. We are involved in a war in Iraq because the majority of people in this country — probably driven by fear — supported adopting a policy of aggressive war. I spoke out against it at the time (and since), wrote my representatives, and I’ve refused to reward the party that adopted that policy with a single vote as long as that’s their official policy. But I was never under any illusion that I somehow wasn’t in the minority. I lot of people are fed up with that war now, but that’s mostly fatigue and not some fundamental shift in attitude.

    However, the category mistake I had in mind didn’t have anything to do with that. Rather, whatever you think of charity, the health care act doesn’t really have anything to do with charity. It has some provisions to expand Medicaid, but those are more provisional than not. Most of its focus is on the small portion of the population that is not covered by the VA, Medicare, Medicaid, or large employer-based plans (which already had to cover pre-existing conditions I think). Its focus is primarily the population of individuals and small businesses who cannot obtain private insurance and, if they can, are the victims of the worst abuses. And that has nothing to do with charity. It’s primarily long overdue insurance reform. There are tweaks elsewhere, but little significant. That’s the category mistake I had in mind.

    The single-payer system is not any more the “easy” button than anything else.

    This statement makes me wonder what I did to so poorly express myself in my post. While I stated I didn’t have a strong preference between the VA, Medicare, or FEHB models (think UK, Canada, and Switzerland), I personally leaned toward the FEHB or Switzerland model, which is nothing like a single payer system. In fact, the hodge podge we did adopt is sorta like the Switzerland model, except instead of being for everyone it’s just for those who don’t currently have any good options.

    Health care in general is an important issue to me or I wouldn’t have written a post about it. But I’m mostly concerned about what my kids and grandchildren will face. I’m not particularly concerned about myself and much less concerned about what people think about federal employees.

  7. 7 Scott said at 5:03 am on September 22nd, 2010:

    I have an idea. I covered some fairly specific features of the health care act I liked in my post and I also covered the various available options. I briefly expressed the fact that I’m concerned that the act does too little and won’t be enough of a beginning to develop in time to actually solve the problem. But I also accept that that’s usually the way we do things in this country. We make a start with a partial law and mold it over time.

    So, what specifically are the features of the health care act that you don’t think should be implemented, why, and what would you do instead? And if you don’t like any of the three general approaches I outlined (used in some form or another by all the nations I’ve looked at), what’s your solution?

  8. 8 Saturday Evening Blog Post – September Edition said at 9:15 am on October 2nd, 2010:

    […] edition of the Saturday Evening Blog Post, hosted by Elizabeth Esther, I selected my post on Health Care in the US. I rarely write on political topics, but that was my favorite post from the past month. Check out […]

  9. 9 Weekend Fisher said at 6:51 pm on October 2nd, 2010:

    Hi again

    You request specifics on the act. Apparently the text of the bill is large enough that those who voted for it, against it, or signed it hadn’t actually read it in its entirety either, so I can’t guarantee my analysis is complete but here it is in part. At any rate, for the part that bothers me most, the big picture will suffice. It’s easy to pick little nits about specific things I object to — but I think that’s the wrong bunny trail or (more precisely) a red herring. I really don’t want the government in the middle of my health insurance on that level at all, whether or not I object to any of the umpteen things that some people have mentioned that they mind. One of the points of the U.S. Constitution was to keep the government from micromanaging the people and getting in the middle of our business on that level. I object to the micromanagement itself, more so than to any particular decision made as a consequences of that micromanagement. It’s not as though one individual decision could change — or even a whole set of them — and make me think, “All better! They’re micromanaging in accordance with my own decision-making schema now!” My point is precisely that they shouldn’t be micromanaging at all. I am a firm believer in giving as much control as possible over peoples’ own lives to those specific individual people.

    The steps I’d be interested in trying are based on my perception of the problem, so I should sketch that out: I see that one group of people pays the majority of the cost (employers), another group of people provides the services (health care workers), another group receives the services (patients), and another group still gets a significant amount of the profits by brokering the financial arrangements (insurance companies). How did we get such a convoluted scheme? Well, those around in earlier years tell me it was a way to keep the government from going deeper into the employees’ pockets, a way for employers to provide something to the employees that the government couldn’t confiscate or deem themselves entitled to a portion. And so we got a needlessly complicated system that completely lacked many of the usual incentives for efficiency and the type of innovation that has made supply of goods and services expand — and prices stay more reasonable — in a number of other areas. The employers’ involvement also has the unintended consequence of making the usual means of paying for health services way too dependent on the question, “Who is your employer?”, and making it so a person has no real choice over their insurance company or insurance plan. Then we add on a legal system that could use some reform also, as there are people who abuse the courts as a get-rich-quick scheme in litigation, complicating things for people who really did suffer and really do deserve compensation. Those in the field have complained of the legal side as a significant expense.

    So with that assessment of the problem, I’d love to see these things as the “round 1” moves towards a solution:

    1. Changes in the legal system so that if a health provider is following JAMA guidelines and can demonstrate that they were doing so, what they do is simply not malpractice, by definition, and cannot be construed as such legally. Any opportunistic litigation brought will not merely be lost but preferably would even be dismissed without a trial. That would make “reasonable suspicion of a breach of JAMA guidelines” (or whatever guidelines were adopted) a prerequisitive for a trial — or possibly for even filing a suit in the first place. It would make “proof of following JAMA guidelines” all that was necessary to successfully defend against a suit. Along the same lines, if the patient withheld information when asked, or refused medical advice, the health provider would not be responsible for the outcome. (A relative of mine is pers0nal friends with a health provider who has settled cases out of court for patients who refused their advice with bad consequences … but you can’t always guarantee winning in court as things are, even if the patient refused your advice, so massive payments were made for things that were literally no fault of the physician.) As a side note along the same lines, it would be nice if the bar associations (on the lawyer side of the equation) had stronger ethical guidelines against opportunistic lawsuits that amount to extortion, while still upholding the rights of those with legitimate grievances to pursue them. I’d love to see the legal associations police themselves about who was giving their profession a bad name.

    2. I’d like to see the financial incentives brought back into line with the normal way things are made affordable. I’d like to see the people receiving the services have control over their situation by the usual means of being the ones who select and pay their providers, as is the normal case in most transactions. I’d like to see the people providing the services have financial incentive to provide the best and most efficient service possible, as is again usually the case in most occupations. While that is the goal, there are a number of ways to move toward it from our current situation. In a more reasonable environment, employees or even the self-employed or homemakers could buy health insurance from the company of their choice at reasonable prices much like car insurance, and the actuarial tables would depend on things like “Do you smoke?” rather than “Are you employed by IBM?” (or the IRS, as the case may be). Again, in a more reasonable environment, the local Physician’s Association where I take my children would offer its own prepaid plan that I could pay into, and the physicians could contract with their usual hospitals and labs for services there as they see fit. If I were short on cash, I’d like to see an option where I could have “catastrophic-only” coverage, or have a higher deductible in return for a lower premium, or any of the other kinds of financial arrangements that are common when you select and buy your insurance personally based on an actuarial group rather than an employment group. As age goes up and health goes down, there are various options for how the PA’s or insurance companies could smooth out the payments over time; in a more reasonable world, those costs/benefits of the plan would be published and on the table as part of the contract at the time of selecting a policy.

    There would always be room for government-mandated charity. I can’t imagine that Medicaid would disappear, nor would I want it to. But I am firmly of the opinion that the normal case should be that people are responsible for themselves. I am also firmly of the opinion that the more players that get into the game, and the further it gets from “a patient and their provider”, the more skewed the incentives will become.

    I suspect that the government mandating universal health insurance will exacerbate the problems that I have described with the existing system, rather than helping resolve them.

    One final thing that bothered me about the health care reform act: the sheer size of the legislation hints of an underlying mindset that says everything can be taken care of with a huge new system in one massive sweep (even it if may need to be tweaked later). This “massive sweep” approach overlooks the “law of unintended consequences.” Think back to the unintended consequences of the employer helping to pay for medical insurance. It was a relatively small change compared to the recent legislation, but it still had consequences that were far-reaching and not entirely good. The more players you add to a game with more competing incentives, the more complicated things become — and the more unintended consequences ensue.

    I am a firm believer in reforming things by steps rather than by massive sweeps. That’s why buildings start with foundations and the foundation is checked to ensure it is strong and level before anything is added to it. A “massive overhaul” of just about anything is typically accompanied by either arrogance or short-sightedness, and the fact that it was all well-intended doesn’t mitigate the consequences in the least.

    You may also be interested in an organization that has been one of my favorite charities for years now. It goes by the name Paper Houses (for short), or Paper Houses Across the Border. The founder/organizer and other volunteer administrators pay 100% of their own administrative overhead, so that when I make a donation, 100% (literally 100%) of that donation goes straight to the intended recipients. There is not a government agency that can rival that, despite how often anyone might say that charities are inferior to the government in handling the money received from me. I’m not saying I’d choose to donate to Paper Houses over paying for treatment for a poor person’s broken arm under Medicaid; but I am saying I can easily imagine things that I either already am or will be paying for as mandated charity through fiat / paycheck deduction, that to me are a lot less important than this organization’s work and mission. There comes a time and a place where the people not only can but should tell the government that it does have limits, and may well be overreaching itself as far as what is mandatory for us to fund.

    But that’s a secondary point; the primary point is about micromanagement. Even with the best of intentions, it’s not a good idea.

    Take care & God bless

  10. 10 Scott said at 12:12 am on October 3rd, 2010:

    You request specifics on the act. Apparently the text of the bill is large enough that those who voted for it, against it, or signed it hadn’t actually read it in its entirety either, so I can’t guarantee my analysis is complete but here it is in part.

    Yes, that is an issue. As Lavonne Neff (wife of David Neff, editor of Christianity Today) noted a while back on her blog, the Swiss managed to do health care reform with an act that was originally 11 pages (I think) long. And even today after fixing problems and otherwise tweaking it, it’s only something like 64 pages long. But lengthy, overly verbose, and at times almost indecipherable laws seem to be the norm in our country. I’m not sure I see any clear way to fix it. Once such habits become entrenched, they seem to be self-perpetuating.

    One of the points of the U.S. Constitution was to keep the government from micromanaging the people and getting in the middle of our business on that level.

    Really? I’ve read the document many times over the course of my life and must have missed that section of it. In reality, even at the time there was a great deal of disagreement over the extent of the role of the federal government. However, the Civil War largely settled much of that disagreement in favor of those who posited a strong central government as necessary. The postbellum US was radically different in many ways from the antebellum US. Even the way we referred in popular speech to the name of our country (from a plural to a singular) changed. However, the health care reform act doesn’t have anything in it that could reasonably be called “micromanaging” our health care decisions.

    I do agree that the employer-based insurance health care system we have in place is overly complex and, especially since we went crazy allowing every aspect to move from largely non-profit to almost totally for-profit in the nineties, is grossly inefficient and a massive drain on our entire country. It costs grossly more per capita than any other country in the world and delivers comparatively abysmal results. Exactly why we need health care reform in the first place, actually.

    Actually, it’s the privatized for-profit malpractice insurance industry that is a massive drain on our physicians and hospitals. However, nobody seriously argues that there doesn’t need to be legal reform. In fact, there was a lot of effort to include more of that in the act. It’s one of the many things that largely didn’t make it all the way through to the final act, but which we really needed. I have a number of family and friends in the health care industry myself, so I’m not exactly uninformed. The failure to put real reforms in that part of the system is one of many things we’ll have to put in place later. If the Republicans had actually participated in the process, it probably would have been in place already. It was certainly on the table through most of the process and it will eventually have to be done.

    I wouldn’t hold my breath waiting for the legal profession as a whole to be more honorable, though. And I say that as someone with lawyers in my family and a son in law school. Many and maybe even most lawyers are honorable men and women. But the attraction for bottom feeders seems unavoidable.

    As far as point number two goes, it sounds like you want everyone in the country to suffer under the completely broken and bankrupt (financially and moral) individual insurance market. That’s really the main part of the market this act reforms with tweaks in other parts. The large employer-based plans were already legally prohibited from excluding preexisting conditions and some of the other worst conditions. That’s also the only part (other than VA and Medicare) that’s been really at all affordable. I certainly know I would have a very difficult time affording my health insurance without the employer subsidy and the majority of people who make less than what I presently do absolutely couldn’t.

    Or are you under the illusion that if we just trimmed a little fat here and there each individual could somehow provide for all their health care needs over the course of their whole life? That looks to me like the invincible feeling that whispers, “I can beat the odds,” when the truth is that none of us will.

    So if we end direct large employer subsidies for health insurance, I don’t grasp what you suggest would take their place. Or do you believe we can simply end something that massive and do nothing? I grasp the ideology, but I don’t see the logic. Every single one of us will either experience an individually unaffordable health crisis ourselves or watch someone in our very close circle experience one. Sometimes a chronic and lifelong crisis. If you “normalize” those actuarial tables at the individual level with no other cost sharing (such as a universal pool participating in an insurance exchange with subsidies for many in the pool) none of us could afford the resulting individual insurance. This isn’t car insurance where you can avoid a lot of risks and if push comes shove, don’t drive. Health care is something you can’t ultimately do without and which, if push comes to shove, you’ll pay everything you have to get, do anything you need to do, and sign as many debt vouchers as you need to sign. If, for example, it’s your child that needs the care, there isn’t a price point at which care is too expensive. There just isn’t. This is fundamentally different from any other insurance.

    As far as the mandate to carry insurance goes, there isn’t any other choice except for government provided care and single payer approaches. You can’t prohibit refusal to cover pre-existing conditions (or really prohibit refusing coverage in general) without the universal mandate. It just doesn’t work. Some people will play the odds and only buy the insurance when faced when an enormous cost. The will, for whatever reason, opt out of the societal risk sharing until they need it and then expect society to bear the cost. That’s been proven already. Nor does it help to say we won’t provide coverage (our existing system, actually). Even though we will deny enough care to actually save their lives, we will still spend sometimes hundreds of thousands of dollars in emergency care to them rather than simply allowing them to die. That cost is currently absorbed by the rest of us.

    Besides, the prime example of functioning health insurance exchange model, Switzerland, has that mandate as one of the cornerstones of their system. If you don’t like it, that’s fine. What exactly do you propose to take its place?

    Moreover, this is hardly a sweeping reform act. In fact, it’s so incremental and modest (despite its many pages of blabber) that the biggest risk is that it doesn’t actually do enough to get us over the hump and ahead of the health care crisis wave. I’m not convinced that it’s enough change to actually build any lasting momentum, or at least not enough to overcome the inertia of our system. In fact, that was one of the main complaints in my post. I utterly fail to see where you believe the massive change lies in this act.

    I’ll take it, because the only alternative was to see nothing at all done for another couple of decades (assuming the whole system didn’t collapse before then like the massive mortgage shell game did). But I’m not really happy about the tiny, incremental changes the act ultimately contains. I think we need to seriously pick either the VA, the Medicare, or the FEHB model and begin moving the whole country toward that model. I prefer the Switzerland/FEHB model myself, but I think any of the three — if they were more universal in nature — would be better than the mess we have now.

    It’s good that you found a charity which has independent sources of funding allowing all donations to go straight to the charitable work. Most don’t have that luxury. However, I think you are still missing my point. Go back and read my comments. I was mostly comparing the government services to private, for-profit services. There isn’t any such thing as “government-mandated charity”. The government doesn’t do “charity.” Most of its services don’t necessarily have exact parallels anywhere else, but they all exist no for charity, but because we’ve decided it fills a societal need. We don’t think it’s a good thing as a society to let people starve. Old people used to be cared for by their extended families (though many weren’t). But as we live longer and urbanization and transportation have led to familial fragmentation, we’ve decided that some minimum defined retirement benefit for all people who have worked is a good thing. (That’s the largest bulk of what SSA does.) We’ve collectively decided that those who are disabled for any reason shouldn’t just be abandoned by society. We’ve decided pregnant and nursing women and small children should have enough basic nutrition for healthy development (WIC) and that it injures us as a nation when that doesn’t happen. We’ve decided that hungry children can’t really learn and that an educated population is to our benefit. The list goes on and on. Those are not “charity”. They are things that we, as a nation, have decided are collectively good for our society.

    And I tend to agree. I’m glad I didn’t live in our country in the late nineteenth and early twentieth centuries.

    Government is not charity, but it is reasonably efficient at the things we do decide it should do. And there is no charity that can function at the scale of what we can all collectively do. (In our particular country, that is the government, however alienated you might feel from it. We get the government we deserve.) I’m not sure exactly what government services you consider “charity”, but whatever they are, if the government stopped doing them, no private charity could take its place. It simply wouldn’t happen anymore. I have family and friends in the non-profit sector. The can’t even fill the present gaps. We can do collectively things we can’t possibly do in a fragmented way. Moreover, people are known to be much less generous than they imagine themselves to be. But we can decide together that we ought to do something and when we spread the cost across our society, make it essentially mandatory so nobody skips out on their part, then we can make things possible which otherwise aren’t.

    Again, all of which has nothing really to do with health care reform. This act was aimed at working Americans. The poor already have programs of one sort or another. There are some things aimed at helping the “working poor” who make too much for other programs, but that’s a small part of the reform act. Most of the reforms in the act are not designed or intended for the poor at all. You seem to have the idea that the health care reform act was about “charity” and for the life of me I can’t figure out where you’re getting that idea. But it comes up so much it seems to be close to the core of your objections.

    The act is not about charity in any sense. While it has a lot of pieces, the majority of its reforms are aimed at the portion of our population that currently lives under the individual and small employer private for-profit insurance market — some 40 million of whom are uninsured and almost all of whom are underinsured — because they can’t get insurance (either at all or at a price that anyone short of a millionaire could afford). And it doesn’t even do that great a job at reforming that piece of our health care system. But it does at least end some of the worst abuses and lays the groundwork for something that might possibly be made better. Yes, there are bits to, for example, allow all of us (mostly those of us with large employer plans) to keep insuring our children for longer so they don’t fall into that part of the market as quickly. And there are a few Medicare tweaks. Other odds and ends like that. But the bulk of it is aimed squarely at the worst part of our system today. And that’s not charity. If those people were actually “charity” cases, they would qualify for Medicaid in most cases.

    Grace and peace, my friend. I still don’t really understand why you perceive the health care act they way you do, but I appreciate the discussion.