I'm not sure what's more vomit-inducing-the various reform proposals themselves or the moronic level to which public discourse about vital issues has degenerated.
Should I be shocked by the willful obfuscation of the issues by the Right, the unwillingness to confront the deeper healthcare issues by the Left, and the merciless determination of the health insurance industry to protect its highly profitable status quo no matter the cost to the nation? I suppose not.
Yet, with each town hall meeting, each new "incremental" proposal, each retrenchment by the Obama administration, each MoveOn video packed with healthcare horror stories, each healthcare budget analysis, each Glenn Beck tirade, I find myself shaking my head.
There is hope. The changes we need-some of them, anyway-are going to come from healthcare practitioners, from patients, and believe it or not, from large employers whose backs are broken by healthcare costs, and who are suddenly pushing back on the insurers. We'll get to all of that in my next column, but first, let's clear up a few things.
'Death Panels' & Rationing
Guess what folks? There are already faceless, nameless, merciless bureaucracies deciding who gets how much care. They're called insurance company utilization review panels. They decide what treatments from an already limited menu of "covered services" are "medically necessary" for a given individual with a given set of health challenges.
These panels belong to gigantic for-profit insurance companies whose primary fiduciary responsibilities are to shareholders, not to the people they insure, the doctors they pay, or the big employers who pay their ever-increasing premiums. The people who work on these panels have to get paid, and of course the executive echelon in the insurance world makes sure it maintains the lifestyle to which it has become accustomed, no matter what it costs everyone else. It's all part of the "administrative" costs of insurance-based medicine.
So instead of one federal Big Brother, we now have dozens of corporate Big Brothers determining who gets what and for how much. And we have to pay them handsomely for it! Is that more "free"? Does that engender "choice"? Does it foster innovation in medicine? I don't think so.
Of course, all this only applies to people with insurance. If you're among the 50 million (and growing) without insurance, your access to medical services-or lack thereof-is more random. If you can get to the emergency room, you might get care. If you can afford to pay a doctor, or have a friend in the biz, you might get care. If you end up in the hospital with something horrible, the "system" will take care of you but your costs will be passed along to someone. That'll work so long as the hospitals can keep their doors open. But talk to anyone working in the hospital industry and you'll realize that many hospitals are near collapse.
Bottom line is, some peoples' grandmas (or wives, husbands, brothers, parents or children) are already meeting with death or disability due to lack of access to medical services…and that's occurring through profit-driven decision-making or plain ol' lack of access. I'd call that rationing, except rationing implies hard decisions guided by clearly stated and reasonable (if unpleasant) principles. What we have now is "ir-rationing," governed primarily by greed, short-term gain and a conspiracy of blind eyes.
Rationing is Evil
Seems like no one in Washington actually wants to say the "R" word. But rationing is what we need to do...unless we decide as a country that we're going to simply pay for everything for everybody. That's a recipe for total economic meltdown, given our aging population and our frightening burden of chronic disease, much of which is lifestyle and behavior-induced.
The fear-mongers scored big this summer with their "Obama's gonna kill your momma" argument. What they left out was the fact that many people do not want to spend their last days in intensive care units, hooked up to ventilators, with tubing running through every orifice, and racking up huge bills for their survivors (even with insurance, end-of-life care often carries tremendous non-covered costs). That's why people sign living wills and "do not resuscitate" orders.
Decisions about life-threatening conditions and end-of-life care are difficult and complicated. The question is, who makes those decisions and based on what? Right now, there's very little intelligence on how we're allocating our resources. We spend exorbitantly on end-stage care, and almost nothing on real preventive healthcare (note to President Obama: Mammography is not preventive medicine, it's disease detection. The sooner you guys get clear about what real prevention is, the sooner we can have an intelligent debate about reform).
ICUs and surgical suites are big revenue-centers for most hospitals-it's a big part of how they stay afloat, and it'll stay that way so long as someone is willing to pay the bills. But too many families are being completely bankrupted by catastrophic illnesses-and many of them have insurance!
Bottom line is, something's gotta give. As a nation we can't give unlimited medical services to everyone AND cut costs AND ensure that insurance companies make big profits AND keep our hospitals solvent AND make healthcare accessible to more people. We can't have it all. So that means prioritizing and rationing, whatever you choose to call it.
Insurance Equals Healthcare
This syllogism is the cornerstone of the Obama plan, as it was for the Clintons in 1992. Universal coverage is the stated objective. All the various debates are about how to get there. No one in the Democratic camp and very few on the Republican side are intelligently questioning whether this is the right goal. THAT is one of the biggest problems with the health reform dialog, and I think, a big reason many ordinary citizens across the political spectrum are uneasy.
I keep hearing about all these people who "love" their private insurance plans and fear government "takeover." Who are they? I've never really met anyone who loves his/her health plan (of course many of my friends are uninsured, but that's another story). But I have met a lot of people who hate their plans, and let's not even get into doctors' feelings on the matter. So why are we debating about how to get more people involved in the existing, dysfunctional system?
The key question, to me, is not, "How do we get more people covered?" but, "What should health insurance be for?"
It should be for what it used to be for, way back in the old days: catastrophic, expensive things that happen rarely and only to a relatively small number of people on any given day. It makes absolutely no fiscal or moral sense to run commonplace, routine and relatively inexpensive stuff through the machinery of insurance: it only adds administrative cost, brings profit-minded third parties into the patient-healer relationship, limits choice and burdens everyone with paperwork...all without adding any value.
Think about it: does insurance-based medicine reduce costs? No! It increases costs by adding layers of overhead. Does it improve outcomes? Not according to all standard accepted measures of good public health. In fact, the pressure to see more patients in less time actually increases medical errors and adverse effects. Does it improve end-user satisfaction? If so, why is everyone-doctors, patients, employers-kvetching?
Insurance is about sharing risk. It works well for expensive things that happen infrequently and unpredictably. It doesn't work for stuff that happens every day. Imagine if people expected their homeowner's insurance to pay for their toilet paper, or that new shelving unit, or the plumber who came to unclog the sink!
The cost of care would go way, way down if doctors didn't have to pay out 25%-30% of their total revenue for administrative overhead to deal with insurers. That's the reality of primary care these days, and it's why a lot of doctors are dropping insurance and going to fee-for-service or concierge models.
Until we redefine the role of insurance in healthcare, we're never going to get anywhere with reform. It's as simple-and as complex-as that.
Free Market vs. Socialism
That's how the Right likes to define the reform debate. It's a total obfuscation of the issues. And it's absurd. The existing systems are hardly free markets. In a real free market, buyers are free to choose products or services they perceive as delivering value. Sellers of products or services must assess, woo, and respond to buyers. And the two interact and exchange directly. Insurance-based medicine is nothing like this.
In insurance-governed medicine, patients can "choose" only those doctors who are willing to accept the discounted fees paid by their plans. The insurers' physician reimbursement tables are modeled largely on what the…gasp…the government payors are willing to pay. The whole thing is regulated by a Byzantine matrix of federal and state regulation (just try starting your own independent insurance collective!), and the coding system that governs payment is a proprietary copyrighted system owned by the American Medical Association. If that's "free market," we're in trouble.
And neither is it democratic. You as a patient have no say in the decisions about what does or doesn't get covered in your insurance plan. And neither do your doctors. Those decisions are made by closed-door boards, panels and committees through a process that's anything but transparent.
So, the existing system, which the right wing guardians of liberty are so quick to defend, is really a system of entrenched corporate oligarchies that are every bit as controlling, restrictive and dictatorial as the "socialized" European systems they decry.
At the same time, the Obama plan, despite its "public" insurance option, is hardly socialism. Even with a public option there would still be a huge for-profit insurance sector, and I'd bet that sooner or later the Fed would sub-contract out a lot of those "public option" members to the privates just like they did with "Medicaid Managed Care" and "Medicare Choice Plus" 10 years ago.
Sure, you could argue that the idea of "universal coverage" is "socialist." But as far as I can tell-and no, I have not read the 1000+ page reform proposal-there ain't much in the Obama proposal that would cause Marx and Engels to smile.
The Obama plan would basically be a mandate forcing everyone to buy some form of insurance, with taxpayer dollars subsidizing those who can't afford to pay on their own. But it's all still going to be processed through the multifarious insurance bureaucracies. If that's socialism, it's pretty soft.
Of course we say the "S" word like it's a horrible thing. But as Nicholas Kristof pointed out in his Sept. 3 New York Times editorial, few people mind the fact that we've got things like "socialized" fire and police departments, and a socialized postal system. And let's not forget the socialized air traffic controllers, a socialized interstate highway system, socialized national parks, and a "socialized' military (Question for any Republicans out there: How come you guys never decry the astounding Defense Dept. budgets when you're complaining about "government spending?").
Dare we bring up Medicare? Let's see…owned by the government, administered (for the most part) by the government, paid for by taxpayer dollars...sounds like socialized medicine to me! Sure people bitch about it, but I don't see too many in the over 65 set forgoing their Medicare benefits. Even those who have private insurance will exhaust their Medicare first. After all, why not? It's paid for already, right?
It's All About Asking the Right Questions
The healthcare reform debate has become a morass of ugly politics and industry strong-arming. It has gone so far off track in large part because it's been focused on the wrong questions. How can we get to meaningful reform without asking-clearly and out loud-the larger questions of what constitutes health, what engenders illness, and what kind of systems best help the largest number of people preserve, protect and restore their health?
But let's face it, those kinds of questions are hard to ask when a large sector of our economy is based on selling toxic stuff that endangers health, another large sector is based on selling medicines to "cure" these ills, and a third large sector earns its salt by mediating the medical transactions.
There are good reasons to be critical of the Obama healthcare plan. But as much as I don't like the idea of a mandate to buy insurance, I'm much more afraid of those who would use disinformation to rile peoples' basest impulses and derail intelligent dialog about one of our nation's most pressing issues.
In my next column we'll look at the "Patient Centered Medical Home" model of primary care, which if widely adopted would greatly enhance physicians' abilities to provide comprehensive, prevention-focused care. The model was developed by some of the bluest of blue chip corporations, has bipartisan political support, and could well be our best hope for change in healthcare regardless of what happens to the Obama plan. Stay tuned!