The Long View 2007-09-18: Xenopathy; Episcopal Tyranny; Be Well
Back to our regularly scheduled program.
This in an interesting post, and one of a thread of arguments on healthcare that strongly influenced me. The occasion was John commenting on a plank in Hilary Clinton’s presidential platform that is very much like what the Affordable Care Act turned out to be.
Something I don’t fully understand about how the ACA turned out in practice is that some private insurance got much more expensive, and some was untouched. In my experience, the people who complain that Obamacare ruined their insurance are either self-employed, or employed at small businesses. I know several people who complain that their premiums when up at the same time that their coverage decreased while the deductibles increased. They are wroth, as you might imagine.
However, such complaints seem concentrated into the categories I mentioned. Large corporate health plans seem untouched by that change. So I’m curious, was this just a structural oddity of the insurance market in the US, or a calculated attempt to concentrate the pain on people who were voting for the other guy anyway? I’m genuinely curious, but I lack subject matter knowledge.
The longer term item of interest here is John’s argument that healthcare is a public good, not a public right. He made the argument that the proper functioning of society requires healthcare to be provided well, insofar as doctors take a long time and a lot of money to train, and infrastructure is expensive.
One way or another, this is inevitable. Younger people sometimes ask me, "Why should I have to buy health insurance, when I am in good condition and I have other insurance against most kinds of accidents?" To that I have two answers:
"Stop whining, slacker scum: you will pay till the pips pop!"
My other answer is that the full range of modern health care requires too much infrastructure and too many personnel to be paid for by its immediate consumers. In other words, if you are a 30-year-old who will need dialysis at 60, you and the people who will go to your clinic must start paying to build the machine and educate the doctor now.
John saw this as medicine being like a public utility. An analogy he also extended to the broad US military presence in the world. But he was also arguing from a concept of public or common good that is honestly foreign to almost everyone now.
This is the bit that I found most interesting, and influenced how I approached the question of what really works in healthcare:
The system does medical tests for things it does not need to know and invents new cures for things it can already treat. The system is responding to some market demand, but it's not a demand for health. This other thing that the system is doing, in fact, seems to absorb resources that should be going to ordinary medicine.
I think John correctly identified the market demand, but didn’t quite get the why. The why is what I tried to answer.
Xenopathy; Episcopal Tyranny; Be Well
This is how it starts:
LIMA (AFP) - Villagers in southern Peru were struck by a mysterious illness after a meteorite made a fiery crash to Earth in their area, regional authorities said Monday.
Around midday Saturday, villagers were startled by an explosion and a fireball that many were convinced was an airplane crashing near their remote village, located in the high Andes department of Puno in the Desaguadero region, near the border with Bolivia.
Residents complained of headaches and vomiting brought on by a "strange odor," local health department official Jorge Lopez told Peruvian radio RPP...
There are no reports of zombies yet, but it's only a matter of time.
* * *
Speaking of morbid reflex actions, we see that Bishop Raffaele Nogaro of Caserta has taken it upon himself to prohibit the Latin Mass in his diocese. That link goes to an English-language summary of the story: the following excerpt is, I believe, a translation from the original report in Corriere del Mezzogiorno:
"This case has nothing to do with tolerance," [Bishop] Nogaro said later.
"The Mass in Latin is a distortion of religious fact. Not even university professors who teach Latin pray in Latin. It is not an appropriate instrument for establishing a true relationship with God. To help people to pray is an honorable effort. That is what I try to do in allowing the Tent of Abraham to be used by Muslims and the chapel next to the Cathedral, to be used by the Orthodox.
"But to assail the faithful with sacred images, theatrical choreography and esthetic embellishments does the opposite. The faithful should be offered something valid and educational, not an occasion for disorientation. In short, murmuring prayers in Latin is good for nothing."
Perhaps offering the Orthodox the use of the chapel is a good deed. Maybe the bishop does not know that the Orthodox liturgies make the Tridentine Mass seem like a model of Presbyterian austerity by comparison. No doubt he should stamp out this Slavic obscurantism, too. As for providing worship space to Muslims but prohibiting the traditional Latin Mass to Catholics: you can't make this stuff up.
* * *
As for making things up, no, that was not Fr. Rutler saying the Tridentine Mass at Our Savior in Manhattan on September 9, as I had mistakenly reported, but another upgraded Anglican entirely. Also, though the choir may have sounded like it was being led by John Taverner, the arrangements were actually by Thomas Tallis.
* * *
The last time that Hillary Clinton proposed a national restructuring of the American health-care system, many people said that her plan was very bossy and even that she herself was not a nice person. Well, this time around her plan is called The American Health Choices Plan. It's still pretty bossy, but no bossier than the typical state's auto insurance system. Here are the two key elements:
Individuals: will be responsible for getting and keeping insurance in a system where insurance is affordable and accessible.
The words responsible for in this context mean required to. This is a mandatory system: again, like auto insurance. This why the health insurance companies look on this proposal favorably. The people who will be forced into the system will be, for the most part, younger people in good health.
One way or another, this is inevitable. Younger people sometimes ask me, "Why should I have to buy health insurance, when I am in good condition and I have other insurance against most kinds of accidents?" To that I have two answers:
"Stop whining, slacker scum: you will pay till the pips pop!"
My other answer is that the full range of modern health care requires too much infrastructure and too many personnel to be paid for by its immediate consumers. In other words, if you are a 30-year-old who will need dialysis at 60, you and the people who will go to your clinic must start paying to build the machine and educate the doctor now.
Require Guarantee Issue: Insurers must offer coverage to anyone who applies and pays their premium. This protection, known as guarantee issue, will ensure that no one is ever denied coverage because they are sick or an insurer fears they will be.
This is the flipside of the captive-customer element. Essentially, the health-insurance companies seem to have reconciled themselves to becoming public utilities. They do this in preference to being whipped through the streets in the small hours by an outraged citizenry and tied to stakes in the public squares, where the rays of the rising sun would ignite them and blast them like the bloodsucking vampires they are. In addition to maintaining existing insurance coverage, whether through their employer or privately, people would have the option of selecting from a variety of public plans: this sounds like an extension of Medicare for people who can pay some premium and Medicaid for people who can't. There would be "refundable tax credits" for workers to pay for health insurance, so as to ensure that health insurance premiums never exceed a certain percentage of income. It's not clear whether these credits would act like the Earned Income Tax Credit: would the size of the "refund" be limited by how much income tax was paid, or would it be a pure subsidy?
This proposal aspires to be revenue neutral and to create no new bureaucracy at the federal level. Fair enough, but the plan is very timid about dealing with the key reason for rising costs:
Fund and Distribute Independent Research to Compare Effectiveness of Treatments: In the past decade, there has been an 80 percent growth in the number of drugs prescribed, 100 percent growth in new medical device patents, 300 percent growth in teaching hospital procedures, and 1,500 percent growth in diseases with gene tests. Patients, providers and payers need information on how treatments compare to one another. The American Health Choices Plan funds a Best Practices Institute that would work as a partnership between the existing Agency for Healthcare Research and Quality and the private sector to fund research on what treatments work best and to help disseminate this information to patients and doctors to increase quality and reduce costs.
The insurance companies cannot handle their own paperwork and the trend toward high deductibles tends to turn all care into catastrophic care, but we are having this discussion today because, very recently, something has gone fundamentally wrong with the practice of medicine. The system does medical tests for things it does not need to know and invents new cures for things it can already treat. The system is responding to some market demand, but it's not a demand for health. This other thing that the system is doing, in fact, seems to absorb resources that should be going to ordinary medicine.
The promise of a Best Practices Institute is not enough. If we don't have some idea how to fix this distortion before we establish the new system, the irrational cost pressures will continue as they have under the old.
At the risk of repeating myself, let me say that there is something fundamentally misconceived about discussing this issue in terms of insurance:
End to Unfair Health Insurance Discrimination: By creating a level-playing field of insurance rules across states and markets, the plan ensures that no American is denied coverage, refused renewal, unfairly priced out of the market, or forced to pay excessive insurance company premiums.
On the contrary: the actuarial discrimination between old and young, and sick and well, is eminently fair. It treats people according to their merits. The problem is that this is a context in which fairness is not enough. Health care is not a right: it's a duty. Public health is not socialism, but it requires a high level of social cooperation if it is going to work at all.
Copyright © 2007 by John J. Reilly
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