11 September 2009

My President Can Beat Up Your President: Choosing A Rational Path to a Health Care

President Obama’s speech last Wednesday night was convoluted, hit-and-miss and largely irrelevant blather. Oh, it was well-written and lofty and all of that. The speech appealed to my pride as an American, but then it doesn’t take much to do that. We should be proud that we are Americans.

As a political “necessity,” the President seeks compromise in a world (1) where a substantial number part of his political foes will brook absolutely zero compromise, (2) where a substantial number of his own political groupies are drooling to “help” by sticking the knife in the “other side” wherever they can (and in their wildest dreams ending up with a single-payer system, and (3) where the only compromise in play is some patchwork on a system that is in crisis. Such is not the recipe even for no-bake brownies.

Let us consider the current players, Congress and all of the loudest people participating in the health care & insurance debate. Their primary concerns are not illness, accident or suffering. Oh, they are mostly normal humans who don’t like the abstract idea of cancer eating up young people and so forth, but these are generalities, not gut-check images of dying people. Representatives, Senators, Congressional staff people, the Executive Office of the President, the entire pig-snail bureaucracy, Gucci-suit insurance executives, Armani-suit health care executives, disability examiners, the kinds of doctors who review files rather than see patients, wing-tip & Manolo Blanik trial lawyers on both sides of malpractice cases, HR directors, health care union reps, prominent writers, K Street lobbyists, political pundits, think tank policy wonks, and the usual suspects in the peanut gallery follow the money. And they really have three things in common:

1 - They have good medical insurance so the debate isn’t personal to most of them.

2 - They will continue to prosper personally so long as they focus on money first.

3 - They will moan like they’ve been gut-shot if you say they are all about money and claim that they out-nice Mother Theresa.

Thus, they follow what Hagar the Horrible calls “The Viking Motto”: I got mine.

My own anecdotal observation is this: The amount people care goes up with the amount of blood and feces they get on their hands. I don’t know of any scientific study like that, but the kindest and most caring and most human people about health care are those in the trenches. Perhaps it is the lowly “orderlies” and “Certified Nursing Assistants” who have the greatest caring - and most dignity - of all. But the docs and nurses and x-ray techs and med techs and paramedics and so forth are right there, too.

Following the money is DEstructive. That’s easier. It takes less thought, although the players have to have fewer morals and stronger stomachs. One of the very best follow-the-money strategies is the simplest: If you don’t have good enough facts or shocking enough facts, make stuff up. People will believe it. Thousands of people die of cancer when insurance companies cancel policies after they get sick because the insured didn’t tell the company about their acne. That’s a pretty good story. The champion story of recent months is the one about the bureaucratic Committee to Kill Granny. That was inspired. In 1729, Jonathan Swift wrote A Modest Proposal, where he proposed that the Irish solve their hunger problem by selling and eating their children. That was condemned as cruel satire. The funniest thing is, the 18th Century people knew it was satire and the 21st Century people swallowed the Committee to Kill Granny hook, line & sinker. Who says we’re making intellectual progress?

So let’s take the Vince Lombardi approach. In two years, Lombardi took the Green Bay Packers from the bottom of the NFL to the championship. One of his mantras was “The basics.” What are the basics of health care? They are not instantly to declare that all employers will buy health care or that we’ll switch on Tuesday to a single payer. The basics of health care REQUIRE that we as a nation answer 3 questions. These questions are hard to answer, but the questions are simple and clear:

1 - Who will get health care?
2 - What care will they get?
3 - Who will pay for the care?

Of course I have opinions, and I’m not pretending to hide them. But this is not advocating “my plan,” because I really don’t have one. Let’s identify the questions and consider the process we MUST go through to answer them. If you disagree with what I might think is a good solution, that’s fine with me - but you still have to confront the problems and answer the questions. If you don’t answer the questions, you’re not talking about health care, you’re talking about moving money around and ignoring sick people.

Under the President’s plan “announced” Wednesday, we get the idea that everybody (with unspecified exceptions) with get unspecified health care paid for either by themselves or their employers or unspecified others, possibly financed in an unspecified way by unspecified savings from unspecified waste and fraud.

OK, that sounds harsh. But under many health insurer’s plans, healthy people hopefully won’t get sick and if they do, they’ll try to find a way to deny or limit coverage, and if they can’t do that, they’ll approve treatments which were modern 15 years ago and limit payments for what they do approve to what was reasonable 20 years ago and stick the patient with the rest.

Under the overall prevailing American system, the most advanced medical care in the world is theoretically available. Some people get all of it, some people get some of it and some people get very little of it. Generally, those who get the least are those who work at relatively low paying jobs.

Under the most liberal plan, the single payer, we will provide everybody with everything paid by taxes and pay doctors what we damn well please, but rich folks will pay the best doctors privately because they’ll establish a private-pay, superior care network. Other folks will get the care they get when the system gets around to giving it to them.

Let’s look at some issues that will come up as the questions are considered and answered.


Currently, the rich get good care, and so do people with excellent health insurance. Those in government-as-employer-funded insurance plans (such as members of Congress) have the best insurance of all, which will pay for just about anything forever. Other insurance plans go from good to nearly useless, depending on the plan and that depends mostly on what premiums are paid. Insurance companies are not stupid. They have to take in more than they pay out. If they don’t, they go to a place called “Out Of Business.”

The poor get an acceptable level of health care in many instances. No, I will not retract that. The poor who qualify for Medicaid have health insurance which is better than the insurance of most working people. You may think that’s good, you may think that’s bad, but whatever you think it is, it’s a fact. The “working poor” and “lower middle class” more often get the shaft. With too much income for Medicaid and too little to pay the employee part of health insurance premiums plus deductibles and co-pays, these people are the most at-risk for having medical needs and no way to pay for them. Again - be it good, bad, or just their tough luck, this is a fact in America today. Oh, hospitals tout their level of “charity care,” which is the dollar value of care which they give to people who they know can never pay. That is a good thing, but let’s not get teary eyed here. There is no person called “Hospital” who has to eat macaroni tonight because s/he gave too much charity care this month. The executive staff still gets paid. The power stays on. “Charity care” is another term for “shift the cost.” Somebody pays the cost to treat charity patients. Those costs are just moved to whoever pays for the other patients.

Before we look at what care will be given, let’s consider two special categories of potential patients. First, there are the illegal aliens/illegal immigrants. This is a hot button topic. Representative Joe Wilson improvidently but sincerely blew his top during the President’s speech. That was dumb, but I doubt if it was planned or cynical. Nevertheless, it is CERTAIN that the following event will occur: A car will pull up to an Emergency Room door. A woman will get out, rush in and tell the people inside, “My husband is having a heart attack.” The husband is an illegal immigrant. This is no longer a theoretical debate, and we are cowards if we hide from the issue. We as a society have to decide: Does the guy having the heart attack come in the hospital for treatment that may cost tens of thousands of dollars that others (like taxpayers) will pay, or is he turned away. There is no compromise here. He’s in or he’s out. He’s an illegal immigrant. Society, decide.

The second people to think about are the “they did it to themselves” crowd. This person has lung cancer. S/he was a smoker for 30 years. “They did it to themselves.” Will that affect their access to care? AIDS. (Give me a break - of course there are people who got AIDS purely by non-preventable causes. They are a minority, however. Most AIDS patients could have avoided the disease by using sanitary or sterile precautions.) Are they fully in the system? Fat people. They/we have more heart attacks and strokes. Is it fair that others pay for their/our sinful indulgences?

Again, whatever your answers might be, the questions have to be answered.


America has the most advanced medical care on Earth available to its citizens. That doesn’t mean that all the citizens get that care, but it is available. In 21st Century Health Care America, what care actually will be given?

Preventive care - We know so much about the value of preventive care, but citizens do not take care of their own health and third-party payers either don’t pay or poorly pay for prevention. Dental and vision care are particularly poorly covered, but each can prevent serious (and expensive to treat) medical conditions later. Adults need PSA/prostate exams or mammograms, and every older adult needs colonoscopies. Without good insurance, you don’t get those, and if you contract the diseases they are designed to detect, you will more likely die, but only after you have much more expensive treatment than you would have had if the condition had been caught earlier. Payment for diabetic medications and testing supplies can help avoid amputations or kidney dialysis. Ignore the fact that those are awful things for a patient to experience. Even if we are just following the money, it seems stupid to let those things happen.

Garden variety acute care - We do pretty well there. Appendectomies, hospitalization for pneumonia, getting stitches, lab work and x-rays seem to happen reasonably dependably. When we talk about what care is given, we will have to listen to the doctors mostly. True, there are as many insufferable egomaniac doctors as insufferable egomaniac lawyers as insufferable egomaniac politicians, but the docs are the only ones who know the details of medical care.

Expensive care - As the care becomes more expensive, we look at its cost and necessity more closely. Does this patient really need a cardiac bypass operation, or will placement of a stent do? Does this patient need a month in a rehabilitation center? And what are reasonable costs. (See below, “Who will pay,” about cost containment.)

Experimental and “Hail Mary” care - I want to live forever. Because of my faith, I fully expect to live forever in the broadest sense, but I want to live here on this Earth in a young and healthy body forever. Impossible, you say? Not so fast there, I’m working on it. Most people have the same goal, at least in secret. There are some dread diseases that are almost sure to kill a patient in a relatively short time.

Let’s assume a patient age 60 has cancer of the funny bone. The survival rate for that mythical cancer over one year is 5%. A bone marrow transplant is the treatment, costs around $200,000 and assume that it increases the one year survival rate to 10%. Does the patient want the treatment? Yes. The patient is broke and has no insurance. Do we pay for that treatment from public funds. Hey, says the patient, it’s a bargain, it doubles my chances of living. Hey, says the heartless people who have to balance the books, it’s 200,000 bucks we can spend where it will do more good, you’re 60, and doubling the chance to 10% still is a bad deal. The answer? I don’t know. But we have to decide. When the situation arises, we will not have time for philosophical debate or a 10 day court hearing or extended prayerful reflection. We have to make a decision. The patient is treated. The patient is not treated. Period.

End of life care and other “hopeless” care - Life is precious and we have an obligation to keep a patient alive, period. Everyone has the right to a dignified death at a time of their choosing, and if they are unable to choose, we need to figure out what they would want. Or something else. Or I don’t want to make the decision, doc, you decide, I’m going outside for a smoke. Here is another hot button issue. It is virtually impossible to divorce this one from the appearance of morality and money. Proponents of different views will even embrace those concepts. The anencephalic baby. Anencephalic means no brain. None. No place for conscious thought to form. A soul? Don’t ask me, I’m not that smart. Science says there is no reason to use medical resources on this baby. I cannot tell you the “right” answer. These babies will be born. We as a society have to decide the answer. Granny will die. How long will the standards of treatment support her life? If she is in an irreversible coma, will we put on a respirator and keep her going at $2,000 a day for a month? (How dare you ask the question! No, perhaps how dare I answer it in a way you consider wrong, but we must ask the question and discuss it. If we don’t, we prove ourselves to be cowardly and stupid. I don’t care how strongly you hold your beliefs. But if you are unwilling to talk, you are an idiot.)

Last year, I sat in an ICU as a dear friend died after supportive medication was stopped. This was his choice. The ICU had other patients in crisis, so it was my buddy, me and another buddy. We read the Bible to him, prayed with him and for him, and it took him 11 hours to die. He could have lived a few more weeks or months in pain and almost complete dependence on caregivers. I do not know as a fact what the right thing to do was. I think he did the right thing. I may be wrong. Will we, can we as a society make this decision in the name of efficiency and cost-effectiveness? Decide.


In the largest sense, this is a trick question. Ultimately - the people will pay. Always. There is no Ms. Insurance Company who will be peeved that she is overdrawn because Joe Lunchbucket needed an operation. Her managers may be upset. Her stockholders who depend on dividends may gripe. But notice, those are real people. There is no Captain Government to ride to the rescue and pay gladly for the incomprehensible art on the Hospital walls. But there are taxpayers whose pockets (and sweat) created that value. Real people. So the question is not whether it is insurance, government or individuals who pay. It is simpler. What people pay?
On its face, the simplest and fairest system is that the sick people themselves pay for their own care. If a person of means is impoverished by health care, well, s/he’s the one with the medical needs, it’s not our fault. Here we go, “How heartless!” No, if we don’t ask hard questions, if we are so afraid that we won’t confront them, we are cowardly and stupid.

Any other method of payment shifts the burden to someone else. If the “someone else” is the government (funded by taxes, i.e., the public), employers (funded by customers, i.e., the public), insurance companies (funded by premiums, i.e., the public) or a mix of those, this is simply a risk-spreading device. In other words, it’s insurance whether an insurance company is involved or not. What people pay the premiums?

And here’s where the “single payer” concept breaks down. It would not be a “single payer.” It would be a “200 million people who pay their taxes payer” system with one checkbook. The public foots the bill every time. The wealthier part of the public foots more of the bill every time. So the “who pays” is a matter of degree. How hard will we stick it to how many? And where will we catch them? From their paychecks? Their dividends? Their taxes? Their monthly bills and payments for goods and services? Will we target some and excuse others? If Ohio requires employers to pay full health insurance for workers and West Virginia doesn’t, does West Virginia get the Honda plants? There are lots of issues and lots of dogs in the fight, but make no mistake: People will be paying the bill.

Waste & Fraud?

Walk into a hospital. How many people are wearing scrubs? How many people (men & women both) are wearing suits? Now you know about the waste. Watch what drug sales people drive, google “health care fraud,” check the relationships between doctors, hospitals, owners of MRI’s, critically look at the minutes of hospital boards for what is hinted at but not there, and audit a sample of Medicare billing for whether the services were really provided. Now you know about the fraud.

Tort Reform

I love hysteria. I still remember Schwartzenegger in the Conan movie talking about the joy of hearing the lamentation of the survivors of his slain enemies. Aren’t lawsuits great? OK, some honesty here. Some lawsuits are bizarre, and should not be brought, although not nearly as many as the insurance companies pretend. This is not because malpractice lawyers are all nice and responsible, it is because they want to pay for their Mercedes & Lamborghnis and the other cars they don’t park in front of the Courthouse when they go try a case. A bad case will get thrown out and because these cases are done on a “contingency fee,” (the lawyer gets a piece of the action; no action, no fee), so they’ll not knowingly bring a bad suit. Some plaintiffs’ lawyers, however, are stupid and bring bad suits anyway. There is and always has been a way to throw these suits out, but only after some expense has gone into the defense of them.

Some doctors are good doctors who rarely made mistakes, but once in a while do so. A few doctors are quacks and hacks who blunder their way through bodies happily helping the Grim Reaper. “Tort reform” does not discriminate among these people. Actually, let’s go further with the honestly. This is not tort “reform.” Every change is called “reform.” If someone suggests that we put surviving spouses out in the bitter cold when their mate dies, someone would call it “parental reform.” “Tort reform” is really “targeted lawsuit limitation.” For particular defendants, doctors, we decide that the needs of society are more important than the needs of the individual, and so the person who believes that s/he has been injured by medical negligence (whether s/he is right or wrong) will have a more difficult time proving it and will recover less than what a jury would say were a correct verdict if the harm were inflicted by another sort of defendant. (On the other hand, doctors and insurance companies have lots of money, so malpractice verdicts may be larger than other verdicts.) You can say that lawsuit limitation is a bad idea, you can say that’s a great idea, I don’t care. That’s the purpose of it, and is a policy choice. Let’s just be honest. In the meantime, the liability insurance companies terrorize doctors with tall tales and rape them with jaw-dropping premiums (which get passed on to guess-who, the people who pay for health care).

The whole fear of malpractice suits does add very large costs to the health care system through “defensive medicine.” A doctor can be morally certain that a patient has some minor problem. Then the doctor thinks, well, there’s a 1 in 10,000 chance s/he has some particular major condition which would show on an MRI. Just my luck, the doc thinks, this patient has that, I’ll get sued, and so forth. So the doctor orders an MRI that someone else will pay for, and it’s $750 to $1,000 spent for no rational reason. With the fear that’s out there, justified or not, we can hardly blame those doctors.

And so, here’s the choice. Continue the circus. “You lie!” “There are significant details to be ironed out.” “The time for games is over.” “Socialism.” “Mandate.” Blah, blah, blah. Or employ rational minds. Answer the three questions.

Note: A bright spot: West Virginia’s Governor, Joe Manchin, is encouraging business to offer health insurance to attract and retain good and loyal employees. He’s not telling them how to do it. He’s not asking the Legislature to pass laws or making executive decrees forcing them to do it. He’s communicating logically, using reason, and trusting the honor and intelligence of business people to do the right thing in an efficient way that works for them and that improves life for everyone.

Pippa passes.


No comments: